Some Older Adults Think Stopping CRC Screening at Age 75 Is ‘Unacceptable’

Although a majority of older adults said that guidelines limiting colorectal cancer (CRC) screening after age 75 were acceptable, a substantial minority did not agree, according to results from a cross-sectional study.

Among over 1,200 older adults, a weighted estimate of 60.4% said guidelines on stopping CRC screening at age 75 were acceptable, while 39.6% said these guidelines were somewhat or very unacceptable, reported Jeffrey T. Kullgren, MD, MPH, of the University of Michigan in Ann Arbor, and colleagues.

Of note, in a subgroup analysis of 304 respondents with limited estimated life expectancy, defined as a score of 8 or more on the Lee Index for 10-year mortality, and 969 with longer life expectancy, defined as a score of 7 or lower on the Lee Index, unacceptable responses were nearly identical: 39.2% of the limited group and 39.7% of the longer group.

“These data suggest that limited life expectancy (and the health issues associated with that metric) does not increase older adults’ acceptance of guidelines that seek to de-implement low-value care, although less healthy individuals are most likely to benefit and/or avoid unnecessary harms by following such guidelines,” they wrote in a research letter in JAMA Network Open.

In this study, the authors used data from the Health and Retirement Study (HRS), an ongoing biennial longitudinal cohort study of approximately 20,000 U.S. adults ages 50 and older conducted by the University of Michigan. Participants answered the following question: “Guidelines recommend that patients stop getting screened for colon cancer once they reach age 75. This is because for many healthy patients aged 75 and older, the harms of testing may be greater than the benefits of finding a new cancer. How acceptable is this recommendation to you personally?”

In a commentary accompanying the study, Leigh H. Simmons, MD, of Massachusetts General Hospital in Boston, and colleagues noted that this study “added to the literature about the older adult perspective on CRC screening by disputing the notion that patients with shorter life expectancy will be more likely to choose to stop CRC screening and suggesting that many patients will need strategic, personalized guidance when they face a decision about what age to stop CRC screening.”

They suggested that there could be several reasons why a substantial percentage of patients disagreed with the guidelines. For example, they noted that many of these older adults may be undergoing surveillance colonoscopy for a history of colorectal polyps.

“Thus, telling patients who have previously committed to regular surveillance colonoscopies that they can now stop testing may be unexpected and concerning to them,” they wrote. “Patients will understandably have questions about their risk of developing CRC, given their polyp history, and how much a colonoscopy could lower their risk, yet their clinicians may not be able to answer those questions.”

They also noted that clinicians should be able to communicate concerns about continued testing for older adults “with sensitivity and clarity.”

“Concepts such as the duration of the adenoma-carcinoma sequence, lag time to benefit, and the risk of colonoscopy-related adverse events are not intuitive, and patients may be swayed by phrasing around risk communication,” they wrote, adding that participants may have responded differently to a question that suggested that screening after age 75 is unlikely to prolong survival rather than to find a new cancer.

For this study, Kullgren and colleagues included 1,273 participants. Most (61%) were women, 31.3% were 50 to 59 years old, 31% were 60 to 69 years old, 21.4% were 70 to 79 years old, and 16.4% were 80 and older.

Acceptability was lower among male respondents with limited life expectancy, with the pattern reversed among female respondents (Lee Index for female sex OR 1.89, 95% CI 1.09-3.26).

The authors noted that their study had limitations, including the reliance on self-reported health status and a limited sample size.