Key Points
Question
How frequent is screening colonoscopy, and what outcomes occur when performed in asymptomatic patients older than 75 years with a life expectancy of fewer than 10 years?
Findings
In this cross-sectional study with a nested cohort that included 7067 patients older than 75 years undergoing screening colonoscopies, the percentage of colonoscopies performed on patients with a life expectancy of fewer than 10 years was 30% for those aged 76 years to 80 years, 71% for those aged 81 years to 85 years, and 100% of patients aged beyond 85 years. Fifteen patients (0.2%) were found to have invasive adenocarcinoma with 5 patients undergoing cancer treatment; furthermore, adverse events requiring hospitalization were common at 10 days (13.58 per 1000) and increased with age, particularly among patients older than 85 years.
Meaning
In patients older than 75 years, a large proportion of screening colonoscopies, which were also associated with an increased risk of complications, were among patients with limited life expectancy (<10 years); colorectal cancer was rarely detected and rarely acted on.
Abstract
Importance
The benefits from colorectal cancer (CRC) screening may take 10 to 15 years to accrue. Therefore, screening is recommended for older adults who are in good health.
Objective
To determine the number of screening colonoscopies done in patients older than 75 years with a life expectancy of fewer than 10 years, diagnostic yield, and associated adverse events within 10 days and 30 days of the procedure.
Design
This cross-sectional study with a nested cohort between January 2009 and January 2022 in an integrated health system assessed asymptomatic patients older than 75 years who underwent screening colonoscopy in the outpatient setting. Reports with incomplete data, any indication other than screening, patients who had a colonoscopy within the previous 5 years, and patients with a personal history of inflammatory bowel disease or CRC were excluded.
Exposures
Life expectancy based on a prediction model from previous literature.
Main Outcomes and Measures
The primary outcome was the percentage of screened patients who had limited (<10 years) life expectancy. Other outcomes included colonoscopy findings and adverse events that developed within 10 days and 30 days of the procedure.
Results
A total of 7067 patients older than 75 years were included. The median (IQR) age was 78 (77-79) years, 3967 (56%) were women, and 5431 (77%) were White with an average of 2 comorbidities (taken from a select group of comorbidities). The proportion of colonoscopies performed on patients with a life expectancy of fewer than 10 years aged 76 to 80 years was 30% in both sexes and increased with age—82% of men and 61% of women aged 81 to 85 years (71% total), and 100% of patients beyond the age of 85 years. Adverse events requiring hospitalizations were common at 10 days (13.58 per 1000) and increased with age, particularly among patients older than 85 years. The detection of advanced neoplasia varied from 5.4% among patients aged 76 to 80 years to 6.2% in those aged 81 to 85 years and 9.5% among patients older than 85 years (P = .02). Of the total population, 15 patients (0.2%) had invasive adenocarcinoma; among patients with a life expectancy of fewer than 10 years, 1 of 9 was treated, whereas 4 of 6 patients with a life expectancy of greater than or equal to 10 years were treated.
Conclusions and Relevance
In this cross-sectional study with a nested cohort, most screening colonoscopies performed in patients older than 75 years were in patients with limited life expectancy and associated with increased risk of complications. Colorectal cancer was exceedingly rare.
This cross-sectional study with a nested cohort assesses the number of screening colonoscopies done in patients older than 75 years with a life expectancy of fewer than 10 years.
Introduction
Colorectal cancer (CRC) is a leading cause of cancer-related deaths in the US, and screening is the most effective way to reduce colon cancer mortality.1,2 For adults without symptoms or risk factors, the US Preventive Services Task Force (USPSTF) recommends routine CRC screening in patients aged 45 to 75 years.3 Between ages 76 and 85 years, both the USPSTF and the American Cancer Society recommend that screening be individualized, considering life expectancy, comorbidities, patient preference, and screening history (Grade C); however, there are no recommendations to guide clinicians on how to do so. Because the benefits of CRC screening accrue over a 10-year to 15-year period due to the interval required for the progression of adenomas to CRC,4 screening patients with a life expectancy of fewer than 10 years offers little benefit. The USPSTF, therefore, recommends against screening after age 85. Other guidelines recommend stopping CRC screening for patients older than 75 years with fewer than 10 years of life expectancy or who had a prior negative colonoscopy.5
With the percentage of older adults in the US population increasing, the number of screening colonoscopies should continue to increase.6 However, the potential benefits of CRC screening decrease with age and increasing comorbidity, which further add to the substantial variability in how clinicians approach colonoscopy recommendations in older adults. Furthermore, it is important to consider adverse events, particularly in screening older adults. Prior adverse event studies were limited because they included patients of all ages, different colonoscopy indications, or prolonged observation periods, making it difficult to attribute adverse events to the procedure.7,8,9,10,11,12
The objective of this study was to determine the proportion of screening colonoscopies performed in patients older than 75 years who had a life expectancy of fewer than 10 years. We also evaluated the colonoscopy findings and the associated adverse events.
Methods
Setting
This cross-sectional study with a nested cohort was approved by the institutional review board of the Cleveland Clinic. Informed consent was waived because this was a retrospective study using previously collected data, represented a limited risk to patients, and had a large sample size so it would not have been possible to contact all the patients involved to obtain their consent. We used an internally validated natural language processing algorithm (NLP) engine that was designed and developed in Prolog, a language used for artificial intelligence. The engine includes an interface that allows the NLP engine to read colonoscopy notes within a structured query language database. Algorithms identify each polyp; its size and location are linked to corresponding pathology findings. Procedure details, colonoscopy, and pathology findings are then joined to produce a report that has been shown to have greater than 95% accuracy.13 We used this NLP to obtain procedural and pathology data from colonoscopy reports on all asymptomatic patients older than 75 years who underwent screening colonoscopy at the Cleveland Clinic (Ohio and Florida) in the outpatient setting between January 2009 and January 2022. To verify the indication, we reviewed the indication entered by the endoscopist and excluded all colonoscopies not performed for screening. We also reviewed (J.E.H. and E.H.) a random sample of medical records from 50 patients from each age group to ascertain the indication for colonoscopy and excluded colonoscopies not done for screening. For each patient, we only considered the first screening colonoscopy if more than 1 occurred during the study period. We excluded reports with incomplete data, any indication other than screening, patients who had a colonoscopy within the previous 5 years (to ensure that the colonoscopies included were done for screening), and patients with a personal history of inflammatory bowel disease or CRC. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Patient Data
Demographic data, including patient age and sex, and comorbidities were obtained through electronic medical records. The International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) were used to characterize comorbidities, including diabetes, myocardial infarction, inflammatory bowel disease, rheumatological disease, peripheral vascular disease, paralysis, cerebrovascular disease, chronic obstructive pulmonary disease, congestive heart failure, liver disease, chronic kidney failure, dementia, cirrhosis, and acquired immunodeficiency syndrome.
Estimating Life Expectancy
We estimated the life expectancy of patients based on comorbid conditions using the tool developed by Cho et al14 to calculate the comorbidity-adjusted life expectancy for older adult patients. The tool estimated life expectancy from Medicare claims by comparing survival models with US life tables. We grouped patients into the following 3 groups: no comorbidity, low/medium comorbidity, and high comorbidity. We then estimated the life expectancy for each individual based on their comorbidity group and for the 3 most common comorbid conditions (diabetes, chronic obstructive pulmonary disease, and congestive heart failure). When life expectancy estimated for a specific comorbidity conflicted with life expectancy based on comorbidity burden, we chose the shorter of the two.
Colonoscopy Findings
We identified the quality of bowel preparation and whether the cecum was reached. We categorized the findings of each colonoscopy as normal (no polyps), nonadvanced polyps (1 or more adenomas without villous pathology or high-grade dysplasia or sessile serrated polyps <10 mm with no dysplasia, or hyperplastic polyps <10 mm), or advanced neoplasia (defined as sessile serrate polyp or hyperplastic polyp ≥10 mm, sessile serrated polyp with dysplasia, traditional serrated adenoma of any size, tubulovillous adenoma, villous adenoma, high-grade dysplasia, or CRC). We also evaluated colonoscopy findings by age group and life expectancy. We then manually reviewed the medical records of all patients with CRC to assess for cancer stage, any interventions (chemotherapy and/or surgery) or change in management, and cause of death (if available). Findings on colonoscopies done more than 5 years prior to the index screening colonoscopy were recorded.
Adverse Events
We defined complications as any adverse event within 10 days after a colonoscopy requiring a hospital admission or emergency visit. Two team members (J.E.H. and E.H.) reviewed all medical records and recorded whether the complication was considered related to the procedure. Adverse events were grouped into mild (hospitalization of 1-3 days), moderate (hospitalization of 4-9 days), and severe (hospitalization of ≥10 days, intensive care unit stay, surgery, repeated procedure for adverse event, or death) based on the lexicon by the American Society for Gastrointestinal Endoscopy (ASGE).15 We considered an alternative definition of 30 days and reviewed the record for any deaths within 30 days of the procedure.
Outcomes
The primary outcome was the percentage of screening colonoscopies done in patients with a life expectancy of fewer than 10 years. Secondary outcomes included 10-day and 30-day complications and colonoscopy findings defined as normal, nonadvanced polyps, and advanced neoplasia.
Statistical Analysis
Continuous variables were described using median and IQR, and categorical variables were described by frequency (%). We used χ2 tests to compare categorical data. We assessed the percentage of colonoscopies performed in patients with limited life expectancy (ie, <10 years) according to 5-year interval age categories (76-80 years; 81-85 years; and >85 years) and sex. We also identified patients with a life expectancy of fewer than 5 years. We reported the frequency of the findings recorded on the pathology reports of the index colonoscopy and colonoscopy done more than 5 years prior, when available. For complications, we reported any adverse event as frequencies per 1000. We reported advanced neoplasia on colonoscopy stratified by life expectancy. All statistical analyses were done using R statistical software, version 4.1.1 (R Project for Statistical Computing). A 2-sided significance threshold of P < .05 was used.
Results
Patient Characteristics
From January 2009 to January 2022, a total of 40 546 colonoscopies were performed in a single health system, out of which 7067 patients were found. All participants were older than 75 years and underwent a screening colonoscopy. Colonoscopies were excluded if they were identified as diagnostic colonoscopies (n = 32 225), inflammatory bowel diseases (n = 52), colonoscopies recorded for other reasons than screening (n = 310), having a prior diagnosis of CRC (n = 330), and having a colonoscopy done less than or equal to 5 years prior (n = 562). The median (IQR) age of participants was 78 (77–79) years, 3967 (56%) were women, and 5431 (77%) were White with an average of 2 comorbidities. Further characteristics of the study population and colonoscopy characteristics, stratified by age, are shown in the Table.
Table. Demographics of Study Population.
| Characteristic | No. (%) | |||
|---|---|---|---|---|
| Total | Age, 76-80 y | Age, 81-85 y | Age, >85 y | |
| Total No. | 7067 | 5775 | 1021 | 271 |
| Sex | ||||
| Female | 3967 (56) | 3253 (56) | 537 (53) | 177 (65) |
| Male | 3100 (44) | 2522 (44) | 484 (47) | 94 (35) |
| Age, median (IQR), y | 78 (77-79) | 77 (76-78) | 82 (81-83) | 87 (86-89) |
| Race | ||||
| Asian | 115 (1) | 100 (2) | 15 (2) | 0 (0) |
| Black | 1239 (18) | 981 (17) | 184 (18) | 74 (27) |
| White | 5431 (77) | 4461 (77) | 780 (76) | 190 (70) |
| Othera | 282 (4) | 233 (4) | 42 (4) | 7 (3) |
| Mean (SD) No. of comorbidities | 1.91 (1.60) | 1.30 (1.28) | 2.90 (1.59) | 3.10 (1.63) |
| Mean (SD) life expectancy, y | 9.20 (2.69) | 10.35 (2.56) | 7.76 (1.92) | 6.28 (1.48) |
| Poor bowel preparation | 222 (3) | 174 (3) | 36 (3) | 12 (4) |
| Colonoscopy completion | 6778 (96) | 5560 (96) | 959 (94) | 259 (96) |
Other represents Native Hawaiian or other Pacific Islander, multiracial, unknown/unreported/missing, and other race.
Screening Colonoscopies in Patients With Limited Life Expectancy
In the random sample of 150 colonoscopies that were manually reviewed, 96% were done for screening. The percentage of patients whose colonoscopies were performed despite a life expectancy of fewer than 10 years increased from 30% for patients aged 76 to 80 years (39% of men and 23% of women) to 71% for patients aged 81 to 85 years (82% of men and 61% of women). At each age group, the percentage of colonoscopies done on patients with a life expectancy of fewer than 10 years was higher for men than for women. Beyond the age of 85 years, all patients who had screening colonoscopies had a life expectancy of fewer than 10 years (Figure 1). Very few colonoscopies (3%) were performed for patients with a life expectancy of fewer than 5 years (eFigure in the Supplement).
Figure 1. Proportion of Screening Colonoscopies Performed in Patients Stratified by Life Expectancy, Age, and Sex.
The proportion of colonoscopies done on patients with a life expectancy of fewer than 10 years increased according to age group and was more common in men than women.
Colonoscopy Findings
Among patients older than 75 years, 3997 (56.6%) of those undergoing colonoscopies had normal results, 2669 (37.7%) had a nonadvanced polyp, and 401 (5.7%) had advanced neoplasia. The frequency of detection of advanced neoplasia varied with age from 5.4% among patients aged 76 to 80 years to 6.2% in patients aged 81 to 85 years and 9.5% among patients older than 85 years (P = .02). Colonoscopy findings by age group and life expectancy are presented in eTable 1 in the Supplement. A total of 562 (8%) patients had a colonoscopy more than 5 years before the index examination with a median (IQR) of 7 (6-9) years. Findings were normal in 61.2% of participants. However, 37.0% had nonadvanced neoplasia, and 1.7% had advanced neoplasia. Of the total patient sample, 15 patients (0.2%) were found to have CRC; 10 patients had no intervention (chemotherapy and/or surgery) based on patient and clinician preference. Of patients with a life expectancy of fewer than 10 years, 1 of 9 was treated, whereas 4 of 6 patients with a life expectancy of greater than or equal to 10 years were treated. Patients who did not undergo treatment had a median (IQR) predicted life expectancy of 6 ( 3-7) years (maximum, 9 years) vs 10.5 (10-13) years (maximum, 15 years) in those with an intervention. Only 2 out of 15 patients had cancer-related deaths (eTable 2 in the Supplement).
Adverse Events
The overall rate of adverse events per 1000 patients within 10 days was 13.58 (95% CI, 11.13-16.56), with mild, moderate, and severe events occurring in 3.25 (95% CI, 2.17-4.88), 7.49 (95% CI, 5.74-9.79), and 2.97 (95% CI, 1.94-4.54), respectively. Severe adverse events increased from 2.42 (95% CI, 1.45-4.06) among patients aged 76 to 80 years to 3.92 (95% CI, 1.52-10.03) among patients aged 81 to 85 years and 11.07 (95% CI, 3.77-32.03) among those older than 85 years (P = .03) (Figure 2). The most common events were gastrointestinal bleeding and arrhythmias. The rate of perforations was 0.52 for patients aged 76 to 80 years (95% CI, 0.18-1.52), 1.95 for patients aged 81 to 85 years (95% CI, 0.53-7.11), and 3.69 (95% CI, 0.65-20.06) for patients older than 85 years. Adverse events within 30 days were slightly higher (Figure 2). There were no deaths recorded within 30 days following the colonoscopies. Patients with a life expectancy of fewer than 10 years had twice the rate of complications as those with longer life expectancies.
Figure 2. Rates of Adverse Events per 1000 Patients That Developed After Colonoscopy Screening According to Age.
Adverse events are grouped by severity into mild (requiring hospitalization of 1 to 3 days), moderate (requiring hospitalization of 4 to 9 days), and severe (requiring hospitalization ≥10 days, intensive care unit stay, needing surgery, repeating procedure for an adverse event, or death associated with the procedure). The whiskers indicate 95% CIs. A, Adverse events at 10 days. B, Adverse events at 30 days.
Discussion
In this cross-sectional study with a nested cohort conducted in a single large health system, we found that patients older than 75 years often had a screening colonoscopy despite having a life expectancy of fewer than 10 years. The proportion of patients who had colonoscopies with a life expectancy of fewer than 10 years increased with age—more than 71% of colonoscopies for patients older than 80 years, and 100% of colonoscopies for patients older than 85 years. Most patients undergoing colonoscopies had normal results; 5.7% had advanced neoplasia, and only 0.2% had CRC. Patients with life expectancies of fewer than 10 years were very unlikely to have their cancers treated, whereas the majority of those with a life expectancy greater than or equal to 10 years did opt for treatment. Furthermore, older patients had markedly increased overall endoscopic adverse events, including serious gastrointestinal adverse events, hospitalizations, and perforations.
The USPSTF currently recommends individualized colon cancer screening for people older than 75 years but does not stipulate how the practice might be implemented. Because older patients of the same age can vary significantly in their comorbidities and quality of life, chronological age alone is a poor determinant of who should be screened. In contrast, life expectancy quantified by a patient’s health offers a better measure of who is likely to live long enough to benefit from screening, which is similar to what prior studies have found in veterans undergoing colonoscopy screening.16,17 We found that physicians often ignored life expectancy and offered screening to a large number of patients with a life expectancy of fewer than 10 years, particularly in patients older than 80 years. A prior study by Royce et al18 also showed that a substantial proportion of the US population with limited life expectancy receives cancer screenings resulting in overscreening, which results in higher health care costs and is unlikely to result in net benefit.
Approximately 6% of patients screened had advanced neoplasia, which is slightly lower than what has been reported by others (7%-13.6%).19 Removing these lesions may prevent cancer incidence within a 10-year period but is unlikely to increase overall life expectancy, particularly in older adults. Guidelines call for future research to determine whether the benefits of early detection and resection of advanced lesions outweigh procedural risks in patients older than 75 years.20 Equally important, life expectancy predicted the response to findings. Overall, the finding of CRC was extremely rare, and patients with short life expectancies overwhelmingly chose not to have it treated, obviating the benefit of screening (eTable 2 in the Supplement). Furthermore, very few of these patients died from causes related to their malignant neoplasm.
Colonoscopy is considered a limited resource.21,22 In recent decades, colon cancer has shifted to younger patients, prompting a number of guidelines to recommend screening earlier, further taxing physicians’ abilities to adequately screen those at risk. By reducing unnecessary colonoscopies in those with limited life expectancy, we can ensure that others have access.23 Of course, stopping screening in older adults may be challenging. Physicians must first calculate life expectancy (at least for those younger than 85 years) but may not have the tools to do so. The tool by Cho et al14 offers one potential approach. Future studies should test the effects of making such tools available in electronic medical records. For those with limited life expectancy, conversations may be challenging, especially if physicians have not been trained in addressing end-of-life issues, and patients may still request inappropriate screening. Public campaigns that emphasize the indications and complications of CRC screening could help decrease overuse of this tool.24
The limited benefits of screening among older patients must be weighed against the harms. Several studies have examined postprocedural complications for up to 30 days25,26,27; however, none took into account the estimated life expectancy and its relation to the development of complications. In the current study, we focused on the immediate complications that occurred up to 30 days after endoscopic intervention, classified according to the ASGE recommendations; we found a wide range of complications, particularly in patients older than 80 years. Patients with a life expectancy of fewer than 10 years also had twice the rate of complications as those with longer life expectancies. A recent study had comparable rates of gastrointestinal bleeding (2.28 per 1000) and arrythmias (1.77 per 1000)28; however, they did not look at different age groups in patients older than 75 years. In this study, we did not compare screening colonoscopy with colonoscopy for other indications7 or adverse events specifically related to polypectomy.29 Of particular concern was the high rate of severe hospitalizations among patients aged 81 to 85 years. The total perforation rate in patients older than 75 years was 0.52 per 1000, which is similar to previous studies7; however, for patients older than 85 years, the rate of perforation increased to 3.69 per 1000 patients, which exceeds the quality measures of ASGE/American College of Gastroenterology Task Force on Quality in Endoscopy.30 Furthermore, excess hospitalizations were common, with almost 4% of patients older than 85 years hospitalized within 10 days of the procedure. Others have reported similar rates but included patients having only surveillance or both screening and surveillance colonoscopies.25,31 We found no deaths associated with the colonoscopy, but the current study’s sample was small and unlikely to capture such a rare complication. Previous meta-analyses estimated death rates at 2.9 to 3.0 per 100 000.29,32
Limitations
The current study is not without limitations. First, we included only patients who underwent colonoscopies and have no data regarding patients who were not screened. Second, it is a single-center study, which could limit the generalizability of these findings, even though we included patients from multiple sites in Ohio and Florida. We could not take into account the specialty of the physicians ordering the screening colonoscopy nor patient preference which could have affected the decision to pursue screening. In addition, we relied on an internally validated NLP system, which was 96% accurate; however, a few diagnostic colonoscopies may have been mislabeled as screening. Another limitation is including prior colonoscopies that were only done at Cleveland Clinic, and hence we could have missed other screening examinations that were done at other facilities. Furthermore, we could have missed complications that occurred outside of this health system and hence underestimated the rate of adverse events.
Conclusions
In this cross-sectional study with a nested cohort, we found that a large number of screening colonoscopies in patients older than 75 years were among patients with limited life expectancy, had low yield of CRC, and had increased risk of complications. We show that life expectancy could be a proxy for both health and patient actions once CRC is discovered. Using life expectancy tools prospectively could save limited resources and prevent unnecessary postcolonoscopy complications among patients older than 75 years. Future studies are needed to examine whether presenting physicians with tools to estimate life expectancy can improve the appropriateness of their referrals.
eTable 1. Colonoscopy findings by age group and life expectancy
eTable 2. Patients with colorectal cancer stratified by life expectancy
eFigure. Proportion of screening colonoscopies performed in patients by life expectancy, age, and sex
Data sharing statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Colonoscopy findings by age group and life expectancy
eTable 2. Patients with colorectal cancer stratified by life expectancy
eFigure. Proportion of screening colonoscopies performed in patients by life expectancy, age, and sex
Data sharing statement