Practice Patterns for Stopping Surveillance in Older Patients Are Highly Variable Among Endoscopists
Douglas K. Rex, MD, MASGE, reviewing Rege S, et al. Clin Gastroenterol Hepatol 2021 Jun 30.
The U.S. Multi-Society Task Force on Colorectal Cancer recommends individualizing the decision to stop surveillance colonoscopy in patients aged 75 years and older.
This is a study from a single U.S. academic center performed between 2012 and 2019 that examined 1426 colonoscopies in persons aged 75 or older and whether the endoscopist made a recommendation to stop or continue surveillance or made a different qualified recommendation.
High-risk adenomas included patients with 3 or more adenomas. Most high-risk patients (57.3%) met the criteria based on 3 or more lesions rather than an advanced lesion. The fraction of patients receiving a recommendation to stop surveillance was 34.9%, whereas 51.3% were advised to continue and 13.8% had a different qualified recommendation, which commonly was to defer the decision.
In a multivariable analysis, predictors of stopping surveillance included older age (80-84 years compared to 75-79 years had an odds ratio [OR] of 7.74, which increased to 9.04 in patients 85 years and older) and an American Society of Anesthesiologists (ASA) score of ≥III, which had an OR of 2.04 when compared to an ASA score of I or II. Family history of colorectal cancer (CRC) was associated with a reduced recommendation to stop surveillance (OR, 0.42), as were low-risk polyps (OR, 0.17) and high-risk polyps (OR, 0.02).
Among 17 endoscopists, the average rate of recommending that patients stop surveillance was 26.1%, however, the range was 0% to 61.8%. After accounting for patient age and colonoscopy findings, 42.1% of the variation among endoscopists was unaccounted for.
COMMENTOverall, these results concerning age, comorbidities, and colonoscopy findings are perfectly logical. The authors opined there should be more guidance, given the variable approaches taken by endoscopists. The lack of evidence to give firm guidance is problematic. Although patients with a history of only low-risk adenomas do appear to be at low risk for CRC, compared to the adenoma-free population, part of that risk reduction has recently been shown to result from surveillance colonoscopy. Further, we know that, generally, adenomas are more dangerous in older adults. It might be fair to have variation in practice given the unknowns, and this study did not assess patient preferences. It’s surprising that there was not a higher percentage of endoscopists who deferred the decision to repeat surveillance since comorbidities can change significantly in older patients in 3 to 10 years.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Rege S, Coburn E, Robertson DJ, Calderwood AH. Practice patterns and predictors of stopping colonoscopy in older adults with colorectal polyps. Clin Gastroenterol Hepatol 2021 Jun 30. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2021.06.041)
