Research suggests caution on colonoscopies for seniors
■ One study says too many are done; another says physicians need to talk to patients about cancer screening risks and benefits when recommending testing discontinuation.
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Physicians may need to reduce the number of colonoscopies they do for patients 70 and older, and they should be sensitive to how they talk to seniors about discontinuing these and other cancer screenings, new studies say.
Nearly one in four colonoscopies for older adults may be inappropriate, according to a study published online March 11 in JAMA Internal Medicine, formerly Archives of Internal Medicine.
Guidelines by the U.S. Preventive Services Task Force and the American College of Physicians say a colonoscopy doesn’t need to be repeated within 10 years after a patient age 70 to 75 has a negative screening result and doesn’t experience any symptoms that would suggest retesting. Routine colonoscopies are not recommended for patients 76 to 85, and screening is discouraged in patients older than 85.
For the JAMA Internal Medicine study, researchers evaluated Texas Medicare claims data for patients 70 and older who had a colonoscopy between October 2008 and September 2009 and 5% of data for these Medicare beneficiaries nationwide. They concluded that guidelines might not have been followed in 23.4% of the cases.
“Screening colonoscopy comes with a real risk of complications for older adults, such as perforation, bleeding or incontinence,” lead researcher Kristin M. Sheffield, PhD, said in a statement. The assistant professor in the Dept. of Surgery at the University of Texas Medical Branch, Galveston, said older adults are less likely to benefit from early detection because “the natural history of colon cancer usually involves a slow progression from polyp to cancer.”
The authors said public education campaigns on appropriate screening may reduce unnecessary testing. “Inappropriate use of colonoscopy results in higher Medicare expenditures, involves unnecessary risk for older patients and represents a substantial proportion of endoscopists’ workloads, consuming resources that could be used more effectively,” the study concluded.
Overcoming patient doubts
Another study published online March 11 in JAMA Internal Medicine found that physicians need to be thoughtful about how they tell older patients that cancer screenings are no longer necessary.
After interviewing older adults about stopping cancer screening, whether it was colorectal cancer or other cancer screening, researchers found that patients felt “a strong moral obligation” to continue cancer screenings. Patients also expected physicians to “encourage and endorse screening.”
“I was surprised at the strong negative response patients had when we asked them hypothetically about not having a screening,” said lead researcher Alexia M. Torke, MD, a primary care and palliative care physician at the Indiana University Center for Aging Research in Indianapolis. “Many participants thought it would cause them to question the trust of their doctor.”
Some patients told researchers they would seek a second opinion, while others said they didn’t believe a physician would ever tell them not to get screened. Patients were much more receptive to the idea of not being screened when physicians talked to them about the risks and benefits of their individual situation, Dr. Torke said.
“We have sent the message so well that cancer screening is good that we now need to target messages to two groups of patients,” she said. “We need to tell the younger patients that it is still appropriate. We need to tell the older and sick patients that sometimes it is appropriate to stop the screenings.”
Dr. Torke said physicians need to communicate to older patients that they are not giving up on them because they are not ordering screening tests.
“We need to tell patients we are focusing on other more important things having to do with their care,” she said. “We need to talk about the burdens of screenings in relation to the benefits.”
The studies were issued during National Colorectal Cancer Awareness Month in March. To further create awareness, the American Medical Association is highlighting a Web-based educational program that teaches primary care physicians how to identify hereditary colorectal cancer syndromes.
A hereditary syndrome causes about 5% to 10% of colorectal cancers, the AMA said. Genetic testing sometimes can help diagnose patients suspected of having a hereditary cancer syndrome.
“Rapid developments in genomic medicine have made it possible for physicians to identify hereditary cancer symptoms by looking for specific clues in a patient’s personal and family medical history,” said AMA President Jeremy A. Lazarus, MD. “We developed this educational program to help physicians identify, evaluate, communicate with and manage patients at increased risk for colorectal cancer.”