Practice Patterns and Predictors of Stopping Colonoscopy in Older Adults With Colorectal Polyps

Racial/ethnic disparities in all-cause and cause-specific death among patients with colorectal cancer in the United States from 1992 to 2021: a registry-based cohort retrospective analysis

BACKGROUND

Inequality in mortality among patients with colorectal cancer in the United States has been documented, but the trends over time and the factors contributing to racial/ethnic disparities in all-cause and cause-specific death are unknown.

METHODS

This cohort study used the Surveillance, Epidemiology, and End Results (SEER) registry to analyze patients diagnosed with colorectal cancer from 1992 to 2021. We calculated the cumulative incidence of death for all racial/ethnic groups (Black, White, Hispanic, Asian or Pacific Islander [API], and American Indian or Alaska Native [AI/AN]) by diagnostic period and cause of death. We quantified absolute disparities using rate change in 5-year cumulative incidence of death and used discrete-time models to estimate relative racial/ethnic disparities and the contribution of factors to disparities in death.

RESULTS

The 5-year cumulative incidence of colorectal cancer and all-cause death among Black patients decreased. AI/AN and Black patients consistently had the highest risk of death between 1992 and 2021. Between Black and White, the adjusted HR for all-cause death difference increased from 1.14 (1.10-1.17) in 1992-1996 to 1.29 (1.23-1.35) in 2017-2021. Adjustment for stage at diagnosis, first course of therapy and socioeconomic status explained 46.5 % of the Black-White disparities and 38.4 % of the AI/AN-White all-cause death disparities.

CONCLUSION

Persistent racial/ethnic disparities in patients with colorectal cancer, especially in AI/AN and Black, call for new interventions to eliminate health disparities. Our study provides vital evidence to address racial/ethnic inequality.

Appropriateness of Recommendations for Surveillance Colonoscopy After Polypectomy-A Comparison of Adherence to the 2012 and 2020 USMSTF Guidelines

PURPOSE

The U.S. Multi-Society Task Force (USMSTF) has recommended surveillance intervals that weigh the benefits, harms, and costs of colonoscopy. In 2020, it updated its screening recommendations, and we want to evaluate clinical practice adherence to recommended guideline intervals.

METHODS

A prospective analysis was performed to examine gastroenterologists' recommendations for screening and surveillance colonoscopy from March 2012 to December 2023. Procedures with unknown histology or unsatisfactory bowel preparation were excluded. We compared polyp morphology, histology, and subsequent recommendations made by gastroenterologists to the USMSTF guidelines.

RESULTS

Five hundred thirteen patients and 902 colonoscopies were included. For screening colonoscopies, 200/231 (87%) followed 2012 guidelines, while 75% followed 2020 guidelines. For 1st surveillances, 75% followed 2012 guidelines, and 50% followed 2020 guidelines (p < 0.001). Adherence was also analyzed by year from 2020 to 2023. There were no significant differences in rates for screening colonoscopy and 1st surveillances over this time frame. Since the introduction of the 2020 guidelines for screening colonoscopies, there was a decrease in adherence by 13% for low-risk adenoma (LRA) and an 8% decrease for high-risk adenoma (HRA); there was a 7% increase in adherence for hyperplastic polyps (HP) and an 11% increase in adherence with sessile serrated polyps (SSP). For 1st surveillances, there was a decrease in adherence by 16% for LRA, 11% for HRA, 1% for HP, and 2% for SSP.

CONCLUSIONS

Since the introduction of the 2020 guidelines, gastroenterologists are recommending colonoscopies more frequently than the guidelines call for. Increasing the evidence behind interval recommendations may increase guideline adherence.

Surveillance colonoscopy findings in asymptomatic participants over 75 years of age

Background and Aim

Surveillance colonoscopy for colorectal cancer (CRC) is generally not recommended beyond 75 years of age. The study determined incidence and predictors of advanced adenoma and CRC in older individuals undergoing surveillance colonoscopy.

Methods

This was a retrospective cohort study of asymptomatic older participants (≥75 years), enrolled in a South Australian CRC surveillance program who underwent colonoscopy (2015-2020). Clinical records were extracted for demographics, personal or family history of CRC, comorbidities, polypharmacy, and colonoscopy findings. The associations between clinical variables and advanced adenoma or CRC at surveillance were assessed with multivariable Poisson regression analysis.

Results

Totally 698 surveillance colonoscopies were analyzed from 574 participants aged 75-91 years (55.6% male). The incidence of CRC was 1.6% (11/698), while 37.9% (260/698) of procedures had advanced adenoma detected. Previous CRC (incidence rate ratio [IRR] 5.9, 95% CI 1.5-22.5), age ≥85 years (IRR 5.8, 95% CI 1.6-20.1) and active smoking (IRR 4.9, 95% CI 1.0-24.4) were independently associated with CRC diagnosis, while advanced adenoma at immediately preceding colonoscopy (IRR 1.6, 95% CI 1.3-2.0) and polypharmacy (IRR 1.2, 95% CI 1.0-1.5) were associated with advanced adenoma at surveillance colonoscopy in asymptomatic older participants (≥75 years).

Conclusion

Advanced neoplasia was found in more than one third of the surveillance procedures completed in this cohort. Continuation of surveillance beyond age 75 yeasrs may be considered in participants who have previous CRC or are active smokers (provided they are fit to undergo colonoscopy). In other cases, such as past advanced adenoma only, the need for ongoing surveillance should be considered alongside participant preference and health status.

A survey of current practices in post-polypectomy surveillance in Korea

BACKGROUND/AIMS

We investigated the clinical practice patterns of post-polypectomy colonoscopic surveillance among Korean endoscopists.

METHODS

In a web-based survey conducted between September and November 2021, participants were asked about their preferred surveillance intervals and the patient age at which surveillance was discontinued. Adherence to the recent guidelines of the U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF) was also analyzed.

RESULTS

In total, 196 endoscopists completed the survey. The most preferred first surveillance intervals were: a 5-year interval after the removal of 1-2 tubular adenomas < 10 mm; a 3-year interval after the removal of 3-10 tubular adenomas < 10 mm, adenomas ≥ 10 mm, tubulovillous or villous adenomas, ≤ 20 hyperplastic polyps < 10 mm, 1-4 sessile serrated lesions (SSLs) < 10 mm, hyperplastic polyps or SSLs ≥ 10 mm, and traditional serrated adenomas; and a 1-year interval after the removal of adenomas with highgrade dysplasia, >10 adenomas, 5-10 SSLs, and SSLs with dysplasia. In piecemeal resections of large polyps ( > 20 mm), surveillance colonoscopy was mostly preferred after 1 year for adenomas and 6 months for SSLs. The mean USMSTF guideline adherence rate was 30.7%. The largest proportion of respondents (40.8%-55.1%) discontinued the surveillance at the patient age of 80-84 years.

CONCLUSIONS

A significant discrepancy was observed between the preferred post-polypectomy surveillance intervals and recent international guidelines. Individualized measures are required to increase adherence to the guidelines.

Appropriateness of recommendations for surveillance colonoscopy after polypectomy - a comparison of adherence to the 2012 and 2020 USMSTF guidelines

Background

Screening colonoscopy detects precancerous polyps, which when resected, prevents colon cancer. Recommendations for surveillance colonoscopy after polypectomy are based on the U.S. Multi-Society Task Force guidelines (USMSTF).

Aim

to examine provider recommendations based on 2012 and 2020 USMSTF guidelines.

Methods

A prospective analysis was performed to examine provider recommendations for index screening and surveillance colonoscopy from March 2022 to January 2023. Procedures with unknown histology or unsatisfactory bowel preparation were excluded. We recorded polyp morphology, histology, and subsequent recommendations made by endoscopists, to compare to the USMSTF guidelines.

Results

241 patients were included, with 371 endoscopies reviewed. For index screening colonoscopies, 86%, performed between 2012 and 2020, adhered to 2012 guidelines, while 71%, performed after 2020, adhered to the 2020 guidelines. For surveillance colonoscopies, 62% from 2012 and 2020, and 50% after 2020, adhered to the 2012 and 2020 guidelines, respectively (P < 0.001). For polyp types, recommendations after index colonoscopies showed low-risk adenoma (LRA) had 88% adherence to 2012 guidelines versus 73% adherence to 2020 guidelines. For surveillance colonoscopies, LRA had 73% adherence to 2012 guidelines versus 42% adherence to 2020 guidelines (P < 0.001). Recommendations after index colonoscopy showed high-risk adenoma (HRA) had 79% adherence to 2012 guidelines versus 63% adherence to 2020 guidelines. For surveillance colonoscopies, HRA had 88% adherence to the 2012 guidelines versus 69% adherence to 2020 guidelines (P < 0.001).

Conclusions

Adherence declined for the introduction of 2020 guidelines and was poorer after 2nd surveillance exams. Increasing the evidence for interval recommendations may increase guideline adherence.

Physician Decision-Making About Surveillance in Older Adults With Prior Adenomas: Results From a National Survey

INTRODUCTION

There is no clear guidance on when surveillance colonoscopies should stop in older adults with prior adenomas. We aimed to examine physicians' decision-making regarding surveillance colonoscopies in older adults.

METHODS

In a national mailed survey of 1,800 primary care physicians (PCP) and 600 gastroenterologists, we asked whether physicians would recommend surveillance colonoscopy in vignettes where we varied patient age (75 and 85 years), health (good, medium, and poor), and prior adenoma risk (low and high). We examined the association between surveillance recommendations and patient and physician characteristics using logistic regression. We also assessed decisional uncertainty, need for decision support, and decision-making roles.

RESULTS

Of 1,040 respondents (response rate 54.8%), 874 were eligible and included. Recommendation for surveillance colonoscopies was lower if patient was older (adjusted proportions 20.6% vs 49.8% if younger), in poor health (adjusted proportions 7.1% vs 28.8% moderate health, 67.7% good health), and prior adenoma was of low risk (adjusted proportions 29.7% vs 41.6% if high risk). Family medicine physicians were most likely and gastroenterologists were least likely to recommend surveillance (adjusted proportions 40.0% vs 30.9%). Approximately 52.3% of PCP and 35.4% of gastroenterologists reported uncertainty regarding the benefit/harm balance of surveillance in older adults. Most (85.9% PCP and 77.0% gastroenterologists) would find a decision support tool helpful. Approximately 32.8% of PCP vs 71.5% of gastroenterologists perceived it as the gastroenterologist's role to decide about surveillance colonoscopies.

DISCUSSION

Studies to better evaluate the benefits/harms of surveillance colonoscopy in older adults and decisional support tools that help physicians and patients incorporate such data are needed.

Colon Cancer Screening and the End of Life: Is Age Just a Number?

Age is the strongest risk factor for colorectal cancer. Although there is updated guidance for the age at which to start screening, there is little guidance for individuals or their medical teams on how to decide when to stop. Current recommendations from the US Preventive Services Task Force and other societies focus primarily on age. For patients older than 85 years, guidelines discourage screening because the harms largely outweigh benefits. Although at a population level, the overall benefit of screening in older individuals decreases, one must individualize the recommendation based on comorbidities, functional status, screening history, and gender-not solely base it on age. Patient and caregiver preferences must also be thoroughly explored. Current models struggle with incorporating other colorectal cancer risk factors such as family history, previous adenomas, and modality of previous screening into recommendations and simulations, but are likely to improve with machine learning and whole electronic health record prediction-based approaches.