Spotlight on CRC screening and follow-up
Several recent studies focused on screening and follow-up for colorectal cancer (CRC), including one that found differences in decision making between primary care physicians and gastroenterologists on surveillance colonoscopies in older adults.
Three studies published in the past month focused on colorectal cancer (CRC) screening and follow-up.
The first study found that extending currently recommended 10-year screening colonoscopy intervals may be warranted, particularly for female and younger patients. Researchers conducted a cross-sectional study on screening colonoscopy findings in a German registry from January 2013 to December 2019. Screening colonoscopies were offered to German residents ages 55 years and older since 2002, and the national registry included data from about 90% of the eligible population. The researchers identified 120,298 (60.1% women) screening colonoscopy participants ages 65 years and older who had a previous negative screening colonoscopy at least 10 years prior. They compared the findings with all screening colonoscopies conducted at 65 years or older during the same period (1.25 million). The main outcome was the prevalence of CRCs and advanced colorectal neoplasms (advanced adenomas and cancers). Results were published Jan. 17 by JAMA Internal Medicine.
Prevalence of advanced colorectal neoplasm was 3.6% among women and 5.2% among men 10 years after a negative screening colonoscopy. Prevalence gradually increased to 4.9% and 6.6%, respectively, among women and men who had a negative colonoscopy at least 14 years prior compared to 7.1% and 11.6%, respectively, among all screening colonoscopies. Sex- and age-specific prevalence of advanced colorectal neoplasms at repeated colonoscopies conducted 10 or more years after a negative colonoscopy were consistently at least 40% lower among women than men, were lower at younger versus older ages, and were much lower than among all screening colonoscopies (standardized prevalence ratios for cancers, 0.22 to 0.38 among women and 0.15 to 0.24 among men; standardized prevalence ratios for any advanced neoplasm, 0.49 to 0.62 among women and 0.50 to 0.56 among men). The study was limited by the inability to include all repeated screening colonoscopies and the possibility of healthy participant bias in those repeatedly screened, the study authors noted. “The study results provide evidence that, for asymptomatic patients with a negative baseline examination, the currently recommended screening colonoscopy intervals are safe and suggest that sex and age could guide potential risk-adapted extension of screening intervals beyond 10 years, especially for female and younger participants,” they concluded.
The second study found that follow-up colonoscopy rates after a positive stool-based CRC screening test were low in an average-risk population in the U.S., and socioeconomic factors and the COVID-19 pandemic both associated with lower rates. Researchers retrospectively assessed deidentified administrative claims and electronic health record (EHR) data from June 1, 2015, through June 30, 2021, and conducted qualitative, semistructured interviews with clinicians from five health care organizations. The study population included average-risk primary care patients ages 50 to 75 years with a positive stool-based test result between Jan. 1, 2017, and June 30, 2020, at 39 health care organizations. The study was funded by the Exact Sciences Corporation, which makes stool-based CRC tests, and results were published Jan. 18 by JAMA Network Open.
The cohort included 32,769 patients (51.7% female; mean age, 63.1 years). Follow-up colonoscopy rates were 43.2% within 90 days of the positive stool-based test result, 51.4% within 180 days, and 56.1% within 360 days. Rates varied widely across health care organizations, with a median 360-day follow-up rate of 53.4% (range, 17.4% to 71.8%). In interviews, clinicians reported being surprised by the low follow-up colonoscopy rates, which varied by race, ethnicity, insurance type, presence of comorbidities, and stool-based test type. The strongest positive association was with multitarget stool DNA relative to fecal immunochemical tests (hazard ratio, 1.63 [95% CI, 1.57 to 1.68]; P<0.001), and the strongest negative association was with the presence of comorbidities (hazard ratio for a Charlson Comorbidity Index >4 vs. 0, 0.64 [95% CI, 0.59 to 0.71]; P<0.001). The early COVID-19 pandemic was associated with lower follow-up colonoscopy rates. Limitations of the study were the convenience sample of health care organizations and the reliance on EHR data and outbound billing claims, the authors noted.
The third study focused on physician decision making regarding surveillance colonoscopies in older adults, finding that primary care physicians (PCPs, including those in internal medicine, family medicine, general practice, and geriatric medicine) had different opinions than gastroenterologists. Researchers mailed a survey to a random sample of 1,800 PCPs and 600 gastroenterologists from the American Medical Association Masterfile. They asked whether the physicians would recommend surveillance colonoscopy in vignettes with varied patient age (75 or 85 years), health (good, medium, or poor), and prior adenoma risk (low or high). They looked at the association between surveillance recommendations and patient and physician characteristics, as well as assessed decisional uncertainty, need for decision support, and decision-making roles. Results were published Jan. 19 by the American Journal of Gastroenterology.
Of 1,040 respondents (response rate, 54.8%), 874 were eligible and included in the study. Family medicine/general practice was the most common specialty represented (36.2%), followed by gastroenterology (31.5%) and internal medicine (30.6%). Overall, recommendation for surveillance colonoscopies was lower if the patient was older (adjusted proportions, 20.6% vs. 49.8% if younger), in poor health (adjusted proportions, 7.1% vs. 28.8% if in moderate health and 49.8% if in good health), and if prior adenoma was 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%). More than half (52.3%) of PCPs and 35.4% of gastroenterologists reported uncertainty regarding the balance of benefits and harms of surveillance in older adults, and most (85.9% of PCPs and 77.0% of gastroenterologists) said they would find a decision support tool helpful. About one-third (32.8%) of PCPs versus 71.5% of gastroenterologists perceived it as the gastroenterologist's role to decide about surveillance colonoscopies.
The study relied on physicians' self-report, among other limitations, the authors noted. “There are no existing surveillance colonoscopy guidelines that integrate patient age, health and adenoma risk and physicians report significant decisional uncertainty,” they wrote. “Developing the evidence base to evaluate the risks and benefits of surveillance colonoscopy in older adults, and decisional support tools that help physicians and patients incorporate available data and weigh risks and benefits are needed to address current gaps in care for older adults with prior adenomas.”