Previous articles in this series have covered when to start colorectal cancer screening (age 50 for most people), the best test to find and prevent colorectal cancer (colonoscopy), and how often to repeat normal colonoscopies (every 10 years). In this last installment, we will discuss when to stop screening for colorectal cancer.
It is sometimes an awkward conversation to have, but the truth is that at a certain age, we eventually stop checking people for things that may cause them future harm. Think of it this way: A healthy 50-year-old person may have another 30-40 years of life ahead of them, so it makes sense to ensure that they won’t get their life cut short by a somewhat preventable thing like colon cancer. A healthy 87-year-old, statistically speaking, may only have another few months or years of life left before the clock runs out. So finding a small colon polyp that may take another 10 years to grow into a cancer doesn’t make much sense, since there are competing causes of mortality that will more likely claim this patient’s life by the age of 97 (namely heart disease, dementia, stroke, falls, pneumonia, other cancers…you get the drift).
I think we would all agree that it is impossible to even remotely predict the age that an individual will live to be. Some people have major medical issues that cause death at age 50-60, and others live well into their 90’s without having a single problem besides the expected aches and pains. Doctors are not completely in the dark however: We can predict a somewhat shorter life for those with certain chronic medical conditions, smokers, alcoholics, etc., but the truth is that these predictions are not terribly accurate for each individual. The CDC can tell me that life expectancy for smokers is 10 years less than nonsmoking peers, and that may be true in general, but we have all seen or heard stories of people like “Good Ol’ Grandpa Bill, who drank like a fish and smoked like a chimney, and lived ’till the ripe ol’ age of 99 with nary a hangnail, only to die peacefully in his sleep” to know that individuals can beat statistics…just not most individuals.
So what do the published guidelines say regarding when to stop routine screening for colorectal cancer? The US Preventive Services Task Force states that routine colorectal cancer screening should continue to age 75. From ages 76-85 the recommendation is to not offer screening to most individuals, with the caveat that certain individuals in this age group will still benefit from screening. That is, offer screening to 76- to 85-year-old patients on a case-by-case basis. And if your patient has beaten the odds and makes it to age 86 or above, the recommendation is to not offer colorectal cancer screening any longer.
Let’s not forget that these are recommendations for screening only. If the patient is symptomatic (bleeding, anemic, change in bowel habits, abdominal pain, abnormal imaging, etc.), or has a personal history of polyps, then these stopping rules for age do not apply. A common statement that I hear all the time from symptomatic elderly patients after I suggest a colonoscopy is “Sorry, my last doctor told me I don’t have to have another colonoscopy again.” That is true for screening, but not if we are looking for a problem that we already suspect we might find.
Like any guideline, following the recommendation to stop screening most patients at age 75 is really a one-size-fits-all solution to an individual problem. It’s not a bad guideline, and it is true for most patients, but blindly following these recommendations can also deprive some patients who may benefit from screening. I like to think about it this way instead: If the individual has a reasonable chance at living for another 10 years or so, then they should be offered screening colonoscopy. This may lead to not screening a 62-year-old with several active major health problems, and it may lead to screening an active and otherwise healthy 88-year-old with a family history of longevity. The point is, it is a tailored solution to the issue. Interestingly enough, the elderly patients that benefit most from screening are the ones who have never been screened before, since a consistent history of not having polyps on earlier colonoscopies is somewhat predictive of continuing to not have polyps into old age.
I’ll end the article with a brief anecdote to show how these decisions can be difficult to make. This is a true story from a few years ago: A mostly healthy 87-year-old man comes into the office with a chief complaint of “I want a colonoscopy.” He states his wife passed away recently from colon cancer, and her former gastroenterologist did not want to screen her due to her age (despite her asking repeatedly a few years prior to her death). He was very worried about having the same fate. Given his age, I should not have screened him. I did anyway, and he had a fairly large polyp that I removed. Would this polyp have turned into a cancer that would have caused his death? There is no way to know for sure, but I saw the same patient just recently, now over 90-years-old, and he’s doing just fine.
van Hess F, Saini SD, Lansdorp-Vogelaar I, et al. Personalizing colonoscopy screening for elderly individuals based on screening history, cancer risk, and comorbidity status could increase cost effectiveness. Gastroenterology 2015;149:1425-37.