Colonoscopy Over Age 75 Is The Best Bet For Cancer Detection
Overview
Surveillance colonoscopy for colorectal cancer (CRAdvancing age is a well-documented risk factor for the development of advanced adenomas and the subsequent risk of colorectal cancer (CRC). Current guidelines lack specific recommendations for managing surveillance in older populations. This study identified advanced neoplasia, including CRC and advanced adenomas, in over one-third of the surveillance population aged 75 years and older. Key factors associated with advanced neoplasia in this group included having an advanced adenoma at the previous colonoscopy, being aged 85 years or older, active smoking, polypharmacy, and a prior history of CRC. Notably, individuals with a personal history of CRC, who continued surveillance beyond 75 years, were found to be at the highest risk for CRC.
The Australian National Cancer Control Indicators report indicated that the incidence of CRC is significantly higher in individuals aged 75 and older, with a rate of 389 per 100,000, compared to 130 per 100,000 in those aged 50 to 74. In this study, advanced neoplasia was found in 37.85% of surveillance participants over 75 years, including 1.58% with CRC, which is higher than the 13.1% of advanced neoplasia found in younger adults (mean age 63 years) in the same surveillance program. The incidence of CRC in older participants without a prior CRC was similar to that in younger adults (1.1%), but much higher in those with a lifetime history of CRC (4.2%).
These findings underscore the importance of regular surveillance colonoscopies for individuals with a lifetime history of CRC and those with advanced findings in their immediate prior colonoscopies, irrespective of age. The study also observed an equal distribution of advanced-stage and early-stage CRC, which may be due to the higher incidence of metachronous or recurrent cancers in elderly individuals following a prior CRC diagnosis, necessitating frequent follow-up colonoscopies. Therefore, identifying high-risk individuals aged 75 and older who are fit for colonoscopy is crucial.
One concern in this older population is the increased risk of procedural complications, with age and comorbidities being significant factors associated with higher hospitalization and mortality rates. Age over 75 and increasing Charlson Comorbidity Index (CCI) scores are known risk factors for adverse outcomes from colonoscopy. A study by Causada-Calo et al. found a higher incidence of 30-day postoperative complications in the ≥75 age group (6.8%) compared to the 50–74 age group (2.6%). In an average-risk population, colonoscopy showed no benefit in reducing CRC mortality in participants over 75 years with multiple comorbidities.C) is typically not recommended for individuals over 75 years old. This study aimed to identify the incidence and predictors of advanced adenoma and CRC in elderly individuals undergoing surveillance colonoscopy.
A retrospective cohort study was conducted with asymptomatic participants aged 75 years and older, enrolled in a South Australian CRC surveillance program and who underwent colonoscopy between 2015 and 2020. Data on demographics, CRC history, comorbidities, medication use, and colonoscopy results were collected. Multivariable Poisson regression analysis was used to determine the associations between clinical variables and the detection of advanced adenoma or CRC.
The study analyzed 698 surveillance colonoscopies from 574 participants aged 75-91 years (55.6% male). The incidence of CRC was 1.6% (11/698), and 37.9% (260/698) of the procedures identified advanced adenoma. Independent predictors for CRC diagnosis included a history of CRC (incidence rate ratio [IRR] 5.9, 95% CI 1.5–22.5), age 85 years or older (IRR 5.8, 95% CI 1.6–20.1), and active smoking (IRR 4.9, 95% CI 1.0–24.4). Advanced adenoma at the prior colonoscopy (IRR 1.6, 95% CI 1.3–2.0) and polypharmacy (IRR 1.2, 95% CI 1.0–1.5) were linked with advanced adenoma detection during surveillance.
More than one-third of the surveillance procedures identified advanced neoplasia. Continuing surveillance beyond the age of 75 may be warranted for individuals with a previous CRC diagnosis or who are active smokers, provided they are fit for colonoscopy. In cases involving only past advanced adenoma, the decision to continue surveillance should consider the participant’s health status and preferences.
Introduction
Colorectal cancer (CRC) is among the most prevalent cancers globally, with its occurrence increasing with age. As the population of individuals over 80 years is projected to more than triple in the next 30 years, effective CRC prevention strategies are essential. While most secondary prevention programs for CRC screening and surveillance extend up to age 75, the appropriate cessation age for these programs in older populations is unclear.
CRC typically develops through an adenoma to carcinoma sequence. Early detection and removal of adenomas or other precancerous lesions can prevent their progression to cancer, thereby reducing CRC incidence. Many countries implement fecal occult blood tests (FOBT) in organized screening programs for early detection of colorectal neoplasia. Regular colonoscopy surveillance is recommended for individuals with a history of neoplasia or a significant family history of CRC.
Although screening and surveillance significantly reduce CRC incidence and mortality, the decision to continue surveillance beyond age 75 is complex, with varying global guidelines. The American Society for Gastrointestinal Endoscopy (ASGE) refrains from making recommendations for surveillance beyond age 75 due to uncertain benefits. The European Society of Gastrointestinal Endoscopy (ESGE) advises ceasing surveillance by age 80, or earlier if comorbid conditions limit life expectancy. Australian guidelines similarly suggest that surveillance is unlikely to benefit most individuals over 75, recommending personalized clinical decisions instead. Studies indicate that for older adults, the risk of mortality from other causes often exceeds that from CRC.
Overall, there is limited evidence on the benefits of surveillance colonoscopy in individuals over 75, particularly when considering other risk factors. To enable informed decisions about continued surveillance colonoscopy in this age group, it is crucial to identify risk factors beyond age alone, such as comorbidities, procedural complications, and life expectancy. Additionally, the incidence of CRC and advanced adenomas in older individuals at higher risk due to personal or family history of CRC has not been well documented.
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This study aims to determine the incidence of CRC and advanced adenoma during colonoscopies in asymptomatic individuals over 75 years of age undergoing surveillance. It also seeks to identify demographic and clinical risk factors associated with the development of these advanced neoplastic lesions.
Method
This retrospective analysis (2015–2020) focused on participants aged 75 years and older undergoing surveillance colonoscopy as part of the South Australian Southern Cooperative Program for the Prevention of Colorectal Cancer (SCOOP). The study included individuals with a history of colorectal neoplasia or significant family history of colorectal cancer (CRC). Conducted at three public hospitals in southern Adelaide (Flinders Medical Centre, Noarlunga Hospital, Repatriation General Hospital), the analysis only considered asymptomatic participants with complete colonoscopy and available pathology results. Excluded were cases with poor bowel preparation, incomplete intubation, indeterminate pathology outcomes, or a diagnosis of inflammatory bowel disease.
For each colonoscopy, clinical records were reviewed to document age, sex, BMI, socioeconomic status, medical comorbidities, polypharmacy, smoking status, and alcohol intake. Age was categorized into 75–79.9, 80–84.9, and ≥85 years, while BMI was a continuous variable. Socioeconomic status was divided based on the median score of relative socioeconomic advantage and disadvantage. Medical comorbidities were quantified using the modified Charlson Comorbidity Index (CCI), and personal and family history of CRC were recorded as binary variables.
Outcomes were categorized into CRC (cancer invading beyond the muscularis mucosa) and advanced adenoma (adenomas or sessile serrated lesions ≥10 mm, high-grade dysplasia, villous changes, or concurrent small tubular adenomas). Advanced neoplasia included both advanced adenoma and CRC, with CRC staged according to the AJCC guidelines.
Descriptive statistics provided participant demographics, with analyses conducted for the entire cohort and stratified by lifetime CRC history. Chi-squared tests compared the incidence of advanced adenoma and CRC, while the Kruskal-Wallis test compared continuous data. Multiple imputation addressed missing data, assuming a non-monotonic missing pattern. Multivariable Poisson regression identified predictors of advanced adenoma or CRC, adjusting for key demographic and clinical factors. Incidence Rate Ratios (IRR) with 95% confidence intervals (CI) were reported, and all analyses were performed using STATA version 16.0, with a P value <0.05 deemed significant.
Result
During the audit period, 1,494 colonoscopies were performed on participants aged 75 and older. Exclusions were made for colonoscopies conducted for non-surveillance reasons: 364 for symptoms, 216 for follow-up of a positive FOBT result, and 97 for follow-up of an incomplete procedure. Additionally, 52 colonoscopies were excluded due to inflammatory bowel disease, poor bowel preparation, or indeterminate pathology outcomes. This left 698 surveillance colonoscopies for analysis, representing 574 unique participants.
The demographics of these 698 surveillance colonoscopies are detailed in Table 1. The cohort comprised 55.6% males, with a median age of 78.5 years (IQR 76.6–80.8). The majority (67.3%) were aged 75–79.9 years, 28.4% were 80–84.9 years, and 4.3% were over 85 years old. Among 686 classified by CCI, most had a CCI of ≥5. A significant portion (27.5%) had a prior history of colorectal cancer (CRC), and almost half followed an advanced neoplasia, with 10% having been diagnosed with CRC and 39.1% with advanced adenoma at their immediate prior colonoscopy.
The incidence of CRC in these surveillance colonoscopies was 1.58% (11/698). Participants with a history of CRC had a higher incidence (8/129, 4.2%) compared to those without (3/569, 0.5%). Most cancer findings were metachronous or recurrent CRC following a prior diagnosis. Among the three cases without prior CRC, two had recent advanced adenoma findings, all were males aged 79.0–80.2 years, and two had a family history of CRC. The stages of the 11 CRC cases were as follows: two at stage I, three at stage II, three at stage III, and three at stage IV.
Poisson regression analysis identified age ≥85 years (IRR 5.76, 95% CI 1.59–20.86), a history of CRC (IRR 5.88, 95% CI 1.51–22.85), and active smoking (IRR 4.89, 95% CI 1.00–24.39) as independent risk factors for CRC at surveillance colonoscopy. There was no significant association between CRC development and factors such as sex, socioeconomic status, CCI, BMI, alcohol intake, polypharmacy, or family history of CRC (P > 0.05).
For participants with a lifetime history of CRC (n = 192), age ≥85 years (IRR 7.69, 95% CI 1.51–39.22) and active smoking status (IRR 11.60, 95% CI 1.53–87.79) remained significantly associated with CRC at surveillance colonoscopy
Regarding advanced adenomas, 37.85% (260/698) of surveillance colonoscopies in participants over 75 years detected advanced adenomas. Multivariable logistic regression showed significant associations between advanced adenoma findings and having advanced adenoma at the most recent prior colonoscopy (IRR 1.61, 95% CI 1.31–1.97) and polypharmacy (IRR 1.24, 95% CI 1.01–1.53). Other factors, including age, sex, socioeconomic status, family history of CRC, CRC at index colonoscopy, CCI, alcohol intake, smoking status, and BMI, were not significantly associated (P > 0.05).
For those with a lifetime history of CRC, the only significant variable for advanced adenoma at surveillance was a prior advanced adenoma (IRR 2.19, 95% CI 1.29–3.72).
Conclusion
Advancing age is a well-documented risk factor for the development of advanced adenomas and the subsequent risk of colorectal cancer (CRC). Current guidelines lack specific recommendations for managing surveillance in older populations. This study identified advanced neoplasia, including CRC and advanced adenomas, in over one-third of the surveillance population aged 75 years and older. Key factors associated with advanced neoplasia in this group included having an advanced adenoma at the previous colonoscopy, being aged 85 years or older, active smoking, polypharmacy, and a prior history of CRC. Notably, individuals with a personal history of CRC, who continued surveillance beyond 75 years, were found to be at the highest risk for CRC.
The Australian National Cancer Control Indicators report indicated that the incidence of CRC is significantly higher in individuals aged 75 and older, with a rate of 389 per 100,000, compared to 130 per 100,000 in those aged 50 to 74. In this study, advanced neoplasia was found in 37.85% of surveillance participants over 75 years, including 1.58% with CRC, which is higher than the 13.1% of advanced neoplasia found in younger adults (mean age 63 years) in the same surveillance program. The incidence of CRC in older participants without a prior CRC was similar to that in younger adults (1.1%), but much higher in those with a lifetime history of CRC (4.2%).
These findings underscore the importance of regular surveillance colonoscopies for individuals with a lifetime history of CRC and those with advanced findings in their immediate prior colonoscopies, irrespective of age. The study also observed an equal distribution of advanced-stage and early-stage CRC, which may be due to the higher incidence of metachronous or recurrent cancers in elderly individuals following a prior CRC diagnosis, necessitating frequent follow-up colonoscopies. Therefore, identifying high-risk individuals aged 75 and older who are fit for colonoscopy is crucial.
One concern in this older population is the increased risk of procedural complications, with age and comorbidities being significant factors associated with higher hospitalization and mortality rates. Age over 75 and increasing Charlson Comorbidity Index (CCI) scores are known risk factors for adverse outcomes from colonoscopy. A study by Causada-Calo et al. found a higher incidence of 30-day postoperative complications in the ≥75 age group (6.8%) compared to the 50–74 age group (2.6%). In an average-risk population, colonoscopy showed no benefit in reducing CRC mortality in participants over 75 years with multiple comorbidities.
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