Elsevier

Cancer Treatment Reviews

Volume 33, Issue 6, October 2007, Pages 528-532
Cancer Treatment Reviews

CONTROVERSY
Colorectal cancer screening in elderly patients: When should be more useful?

https://doi.org/10.1016/j.ctrv.2007.04.004Get rights and content

Summary

Current guidelines endorse colon cancer screening every 5–10 years in persons over 50 years of age. However, there is no consensus regarding what age is appropriate to stop screening. Prior history of neoplasia seems to be a strong risk factor for colorectal neoplasia development in elderly people and should be considered when deciding the need for continuing screening/surveillance, however, clinical judgment of comorbidities is still required to individualize screening practice. Screening colonoscopy in very elderly persons (aged ⩾80 years), i.e. should be performed only after careful consideration of potential benefits, risks and patient preferences. The aims of this paper are to: (1) determine the best type of colorectal cancer screening (faecal occult blood testing, flexible sigmoidoscopy, double-contrast barium enema and colonoscopy) and its association with age and health status among elderly veterans and (2) describe the outcomes of colorectal cancer screening among older veterans who have widely differing life expectancies (based on age and health status).

Introduction

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in North America. The incidence, that is approximately 650,000 cases per year worldwide and 30,000 in Italy, has increased in recent years while the mortality, that was approximately of 278,446 male and 250,532 female cases per year worldwide in 2002 and 9061 male and 7909 female cases in Italy in the same year, has decreased or stabilised.1 In persons over 85 years, CRC constitutes, one third of all neoplasms with 70% of patients aged 65 years or older.2 Particularly, in persons >65 years old, the incidence of colon cancer is about 120 new cases per 100,000 inhabitants per year (and in persons >75 years old is about 200/100,000 inhabitants per year) and mortality is about 90 per 100,000 inhabitants per year.3 The time from the first symptom to the first medical consultation in the elderly is so long and it is about 113.4 days (16.2 weeks) for rectal cancer and 88.9 days (12.7 weeks) for colonic cancer. The time from first examination to treatment is 154.0 days (22.0 weeks) for rectal cancer and 135.1 days (19.3 weeks) for colonic cancer.4 Because of the dimension and the gravity of the problem, current guidelines recommend CRC screening for all persons 50 years or older, properly to anticipate the time of diagnosis, but at this moment there is no specific age limit above which screening is not recommended. Probably for this reason, nowadays, the number of screening colonoscopies for CRC and its precursor lesions (based on the estimate of the time it takes for an adenomatous (benign tumour) polyp to transform into carcinoma) in elderly US persons is dramatically increasing. Anyway, because the unknown duration over which the risk of CRC remains decreased following a normal colonoscopy, because colonoscopy in very elderly persons is associated with lower procedural completion rates and possibly higher complication rates, and in light that very elderly people have shorter life expectancies potentially limiting the benefits of screening procedures, decisions to undergo a colonoscopy should always be based on the exam impact on elderly people life expectancy.

The aim of this paper is to review all the literature data about screening in the elderly to underline a good and uniform behaviour strategy in people ⩾75 years old.

Section snippets

Definition

Screening is a public health service in which members of a defined population, who do not necessarily perceive they are at risk of, or are already affected by a disease or its complications, are asked a question or offered a test, to identify those individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of a disease or its complications.

Persons >70 years do not necessarily usually perceive they are at risk of CRC. Actually, in the last years,

Conclusion

Since, an estimated 90/100,000 inhabitants per year CRC deaths are expected to occur in patients older than 65 and since the majority of these would be aged 65 or older (65–78% CRC) we believe there could be a substantial potential for population benefit with CRC screening. Moreover, evaluating that 75 deaths and 611 perforations could result from diagnostic colonoscopy with a biennial screening program that is in contrast to an estimated reduction in CRC mortality of 16.7% (or 7740 deaths)

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