IIR 04-427
Impact of Health Status on Colorectal Cancer Screening in Older Adults
Louise C Walter, MD San Francisco VA Medical Center, San Francisco, CA San Francisco, CA Funding Period: January 2006 - December 2010 Portfolio Assignment: Long Term Care and Aging |
BACKGROUND/RATIONALE:
Worsening health can significantly decrease life expectancy, decreasing the likelihood of benefit from colorectal cancer screening. Because life expectancy is better predicted by health status than by age alone, most screening guidelines recommend considering an elderly person's health status when making screening decisions. However, it is unclear to what extent colorectal cancer screening is actually targeted to healthy elderly persons and avoided in unhealthy elderly persons with limited life expectancies. OBJECTIVE(S): The objectives of this project are to 1) determine the rate of colorectal cancer screening and its association with age and health status among elderly veterans; 2) identify determinants for why some healthy elderly veterans with substantial life expectancy do not receive screening and why some unhealthy elderly veterans with limited life expectancy are screened; and 3) describe the outcomes of colorectal cancer screening among older veterans who have widely differing life expectancies (based on age and health status). METHODS: A cohort of 60,933 veterans aged 70 years or older who used the Minneapolis, Durham, Portland, or Greater Los Angeles Healthcare System VAMCs during 2001-2002 was identified by the Colorectal Cancer Screening and Follow-up Data System at the Minneapolis Colorectal Cancer QUERI. For this cohort, data related to colorectal cancer screening and follow-up was extracted from each VAMC's VISTA system, from National Austin data files, and from Medicare. Based on these data 27,068 veterans had an outpatient visit at 1 of these 4 VAMCs in 2001 or 2002 and were due for colorectal cancer screening. Follow-up was assessed using chart review through 12/31/08. FINDINGS/RESULTS: 46% of the 27,068 screen-eligible veterans aged 70 years or older were screened for colorectal cancer during 2001-2002. Only 47% of veterans in best health were screened despite having substantial life expectancy. Although the incidence of screening decreased with age and worsening health, it was still 41% for patients in worst health who had life expectancies less than 5 years (5-year mortality, 55%). The number of VA outpatient visits predicted screening independent of health status, such that veterans in worst health with 4 or more visits had screening rates similar or higher than those of healthier veterans with fewer visits. In addition, among the 2,410 veterans screened with fecal occult blood testing (FOBT) in 2001, 212 (9%) had a positive result and among those patients, only 42% received complete colon evaluation within 1 year. Of the 122 veterans who did not receive complete colon evaluation, 38% had chart documentation that health or preferences did not permit such follow-up. Extending follow-up to 7 years, 56% of the 212 veterans with a positive result received follow-up colonoscopy during this period, which found 34 significant adenomas and 6 cancers. 10% experienced complications from colonoscopy or cancer treatment. 46% of those without follow-up colonoscopy died of other causes while 4 died of colorectal cancer. 87% of veterans with worst life expectancy experienced net burden from screening compared to 70% of those with average life expectancy and 65% of those with best life expectancy (P for trend = 0.048). IMPACT: The findings of this project have significantly contributed to general knowledge about colorectal cancer screening in older adults and were featured in Journal Watch as key findings relevant to practicing clinicians. Also, the VA Preventive Medicine Advisory Committee cites the findings of this project in their new VA colorectal cancer screening guidelines, which emphasize the importance of considering health status when making colorectal cancer screening decisions. In addition, the findings have increased patients' access to information about colorectal cancer screening. For example, the editors for the Annals of Internal Medicine featured the findings of this project in their "Summaries for Patients," directed at helping patients understand important concepts in modern medicine. The project has also received major press coverage including articles in Reuters Health, Health Day, and U.S. News and World Report, which discussed how colorectal cancer screening is both over- and underused in older adults and called for decision aids and guidelines that juxtapose the benefits of preventive services and life expectancy to help clinicians and patients make better decisions about screening and follow-up. External Links for this ProjectDimensions for VADimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Aging, Older Veterans' Health and Care, Cancer
DRE: Diagnosis, Prevention Keywords: Cancer, Frail elderly, Screening MeSH Terms: none |