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IIR 04-427 – HSR&D Study

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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

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.

PUBLICATIONS:

Journal Articles

  1. Kistler CE, Kirby KA, Lee D, Casadei MA, Walter LC. Long-term outcomes following positive fecal occult blood test results in older adults: benefits and burdens. Archives of internal medicine. 2011 Aug 8; 171(15):1344-51.
  2. Day LW, Walter LC, Velayos F. Colorectal cancer screening and surveillance in the elderly patient. The American journal of gastroenterology. 2011 Jul 1; 106(7):1197-206;quiz 1207.
  3. Mehta KM, Pierluissi E, Boscardin WJ, Kirby KA, Walter LC, Chren MM, Palmer RM, Counsell SR, Landefeld CS. A clinical index to stratify hospitalized older adults according to risk for new-onset disability. Journal of the American Geriatrics Society. 2011 Jul 1; 59(7):1206-16.
  4. Carlson CM, Kirby KA, Casadei MA, Partin MR, Kistler CE, Walter LC. Lack of follow-up after fecal occult blood testing in older adults: inappropriate screening or failure to follow up? Archives of internal medicine. 2011 Feb 14; 171(3):249-56.
  5. Hoffman RM, Walter LC. Colorectal cancer screening in the elderly: the need for informed decision making. Journal of general internal medicine. 2009 Dec 1; 24(12):1336-7.
  6. Walter LC, Lindquist K, Nugent S, Schult T, Lee SJ, Casadei MA, Partin MR. Impact of age and comorbidity on colorectal cancer screening among older veterans. Annals of internal medicine. 2009 Apr 7; 150(7):465-73.
  7. Carey EC, Covinsky KE, Lui LY, Eng C, Sands LP, Walter LC. Prediction of mortality in community-living frail elderly people with long-term care needs. Journal of the American Geriatrics Society. 2008 Jan 1; 56(1):68-75.
  8. Walter LC, Lewis CL. Maximizing informed cancer screening decisions. Archives of internal medicine. 2007 Oct 22; 167(19):2027-8.
  9. Lee SJ, Moody-Ayers SY, Landefeld CS, Walter LC, Lindquist K, Segal MR, Covinsky KE. The relationship between self-rated health and mortality in older black and white Americans. Journal of the American Geriatrics Society. 2007 Oct 1; 55(10):1624-9.
Journal Other

  1. Chang A, Walter LC. Recognizing dementia as a terminal illness in nursing home residents: Comment on "Survival and comfort after treatment of pneumonia in advanced dementia". Archives of internal medicine. 2010 Jul 12; 170(13):1107-9.
Book Chapters

  1. Walter LC. Cancer Screening in Older Adults in Geriatric Oncology. In: Patient Assessment and Treatment. New York, NY: Springer; 2009. Chapter 3. 47-70 p.
Conference Presentations

  1. Walter LC, Casadei M. Long-term outcomes following positive fecal occult blood test (FOBT) results in older adults: benefits and burdens. Paper presented at: American Geriatrics Society Annual Meeting; 2010 May 14; Orlando, FL.
  2. Walter LC. Cancer Screening in the Elderly. Paper presented at: University of California Davis School of Medicine Grand Rounds Meeting; 2010 Feb 4; Davis, CA.
  3. Walter LC. Cancer Screening in Older Adults. Paper presented at: Society of General Internal Medicine California / Hawaii Regional Annual Meeting; 2009 Oct 25; Indian Wells, CA.
  4. Walter LC. Cancer Screening in Older Adults: Outstanding Scientific Achievement for Clinical Investigation Award Plenary Presentation. Paper presented at: American Geriatrics Society Annual Meeting; 2009 May 1; Chicago, IL.
  5. Walter LC, Casadei M. Outcomes of fecal occult blood testing (FOBT) among elderly veterans. Paper presented at: American Geriatrics Society Annual Meeting; 2009 May 1; Chicago, IL.
  6. Walter LC. Targeting of Colorectal Cancer Screening to Healthy Elders. Paper presented at: RWJ Foundation Generalist Physician Faculty Scholars Program National Annual Meeting; 2008 Dec 5; Ft. Lauderdale, FL.
  7. Walter LC. Screening for Common Cancers in the Senior Adult. Paper presented at: International Society of Geriatric Oncology Annual Meeting; 2008 Oct 17; Montréal, Canada.
  8. Walter LC. Cancer Screening in the Elderly. Paper presented at: Johns Hopkins University Geriatrics Grand Rounds Assembly; 2008 Jun 27; Baltimore, MD.
  9. Walter LC. Unintended Consequences of Performance Measures in Older Adult. Paper presented at: McGill University Division of Geriatric Medicine Grand Rounds Assembly; 2008 May 6; Montréal, Canada.
  10. Walter LC, Casadei M. Lack of Follow-up After Fecal Occult Blood Testing in Older Adults: Inappropriate Screening or Failure to Follow Up? Paper presented at: American Geriatrics Society Annual Meeting; 2008 May 4; Washington, DC.
  11. Walter LC. The Benefits and Pitfalls of Screening in Very Frail Older Persons. Paper presented at: American Geriatrics Society Annual Meeting; 2008 May 3; Washington, DC.
  12. Walter LC. Using Prognosis to Guide Decisions. Paper presented at: Hospitalist Annual Conference; 2008 Apr 21; San Francisco, CA.
  13. Walter LC. Research on Cancer Screening in the Elderly. Paper presented at: Stanford University Epidemiology Research Annual Seminar; 2008 Feb 26; Palo Alto, CA.
  14. Walter LC. Cancer Screening in the Elderly: a Framework for Individualized Decisions. Paper presented at: Dartmouth Institute Research Center Seminar; 2007 Nov 19; Dartmouth, NH.
  15. Walter LC. Cancer Screening in the Elderly. Paper presented at: University of Chicago Internal Medicine Residency Program Annual Seminar Series; 2007 Oct 12; Chicago, IL.
  16. Walter LC, Lindquest K, Shult T, Nugent S, Casadei M, Partin M. Relationship of Health Status and Colorectal Cancer Screening Among Elderly Veterans. Presented at: American Geriatrics Society Annual Meeting; 2007 May 5; Seattle, WA.
  17. Walter LC, Lindquist K, Schult K, Nugent S, Casadei M, Partin M. Relationship of health status and colorectal cancer screening among elderly veterans. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 21; Toronto, Canada.


DRA: Aging, Older Veterans' Health and Care, Cancer
DRE: Diagnosis, Prevention
Keywords: Cancer, Frail elderly, Screening
MeSH Terms: none

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