The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment.
To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies < 5 years.
Minneapolis, Durham, Portland, and West LA VA’s with linked national VA and Medicare administrative claims.
27,068 patients > 70 years who had an outpatient visit in 2000 and an outpatient visit at 1 of 4 VA’s during 2001–2002 and due for screening.
The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema during 2001–2002 based on national VA and Medicare claims. Charlson comorbidity scores were used to stratify patients into 3 groups ranging from no comorbidity (score=0) to severe comorbidity (score > 4) and 5-year mortality was determined for each group.
46% of patients were screened during 2001–2002. Only 47% of patients with no comorbidity were screened despite having life expectancies > 5 years (5-year mortality=19%). While the incidence of screening declined with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies < 5 years (5-year mortality=55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and > 4 visits had similar or higher screening rates than healthier patients with fewer visits.
Some tests may have been performed for non-screening reasons. The generalizability of findings to persons who do not use the VA is uncertain.
Advancing age was inversely associated with colorectal cancer screening while comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies.