Colon to Rectum
JAMA Intern Med. 2023;183(5):426−34
Association of life expectancy with surveillance colonoscopy findings and follow-up recommendations in older adults
Importance: Surveillance after prior colon polyps is the most frequent indication for colonoscopy in older adults. However, to the authors’ knowledge, the current use of surveillance colonoscopy, clinical outcomes, and follow-up recommendations in association with life expectancy, factoring in both age and comorbidities, have not been studied.
Objective: To evaluate the association of estimated life expectancy with surveillance colonoscopy findings and follow-up recommendations among older adults.
Design, setting, and participants: This registry-based cohort study used data from the New Hampshire Colonoscopy Registry (NHCR) linked with Medicare claims data and included adults in the NHCR who were older than 65 years, underwent colonoscopy for surveillance after prior polyps between April 1, 2009, and December 31, 2018, and had full Medicare Parts A and B coverage and no Medicare-managed care plan enrollment in the year prior to colonoscopy. Data were analyzed from December 2019 to March 2021.
Exposures: Life expectancy (< 5 years, 5 to < 10 years, or ≥ 10 years), estimated using a validated prediction model.
Main outcomes and measures: The main outcomes were clinical findings of colon polyps or colorectal cancer and recommendations for future colonoscopy.
Results: Among 9831 adults included in the study, the mean (SD) age was 73.2 (5.0) years and 5285 (53.8%) were male. A total of 5649 patients (57.5%) had an estimated life expectancy of ≥ 10 years, 3443 (35.0%) of 5 to < 10 years, and 739 (7.5%) of < 5 years. Overall, 791 patients (8.0%) had advanced polyps (768 [7.8%]) or colorectal cancer (23 [0.2%]). Among the 5281 patients with available recommendations (53.7%), 4588 (86.9%) were recommended to return for future colonoscopy. Those with longer life expectancy or more advanced clinical findings were more likely to be told to return. For example, among patients with no polyps or only small hyperplastic polyps, 132 of 227 (58.1%) with life ex-pectancy of < 5 years were told to return for future surveillance colonoscopy versus 940 of 1257 (74.8%) with life expectancy of 5 to < 10 years and 2163 of 2272 (95.2%) with life expectancy of ≥ 10 years (p < 0.001).
Conclusions and relevance: In this cohort study, the likelihood of finding advanced polyps and colorectal cancer on surveillance colonoscopy was low regardless of life expectancy. Despite this observation, 58.1% of older adults with < 5 years’ life expectancy were recommended to return for future surveillance colonoscopy. These data may help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps.