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):
It is unclear to what extent colorectal cancer screening is actually targeted to healthy elderly veterans and avoided in unhealthy elderly veterans with limited life expectancies. Therefore, the aims 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 expectancies do not receive screening and why some unhealthy elderly veterans with limited life expectancies 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:
This is a cohort study of 49,658 veterans aged 70 years or older at the start of 2001 who used the Minneapolis, Durham, Portland, or Greater Los Angeles Healthcare System VAMCs during 2001-2002. This cohort is included in the Colorectal Cancer Screening and Follow-up Data System at the Minneapolis Colorectal Cancer QUERI, which has extracted data related to colorectal cancer screening and follow-up from each VAMC’s VISTA system, from National Austin data files, and from Medicare.
FINDINGS/RESULTS:
This project was initiated on January 1, 2006. We have completed the data collection and analyses for Aim 1 and have begun analyzing outcomes data for Aims 2 and 3. We found that 42% of the 26,677 screen-eligible veterans aged >/= 70 years were screened for colorectal cancer during 2001-2002. Although screening rates decreased with advancing age, within each 5-year age group the percentage of veterans screened did not decline with worsening health. Among elderly veterans who were screened, 74% had fecal occult blood testing (FOBT), 15% had colonoscopy, 9% had sigmoidoscopy, and 2% had a barium enema. Of the 4,414 veterans screened with FOBT at the 4 VAs, 10% had a positive FOBT result. Among those with a positive result only 23% received a follow-up test in the next 6 months. Age and health did not impact rates of follow-up except worsening health was associated with decreased follow-up in veterans aged 70-74. Reasons for lack of follow-up included: the patients poor health or preference (13%); notes indicated a plan for colonoscopy but no reason why it was not performed (31%); notes lacked any acknowledgement of positive FOBT (50%).
IMPACT:
There is considerable uncertainty about optimal colorectal cancer screening strategies for elderly veterans. Understanding how clinicians are targeting screening among elderly veterans and the outcomes associated with these screening decisions are critical to improving colorectal cancer screening decisions in older veterans as well as to improving national screening guidelines and VA performance measures in this area. Our findings to date suggest the need for system changes which facilitate follow-up of positive FOBT results and emphasize that clinicians should decide on whether they would pursue colonoscopy before ordering screening FOBT.
PUBLICATIONS:
Journal Articles
- Walter LC, Lewis CL. Maximizing informed cancer screening decisions. Archives of Internal Medicine. 2007; 167(19): 2027-8.
