Colorectal Cancer Screening in the Older Adult: A Case-Based Approach 58 Brijen J. Shah and Sita Chokhavatia Questions and Answers 1. A 77-year-old female with type 2 diabetes, end-stage renal disease on dialysis, and heart failure (EF 45%) is referred by her primary physician for colon cancer screening. She is asymptomatic and has never been screened for colon cancer. She walks with a walker and lives alone but has a home health aide 12 h a day. Her daughter, who has accompanied her, notes that her short-term memory and ability to remember is less in the last few years. Which of the following is NOT part of shared decision-making about screening for colon cancer in this patient? a. Patient preferences b. Life expectancy c. Age-speciﬁc mortality d.Ability to undergo surgery and chemotherapy if cancer were found Answer: d This is a 77-year-old patient who has never been screened. According to the US Preventive Services Task Force, for patients between 75 and 85 years of age, screening decision should be individualized based on comorbidities. The framework provided by Walter and Covinsky uses patient preferences, life expectancy, and age-speciﬁc mortality to derive a risk of dying from colon cancer to help make a screening decision, in addition to the harms/ beneﬁts of the screening examination. This patient’s heart failure and ESRD will likely shorten her life expectancy more than the risk of death from colon cancer. When calculating her life expectancy, her comorbidities place her in the lowest 25th percentile for her age. Although it is important to think about what would need to be done if a cancer is found, this concept is not part of the framework and can be discussed with the patient and family after the examination. The learning point in this question is to recall the elements of the Walter/Covinsky model to help justify the need to not offer screening. 2. For a male patient 85 years old, with coronary artery disease, hypertension, history of transient ischemic attack and chronic kidney disease, stage 4, what is the risk of death from colorectal cancer? Use the tables provided in the text as a reference. a. 1.6% b. 6.8% c. 0.8% d. 2.7% Answer: c This patient’s advanced kidney disease and coronary artery disease place her in the lower quartile of health compared to her peers. Stage 4 kidney disease is advanced and she is close to initiation of renal replacement therapy. Using Table 58.2, ﬁnd the 85–89-year-old age group and the third row in that cell represents data for the lowest quartile of health. His life expectancy is 2.2 years and his risk of colon cancer death is 0.8% per year. With such a short life expectancy given his age, gender and comorbidities, a screening colonoscopy carries little beneﬁt and his advanced age and kidney disease place him at a greater chance for complications from the procedure. 3. You are obtaining consent from a 72-year-old male with coronary artery disease with a stent, hypertension, and benign prostatic hyperplasia for screening colonoscopy. As part of the consent process, he asks you about the risk of complications with the procedure. The most frequent periprocedural complication in older patients is: a. Perforation b. Cardiopulmonary complications c. Postpolypectomy bleeding d. Infection Answer: b Based on a meta-analysis, cardiopulmonary complications were the most common complication after colonoscopy followed by postpolypectomy bleeding and perforation. C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology, DOI 10.1007/978-1-4419-1623-5_58, © Springer Science+Business Media, LLC 2012 601 602 In patients with coronary artery disease with stents, attention should be paid to the management of clopidogrel. Although endoscopy is a low-risk procedure, screening examinations are elective and should not be undertaken in close proximity to recent cardiac events. For patients on clopidorgrel, it is best to wait if an intervention (polypectomy) is expected until the clopidogrel can safely be B.J. Shah and S. Chokhavatia stopped. For those with a recent MI, colonoscopy may be associated with higher risk and cardiopulmonary complications. In older patients, abdominal pain may not be the only sign for perforation and other signs such as nausea/vomiting and fever should be elicited especially if patients have impaired cognitive status, are diabetic or are on steroids.