58 Colorectal Cancer Screening in the Older Adult: A Case-Based Approach

Colorectal Cancer Screening in the
Older Adult: A Case-Based Approach
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
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.