Colorectal Cancer Screening in Elderly African-American Patients

Abstract

The study by Smoot DT et al. [1] is an interesting study highlighting the outcome of colonoscopy in elderly African-American patients. The study included 922 elderly patients who underwent colonoscopy; the predominance of females in the study, i.e. 67.7% female vs. 32.4% male, is not discussed. Females are known to have lower incidence of colorectal cancer (CRC) [2] irrespective of race, but the study has shown a higher incidence of CRC 29/623 (4.6%) as compared to males 13/299 (4.4%). Further, the patients are classified into average and high risk groups based on indication of colonoscopy. In the high risk group, inclusion of the subjects with a personal history of CRC is likely to affect the results as the recurrence rates of colon cancer are high and variable depending on the stage and treatment of colon cancer. The United States Preventive Services Task Force (USPSTF) recommends against routine screening for CRC in adults 76–85 years of age [3]. The considerations that support CRC screening in an individual patient are not clear. Thus, decision to recommend CRC in this subgroup depends on multiple factors. The study has highlighted certain factors such as blood in stools to have a high predictive value for CRC. There are multiple other factors which have a potential impact on colonoscopy outcomes in elderly. The results of previous colonoscopies definitely affect rescreening decisions [4], but the interval from previous colonoscopy should be considered when making the decision to repeat the examination. Similarly, advance age and co-morbidities have shown to adversely affect bowel preparation. The study by Smoot et al. [1] fails to provide information about the previous colonoscopy results/interval/bowel preparation/completion rates. It has been reported that risk of adverse events increases with age and with specific co-morbid conditions [5]; thus, this factor needs to be taken into account when making a decision. Another approach can be screening of selected individuals with non-invasive tests, such as the immunochemical occult-blood test, which has a fair sensitivity of 60–85% for colon cancer, followed by colonoscopy wherever indicated. As in countries like the United Kingdom, Italy and Norway offering flexible sigmoidoscopy as a screening tool can be considered in this subgroup [6]. The benefits of detecting CRC early is the mainstay of our efforts to offer screening. The outcome of CRC depends on the stage of diagnosis. Co-existing chronic illness is associated with a substantial reduction in life expectancy after diagnosis of early-stage CRC, and also affects the tolerance to various therapies [7]. Thus, elderly patients with multiple co-morbidities and limited life expectancy are unlikely to be treatment candidates and thus have questionable benefit from screening colonoscopy. The information about the co-morbidities and stage of CRC is not included in this study; hence, it is difficult to comment on the impact of diagnosing cancers in the study. S. Singhal (&) Gastroenterology, Department of Internal Medicine, Chicago Medical School at Rosalind Franklin University, North Chicago, IL, USA e-mail: sdsinghal@gmail.com