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The Effect of Age and Chronic Illness on Life Expectancy after a Diagnosis of Colorectal Cancer: Implications for Screening

Cary P. Gross, MD; Gail J. McAvay, PhD; Harlan M. Krumholz, MD; A. David Paltiel, PhD; Devina Bhasin, MD; and Mary E. Tinetti, MD
[+] Article and Author Information

From the Robert Wood Johnson Clinical Scholars Program and Yale University School of Medicine, New Haven, Connecticut.


Disclaimer: Although this study used the linked SEER–Medicare database, the interpretation and reporting of these data are solely the authors' responsibility.

Acknowledgments: The authors acknowledge the efforts of the Applied Research Program, National Cancer Institute; the Office of Research, Development and Information, Centers for Medicare & Medicaid Services; Information Management Services, Inc.; and the SEER Program tumor registries in the creation of the SEER–Medicare database.

Grant Support: Dr. Gross was supported by a Beeson Career Development Award (1 K08 AG24842) and by the Claude D. Pepper Older Americans Independence Center at Yale (P30AG21342).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Cary P. Gross, MD, Primary Care Center, Yale University School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT 06520; e-mail, cary.gross@yale.edu.

Current Author Addresses: Drs. Gross and Bhasin: Primary Care Center, Yale University School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT 06520.

Drs. McAvay and Tinetti: Yale University Program on Aging, 333 Cedar Street, New Haven, CT 06520.

Dr. Krumholz: Yale University School of Medicine, Sterling Hall of Medicine (SHM), Room IE-61, 333 Cedar Street, PO Box 208088, New Haven, CT 06520-8088.

Dr. Paltiel: Laboratory of Epidemiology and Public Health, Yale University School of Medicine, Room 3050, 333 Cedar Street, New Haven, CT 06520.

Author Contributions: Conception and design: C.P. Gross, G.J. McAvay, M.E. Tinetti.

Analysis and interpretation of the data: C.P. Gross, G.J. McAvay, H.M. Krumholz, A.D. Paltiel, D. Bhasin.

Drafting of the article: C.P. Gross, G.J. McAvay, D. Bhasin.

Critical revision of the article for important intellectual content: G.J. McAvay, H.M. Krumholz, A.D. Paltiel, M.E. Tinetti.

Final approval of the article: C.P. Gross, H.M. Krumholz, A.D. Paltiel, M.E. Tinetti.

Statistical expertise: C.P. Gross, G.J. McAvay.

Obtaining of funding: C.P. Gross.

Collection and assembly of data: C.P. Gross.


Ann Intern Med. 2006;145(9):646-653. doi:10.7326/0003-4819-145-9-200611070-00006
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We found a strong relationship between chronic illness and life expectancy after cancer diagnosis. The relationship was strongest among patients who received a diagnosis of early-stage cancer. We also found substantial variation in life expectancy after a diagnosis of stage I colorectal cancer among older persons. Patients with several chronic conditions had a substantially lower gain in life expectancy associated with early-stage cancer at diagnosis than did their counterparts without such conditions. For instance, a 75-year-old woman with no chronic conditions had a life expectancy of more than 15 years after a stage I cancer diagnosis. If she had 3 or more conditions, however, her life expectancy was approximately 5 years and her benefit from screening would be marginal. This is because she would be unlikely to survive to the point (approximately 4 years) where, in clinical trials of screening, patients randomly assigned to screening had a lower colorectal cancer mortality rate than unscreened participants. These findings suggest that physicians must consider the burden of chronic illness in conjunction with age to estimate the benefits associated with an early diagnosis of colorectal cancer.

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Figures

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Figure 1.
Study flow diagram.

*Patients could have more than one reason for exclusion from the study sample. †During 2-year period before cancer diagnosis.

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Appendix Figure.
Length of follow-up after cancer diagnosis.
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Figure 2.
Life expectancy after diagnosis of colorectal cancer at age 67 years according to cancer stage and number of chronic conditions.
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Figure 3.
Life expectancy after stage I cancer diagnosis according to age, number of chronic conditions, and sex.
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Life expectancy and colorectal cancer screening
Posted on November 10, 2006
Robert C Burack
Wayne State University
Conflict of Interest: None Declared

To the editor:

Gross et al provide important information demonstrating the anticipated reduction in life expectancy that accompanies advancing age and higher co-morbidity burden among patients newly diagnosed with colorectal cancer.(1) While their observations may be particularly informative in considering treatment options following the diagnosis of colorectal cancer, the direct relevance of their observations to decision- making about screening is somewhat more complex. If the benefit of endoscopic screening for colorectal cancer derives from earlier diagnosis of cancer, then life expectancy at the time of diagnosis is particularly relevant. However, to the extent that the endoscopy offers benefit through the identification and removal of colorectal polyps among patients free of colorectal cancer, decisions about screening might better reflect consideration of life expectancy among individuals without colorectal cancer. While the issues of advancing age and co-morbidity are still quite relevant (2;3) it would be of interest to know the extent to which the estimates of Gross et al are sensitive to the presence of colorectal cancer.

References

(1) Gross CP, McAvay GJ, Krumholz HM, Paltiel AD, Bhasin D, Tinetti ME. The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening. Ann Intern Med. 2006;145:646-53.

(2) Lin OS, Kozarek RA, Schembre DB, Ayub K, Gluck M, Drennan F et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295:2357-65.

(3) Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285:2750-2756.

Conflict of Interest:

None declared

Life expectancy and colorectal cancer screening
Posted on February 13, 2007
Cary P Gross
yale
Conflict of Interest: None Declared

The authors reply to Dr. Burack

Colorectal cancer screening can benefit patients through two mechanisms. First, a screening colonoscopy will increase the likelihood of early stage diagnosis among patients with prevalent disease.(1) Because of the slow-growing nature of colorectal cancer, clinical benefits of this "stage-shift" take years to accrue.(1, 2) This is because the colorectal cancer survival benefit is due to detection and treatment of early stage cancers "“ cancers that otherwise would not have resulted in death for at least 5 years. Hence, further understanding of life expectancy after early stage diagnosis should inform decision making about screening by identifying patients unlikely to live long enough to receive this benefit.(3) Second, as Dr. Burack emphasizes, colorectal cancer screening can also benefit patients by removing pre-cancerous lesions, and decreasing the incidence of colorectal cancer. However, it is important to note that the interval between onset of an adenoma and the clinical diagnosis of cancer has been estimated to be as long as 20 years.(4) Trial data support these estimates. The Minnesota Colon Cancer Control Study randomized over 46,000 patients to fecal occult blood testing (FOBT) or a control group.(1) Patients randomized to the annual FOBT group experienced significantly lower colorectal cancer mortality (0.59% vs.0.88% in the control group) after 13 years of follow-up; patients in the FOBT were more likely to be diagnosed with early stage disease.(1) Yet differences in incidence took longer to accrue. While there was no significant difference in incidence rates at 13 years, after 18 years there was a significantly lower incidence rate in the annual FOBT group (3.2%) than in the control group (3.9%; P<0.001).(5) Given that the clinical benefits of "˜stage shift' may be noted in as little as 5 yeaRs, while that of adenoma removal may take 15 years or longer, we feel that the shorter-term interval should guide decision-making. We agree further work is needed to explore factors associated with life expectancy in the cancer-free population. While this analysis was beyond the scope of our study, it is notable that the relative survival of early stage colon cancer approaches 90%.(6) Therefore, although one would not expect substantial differences in life expectancy estimates between early stage colorectal cancer patients and those without cancer, empiric analyses should validate this assumption.

- Cary Gross, Gail McAvay, Mary Tinetti.

1. Mandel J, Bond J, Church T. Reducing mortality from colorectal cancer by screening for fecal occult blood. N Engl J Med. 1993;328:1365- 71.

2. Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet. 1996;348(9040):1467-71.

3. Gross CP, McAvay GJ, Krumholz HM, Paltiel AD, Bhasin D, Tinetti ME. The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening. Ann Intern Med. 2006;145(9):646-53.

4. Loeve F, Boer R, van Oortmarssen GJ, van Ballegooijen M, Habbema JD. The MISCAN-COLON simulation model for the evaluation of colorectal cancer screening. Comput Biomed Res. 1999;32(1):13-33.

5. Mandel JS, Church TR, Bond JH, et al. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med. 2000;343(22):1603-7.

6. Ries L, Eisner M, Kosary C, et al. (National Cancer Institute). SEER Cancer Statistics Review, 1975-2000. 2003.

Conflict of Interest:

None declared

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Summary for Patients

Age, Chronic Illness, and Life Expectancy after a Diagnosis of Colorectal Cancer

The summary below is from the full report titled “The Effect of Age and Chronic Illness on Life Expectancy after a Diagnosis of Colorectal Cancer: Implications for Screening.” It is in the 7 November 2006 issue of Annals of Internal Medicine (volume 145, pages 646-653). The authors are C.P. Gross, G.J. McAvay, H.M. Krumholz, A.D. Paltiel, D. Bhasin, and M.E. Tinetti.

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