Louise C. Walter, MD; Karla Lindquist, MS; Sean Nugent, BA; Tammy Schult, MS; Sei J. Lee, MD, MAS; Michele A. Casadei, BS; Melissa R. Partin, PhD
The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment.
To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies of 5 years or less.
Veterans Affairs (VA) medical centers in Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California, with linked national VA and Medicare administrative claims.
27Â 068 patients 70 years or older who had an outpatient visit at 1 of 4 VA medical centers in 2001 or 2002 and were due for screening.
The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema in 2001 or 2002, on the basis of national VA and Medicare claims. Charlsonâ€“Deyo comorbidity scores at the start of 2001 were used to stratify patients into 3 groups ranging from no comorbidity (score of 0) to severe comorbidity (score â‰¥4), and 5-year mortality was determined for each group.
46% of patients were screened from 2001 through 2002. Only 47% of patients with no comorbidity were screened despite having life expectancies greater than 5 years (5-year mortality, 19%). Although the incidence of screening decreased with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies less than 5 years (5-year mortality, 55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and 4 or more visits had screening rates similar to or higher than those of healthier patients with fewer visits.
Some tests may have been performed for nonscreening reasons. The generalizability of findings to persons who do not use the VA system is uncertain.
Advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies.
VA Health Services Research and Development.
Guidelines increasingly state that screening for cancer should be targeted to people who will live long enough to benefit from it.
The investigators studied receipt of colorectal cancer screening in 27 068 screen-eligible VA patients 70 years or older. Only 47% of patients with no comorbidity (5-year mortality rate, 19%) were screened, whereas 41% with severe comorbidity (5-year mortality rate, 55%) were screened. Rates were somewhat lower for older men but varied only slightly by life expectancy.
Some tests may have been done for diagnosis rather than screening.
In this population of elderly men, screening did not target healthier patients.
Eligibility criteria included having been seen in an outpatient clinic at 1 of 4 Veterans Affairs (VA) centers between 1 January 2001 and 31 December 2002, which indicated that the VA was at least partially responsible for medical care, but data on colorectal cancer screening were gathered during the entire 2-year screening interval from both national VA and Medicare claims. Additional eligibility criteria included having at least 1 outpatient visit between 1 January and 31 December 2000 to define comorbidity as of 1 January 2001.
* Defined by searching VA and Medicare inpatient and outpatient claims before 1 January 2001, dating as far back as 1 October 1992 for VA claims and 1 January 1999 for Medicare claims.
Within each age group, screening incidence decreased only a small amount as comorbidity worsened. The lines illustrate the relatively flat incidence of screening among patients with no comorbidity, average comorbidity, and severe comorbidity for each age group. If screening was targeted to older patients with substantial life expectancies and away from those with severe comorbidity, all lines would start much higher and slope down more steeply.
Number of visits was defined by the number of visits between 1 January 2001 and 31 December 2002 to Veterans Affairs primary care, gastroenterology, or general surgery clinics (clinic codes 301, 303, 305, 306, 307, 309, 312, 321 to 323, and 401).
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Sezione di Chimica Clinica e Microscopia Clinica
April 14, 2009
Hemoglobin values and age are significant predictors of positive faecal occult blood test.
TO THE EDITOR:
Population based mass screening for colorectal cancer (CRC) has been a matter of debate for decades (1). We read with interest the article of Walter et al, who concluded that advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor, so that more attention to comorbidity is needed to better target screening (2). In order to establish the main determinants of positive tests for CRC screening at our laboratory, we retrieved results of faecal occult blood tests (FOBT) performed at the Laboratory Medicine department of the University Hospital of Verona, which serves an area with a population of 270,000 inhabitants and a hospital with 750 beds and specialized care units. Results of FOBT tests performed between March 2007 and March 2009 were retrieved from the databases of our Laboratory Information System for 886 outpatients, excluding subjects who underwent this testing for non-screening reasons, as indicated by cancer-specific medications, diagnoses, and procedures. Overall, we identified 306 positive FOBT tests (35%). In multivariate linear regression analysis, age (standardized beta coefficient=0.178; p=0.004) and hemoglobin values (standardized beta coefficient=-0.313; p<0.001), but not sex (standardized beta coefficient = -0.099; p=0.781), were significant predictors of FOBT positive test. After stratifying the study population according to the hemoglobin thresholds for anemia (<132 g/L in men and <122 g/L in women) (3), the prevalence of positive tests was significantly higher among anemic subjects (86% versus 55%; p<0.001 by Ã·2 test). Taken together our results further support the suggestion of Walter et al, that CRC screening should be better targeted among older patients by considering comorbidity. Moreover, we have also shown that unexplained anemia is an important determinant of positive FOBT tests, especially among older subjects, so that more attention to this condition is needed to guide CRC screening.
1. Lippi G, Brocco G, Guidi GC. The appropriateness of colorectal cancer screening by fecal occult blood tests. Am J Gastroenterol. 2008;103:800-1.
2. Walter LC, Lindquist K, Nugent S, Schult T, Lee SJ, Casadei MA, Partin MR. Impact of age and comorbidity on colorectal cancer screening among older veterans. Ann Intern Med. 2009;150:465-73.
3. Beutler E, Waalen J. The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration? Blood. 2006;107:1747-50.
Researcher, Quantum-Biophysical Semeiotics
April 15, 2009
Colon Cancer Oncological Terrain-Dependent Inherited Real Risk
The paper's conclusions were that advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor. More attention to comorbidity is needed, to better target screening for older patients with substantial life expectancies and avoid screening older patients with limited life expectancies. I fear that neither the Editors of Annals of Internal Medicine nor the authors know that Oncological Terrain as well as Colon Cancer Oncological Terrain- Dependent Inherited Real Risk, conditio sine qua non of colon cancer, do really exist. Why do doctors have to prescribe colon cancer screening if these congenital pathological conditions, recognized since birth, are absent? (1-7).
References. 1. Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Roma, 2004. www.travelfactory.it
2. Stagnaro S. Newborn-pathological Endoarteriolar Blocking Devices in Diabetic and Dislipidaemic Constitution and Diabetes Primary Prevention. The Lancet. March 06 2007. http://www.thelancet.com/journals/lancet/article/PIIS0140673607603316/comments?totalcomments=1
3. Stagnaro S. Rimodellamento Microvascolare, Costituzioni Semeiotico - Biofisiche e Reale Rischio Semeiotico-Biofisico. Ruolo dei Dispositivi Endoarteriolari di Blocco neoformati-patologici www.clicmedicina.it, 10/4/2007, http://www.clicmedicina.it/pagine%20n%2028/rimodellamento.htm
4. Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico- Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Ed. Travel Factory, Roma, 2004. http://www.travelfactory.it/
5. 1Stagnaro S., Stagnaro-Neri M., Oncological Terrain, conditio sine qua non of Oncogenesis, 2004: http://www.gutjnl.com/cgi/eletters?lookup=by_date&days=60
6. Stagnaro Sergio. Bed-Side Prostate Cancer Detecting, even in early stages ("Real Risk" of Cancer): BMC Family Practice, 2005, 6:24 doi:10.1186/1471-2296-6-24 http://www.biomedcentral.com/1471- 2296/6/24/comments#202466
7. Stagnaro Sergio. Clinical tool reliable in bedside early recognizing pancreas tumour, both benign and malignant. World Journal of Surgical Oncology 2005, 3:62 doi:10.1186/1477-7819-3-62; http://www.wjso.com/content/3/1/62/comments
Xijing Hospital, Fourth Military Medical University
April 24, 2009
The effect of race and gender on colorectal cancer screening among older veterans
To the editor:
We read carefully the study by Walter LC and his collegues . They made a conclusion that advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor. Since they were studying veterans, the patients were predominantly men (96%), and extrapolation of their findings to women must be done with caution. In addition, 87% of the subjects were white. Could the authors comment on the effect of race on colorectal cancer screening among older veterans?
1 Walter LC, Lindquist K, Nugent S, Schult T, Lee SJ, Casadei MA, Partin MR. Impact of age and comorbidity on colorectal cancer screening among older veterans. Ann Intern Med. 2009;150:465-73.
Walter LC, Lindquist K, Nugent S, Schult T, Lee SJ, Casadei MA, et al. Impact of Age and Comorbidity on Colorectal Cancer Screening Among Older Veterans. Ann Intern Med. ;150:465–473. doi: 10.7326/0003-4819-150-7-200904070-00006
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Published: Ann Intern Med. 2009;150(7):465-473.
Cancer Screening/Prevention, Colorectal Cancer, Gastroenterology/Hepatology, Gastrointestinal Cancer, Hematology/Oncology.
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