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Commentary

What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older?

1
Department of Surgery, Division of General Surgery, University of Toronto, University Health Network, Toronto, ON M5T 2S8, Canada
2
Department of Surgery, Division of General Surgery, University of Toronto, Toronto, ON M5N 3M5, Canada
3
Department of Surgery, Division of General Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada
4
Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada
*
Author to whom correspondence should be addressed.
Submission received: 8 June 2021 / Revised: 30 June 2021 / Accepted: 6 July 2021 / Published: 9 July 2021

Abstract

:
The current recommendation to stop colorectal cancer screening for older adults is based on a lack of evidence due to systematic exclusion of this population from trials. Older adults are a heterogenous population with many available strategies for patient-centered assessment and decision-making. Evolutions in management strategies for colorectal cancer have made safe and effective options available to older adults, and the rationale to screen for treatable disease more reasonably, especially given the aging Canadian population. In this commentary, we review the current screening guidelines and the evidence upon which they were built, the unique considerations for screening older adults, new treatment options, the risks and benefits of increased screening and potential considerations for the new guidelines.

1. Are Older Adults Represented in Current Colorectal Cancer Screening Guidelines?

Colorectal cancer screening recommendations in Canada currently recommend not to screen adults aged 75 and older; however, over half of colorectal cancer deaths are expected to occur in patients older than this [1,2]. With longer and healthier living, the number of older adults with colon cancer is rising, comprising the greatest proportion of new colon cancers—now one of the most common cancers in those older than 75 years [1,3,4,5,6]. Considerable efforts have focused on tailoring treatment approaches for older adults with colorectal cancer by considering the heterogeneity of health statuses in older adults highlighted by the concepts of physiologic age and frailty [7,8,9,10,11]. Furthermore, advancements in minimally invasive surgical and endoscopic techniques offer added benefits for older adults [12,13,14]. Current guidelines do not reflect these important considerations unique to older adults. In fact, most trials investigating colorectal cancer screening have systematically excluded older adults. Here, we discuss how these unique considerations for older adults should be reflected in updated screening guidelines for colorectal cancer.

2. What Evidence Was Used to Generate Current Guideline Recommendations?

Current screening guidelines are based on the absence of a demonstrated benefit in adults aged 75 and older [2]. This absence is not due to a conclusive demonstration that screening lacks benefit in this age group, but rather represents a gap in knowledge due to systematic exclusion of older adults from available studies on which screening recommendations are based (Table 1). No justification is given for the exclusion of older adults. Studies demonstrating benefit of colonoscopy or flexible sigmoidoscopy for screening mostly excluded patients between the ages of 50 and 54, but screening of these patients using these tests is still recommended. The systematic exclusion of older adults is unfortunately common, and strategic recommendations aim to remedy this gap [15,16,17]. Despite the paucity of evidence available to make recommendations due to systematic exclusion of older adults from studies investigating colorectal cancer screening strategies, the authors of the current guidelines chose to recommend not screening in the age group. Other guideline groups have given conditional recommendations to individualize screening decisions but provide little advice on how this should be carried out [18,19,20,21].

3. What Unique Considerations Are Needed When Assessing Older Adults for Screening?

Recommendations to stop screening beyond age 75 are partly based on reduced life expectancy [2]. Current screening recommendations in older adults do not address the impact of comorbidity, functional status, frailty, and life expectancy, which varies widely among older adults. For example, in a population-based study including 35,755 patients, adults aged 80 or older with no comorbidities had life expectancies greater than 10 years after a diagnosis of stage I colon cancer [33]. Other guidelines specific to the care of older adults recommend older adult-specific assessments to guide shared decision-making [10,11,34,35]. While the comprehensive geriatric assessment is the reference standard process to determine multidimensional health status and develop integrated management plans for older adults, this is not feasible for all older adults and abbreviated screening strategies are advocated [36,37]. This strategy recognizes that an individual’s health status is better understood as multidimensional, including physical, functional, cognitive, and social elements rather than chronologic age alone [7,8]. Many suggested screening tools aim to identify frailty, a state of vulnerability to stressors and increased risk of adverse health outcomes due to multisystem decline in physiologic reserve and function [9,38,39]. Some helpful and commonly used tools that can be used quickly by non-geriatricians include the G8, the clinical frailty scale (CFS), and the vulnerable elders survey-13 (VES-13) [37,40,41,42]. Additionally, decision-support aids are available through ePrognosis (San Francisco, CA, USA), QCancer® (UK), and www.screeningdecision.com (Michigan, MI, USA) (accessed on 1 November 2020) for estimating life expectancy, risk of developing colorectal cancer, and risks and harms of screening [43,44,45,46]. As with the approach suggested for surveillance after polypectomy, this more fulsome assessment of an individual’s health status can be used to appropriately tailor screening decisions through shared decision-making to elicit preferences and values and generate individual screening recommendations [47].

4. How Should the Evolution of Treatment Options Impact Screening Recommendations?

Screening recommendations should also consider the availability of safe and effective treatments for an identified disease. Substantial advancements have been made in tailoring treatment approaches for older adults with colorectal cancer [10,11,48]. Advancements include incorporating geriatric-specific assessments and outcomes of importance, along with evidence focused specifically on older adults with colorectal cancer to aid treatment planning. One example is the rising technical capacity and availability of advanced minimally invasive surgery and therapeutic endoscopy [49,50]. These techniques include laparoscopic surgery, transanal local excisions with advanced platforms, and advanced endoscopic techniques including endoscopic submucosal dissection and full thickness resection [51,52,53,54,55,56]. Several studies have shown excellent outcomes for older adults undergoing laparoscopic surgery compared to open surgery, with similar oncologic outcomes [12,13,14,57,58,59]. Similarly, the understanding of nonsurgical treatments alone or in combination with surgery for older adults has grown [60,61,62,63,64,65]. Approaches may include local excision combined with adjuvant treatment, or even the avoidance of surgery all together [66,67,68]. While many older adults may safely undergo standard treatments, several modifications are now available based on an overall multidimensional health assessment to guide treatment choices [69,70,71,72]. With this tailored approach to older adults with colorectal cancer, excellent goal-concordant outcomes can be achieved [73,74].

5. What Are the Risks and Benefits of Increased Screening?

Certainly, the risks of screening must also be considered. Invasive tests such as colonoscopy appear to have some risk of perforation, bleeding, cardiovascular and pulmonary complications [75]. In contrast, stool-based tests such as fecal immunochemical testing (FIT) are non-invasive and can be safely carried out by older adults [2]. Potential risks of FIT include possible false-positive tests which can increase psychological stress and require further invasive testing [76]. There is potential for overdiagnosis due to a time lag to the benefit of 4.8 years, but this suggests that screening could be continued for older adults with life expectancies greater than this [77]. Patients without screening can present with symptoms such as pain, obstruction, perforation, or bleeding, with much greater risks of treatment in an emergency setting [78,79]. A strategy that carefully balances the risks and benefits of screening based on comprehensive assessment and understanding of tailored treatment approaches is needed.

6. What Should Be Considered in New Guidelines?

Considerable work has been carried out to enable individualization of screening recommendations for older adults, but so far, this work has not been included by guideline authors [80,81]. General strategies use age and comorbidities to tailor estimates of life expectancy and the potential benefit of screening [80,82]. Incorporating cancer risk, screening history, and comorbidities could make screening cost-effective [83,84]. This approach can be operationalized with tools such as ePrognosis (San Francisco, CA, USA), QCancer® (UK), and www.screeningdecision.com (Michigan, MI, USA) [43,44,45,46]. Furthermore, communication about prognosis and the cessation of screening should be carefully considered [85,86,87]. Most patients and clinicians prefer the discussion of screening cessation to be framed around overall health status and changing health priorities, while only some feel that an explicit mention of life expectancy was needed using phrases such as “this test would not help you live longer” [88,89]. However, no studies have explored the preferences and values of older adults regarding noninvasive screening and the avoidance of other outcomes such as symptomatic bleeding, obstruction, and emergency surgery.

7. Conclusions

Guideline recommendations for colorectal cancer screening in adults aged 75 and older must incorporate considerations unique to this age group. Recommendations to not screen adults in this age group were generated based on a lack of knowledge resulting from systematic exclusion of older patients from trials. This recommendation is not justified. Considerable advancements in tailoring treatment approaches for this age group such as minimally invasive surgical and endoscopic treatments and nonoperative treatments should be considered in making screening recommendations. A recommendation for individualized screening is much more justified. This recommendation should also contain detailed advice and guidance on individualization including specific assessment of overall health status combined with shared decision-making to generate a recommendation integrating individual preferences and values. Further studies should evaluate strategies to personalize screening recommendations specific to older adults and investigate the outcomes of most importance to them.

Author Contributions

Conceptualization, A.A. and T.C.; formal analysis, A.A., S.A.C. and T.C.; writing—original draft preparation, A.A.; writing—review and editing, A.A., S.A.C. and T.C. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics; Canadian Cancer Society: Toronto, ON, Canada, 2018; Available online: cancer.ca/Canadian-Cancer-Statistics-2018-EN. (accessed on 1 November 2020).
  2. Canadian Task Force on Preventive Health Care. Canadian Colon Cancer Screening Guidelines. CMAJ 2016, 188, 1–9. [Google Scholar] [CrossRef]
  3. DeSantis, C.E.; Miller, K.D.; Dale, W.; Mohile, S.G.; Cohen, H.J.; Leach, C.R.; Goding Sauer, A.; Jemal, A.; Siegel, R.L. Cancer Statistics for Adults Aged 85 Years and Older, 2019. CA Cancer J. Clin. 2019, 69, 452–467. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  4. Population Projections for Canada Provinces and Territories; Statistics Canada: Ottawa, ON, Canada, 2009; p. 23. Available online: https://www150.statcan.gc.ca/n1/pub/91-520-x/91-520-x2010001-eng.htm (accessed on 1 November 2020).
  5. Canadian Cancer Society. Canadian Cancer Statistics Special Topic: Predictions of the Future Burden of Cancer in Canada. Public Health Agency Can. 2015, 1–151. [Google Scholar]
  6. Siegel, R.L.; Miller, K.D.; Goding Sauer, A.; Fedewa, S.A.; Butterly, L.F.; Anderson, J.C.; Cercek, A.; Smith, R.A.; Jemal, A. Colorectal Cancer Statistics, 2020. CA. Cancer J. Clin. 2020, 70, 145–164. [Google Scholar] [CrossRef] [Green Version]
  7. Decoster, L.; Vanacker, L.; Kenis, C.; Prenen, H.; Van Cutsem, E.; Van Der Auwera, J.; Van Eetvelde, E.; Van Puyvelde, K.; Flamaing, J.; Milisen, K.; et al. Relevance of Geriatric Assessment in Older Patients With Colorectal Cancer. Clin. Colorectal Cancer 2017, 16, e221–e229. [Google Scholar] [CrossRef] [PubMed]
  8. Soto-Perez-de-Celis, E.; Li, D.; Yuan, Y.; Lau, Y.M.; Hurria, A. Functional versus Chronological Age: Geriatric Assessments to Guide Decision Making in Older Patients with Cancer. Lancet Oncol. 2018, 19, e305–e316. [Google Scholar] [CrossRef]
  9. Okabe, H.; Ohsaki, T.; Ogawa, K.; Ozaki, N.; Hayashi, H.; Akahoshi, S.; Ikuta, Y.; Ogata, K.; Baba, H. The American Journal of Surgery Frailty Predicts Severe Postoperative Complications after Elective Colorectal Surgery. Am. J. Surg. 2018, 217, 677–681. [Google Scholar] [CrossRef]
  10. Papamichael, D.; Audisio, R.A.; Glimelius, B.; de Gramont, A.; Glynne-Jones, R.; Haller, D.; Köhne, C.H.; Rostoft, S.; Lemmens, V.; Mitry, E.; et al. Treatment of Colorectal Cancer in Older Patients: International Society of Geriatric Oncology (SIOG) Consensus Recommendations 2013. Ann. Oncol. 2015, 26, 463–476. [Google Scholar] [CrossRef]
  11. Montroni, I.; Ugolini, G.; Saur, N.M.; Spinelli, A.; Rostoft, S.; Millan, M.; Wolthuis, A.; Daniels, I.R.; Hompes, R.; Penna, M.; et al. Personalized Management of Elderly Patients with Rectal Cancer: Expert Recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commissi. Eur. J. Surg. Oncol. 2018, 44, 1685–1702. [Google Scholar] [CrossRef]
  12. Frasson, M.; Braga, M.D.M.; Vignali, M.D.A.; Zuliani, W.; Di Carlo, M.D.V. Benefits of Laparoscopic Colorectal Resection Are More Pronounced in Elderly Patients. Dis. Colon Rectum 2008, 300, 296–300. [Google Scholar] [CrossRef]
  13. Chesney, T.; Acuna, S.A. Do Elderly Patients Have the Most to Gain from Laparoscopic Surgery? Ann. Med. Surg. 2015, 4, 321–323. [Google Scholar] [CrossRef]
  14. Chesney, T.R.; Quereshy, H.A.; Draginov, A.; Chadi, S.A.; Quereshy, F.A. Benefits of Minimally-Invasive Surgery for Sigmoid and Rectal Cancer in Older Adults Compared with Younger Adults: Do Older Adults Have the Most to Gain? J. Geriatr. Oncol. 2020, 11, 860–865. [Google Scholar] [CrossRef] [PubMed]
  15. Mizutani, T.; Nakamura, K.; Fukuda, H.; Ogawa, A.; Hamaguchi, T.; Nagashima, F. Geriatric Research Policy: Japan Clinical Oncology Group (JCOG) Policy. JJCO Jpn. J. Clin. Oncol. 2019, 49, 901–910. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  16. Brintzenhofeszoc, K.; Krok-Schoen, J.L.; Canin, B.; Parker, I.; Mackenzie, A.R.; Koll, T.; Vankina, R.; Hsu, C.D.; Jang, B.; Pan, K.; et al. The Underreporting of Phase III Chemo-Therapeutic Clinical Trial Data of Older Patients with Cancer: A Systematic Review. J. Geriatr. Oncol. 2020, 11, 369–379. [Google Scholar] [CrossRef]
  17. Hurria, A.; Dale, W. Improving the Evidence Base for Treating Older Adults With Cancer: American Society of Clinical Oncology Statement Global Geriatric Oncology View Project Frailty and Social Vulnerability View Project. Artic. J. Clin. Oncol. 2015, 33, 3826–3833. [Google Scholar] [CrossRef]
  18. Bibbins-Domingo, K.; Grossman, D.C.; Curry, S.J.; Davidson, K.W.; Epling, J.W.; García, F.A.R.; Gillman, M.W.; Harper, D.M.; Kemper, A.R.; Krist, A.H.; et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2016, 315, 2564–2575. [Google Scholar] [CrossRef] [PubMed]
  19. Rex, D.K.; Boland, C.R.; Dominitz, J.A.; Giardiello, F.M.; Johnson, D.A.; Kaltenbach, T.; Levin, T.R.; Lieberman, D.; Robertson, D.J. Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer. Am. J. Gastroenterol. 2017, 112, 1016–1030. [Google Scholar] [CrossRef]
  20. Wolf, A.M.D.; Fontham, E.T.H.; Church, T.R.; Flowers, C.R.; Guerra, C.E.; LaMonte, S.J.; Etzioni, R.; McKenna, M.T.; Oeffinger, K.C.; Shih, Y.-C.T.; et al. Colorectal Cancer Screening for Average-Risk Adults: 2018 Guideline Update from the American Cancer Society. CA. Cancer J. Clin. 2018, 68, 250–281. [Google Scholar] [CrossRef]
  21. Helsingen, L.M.; Olav, P.; Jodal, H.C.; Agoritsas, T.; Lytvyn, L.; Anderson, J.C.; Mckinnon, A.; Qaseem, A.; Fog Heen, A.; Siemieniuk, R.A.C.; et al. Colorectal Cancer Screening with Faecal Immunochemical Testing, Sigmoidoscopy or Colonoscopy: A Clinical Practice Guideline. BMJ 2019, 367, l5515. [Google Scholar] [CrossRef] [Green Version]
  22. Jörgensen, O.D.; Kronborg, O.; Fenger, C. A Randomised Study of Screening for Colorectal Cancer Using Faecal Occult Blood Testing: Results after 13 Years and Seven Biennial Screening Rounds. Gut 2002, 50, 29–32. [Google Scholar] [CrossRef] [Green Version]
  23. Lindholm, E.; Brevinge, H.; Haglind, E. Survival Benefit in a Randomized Clinical Trial of Faecal Occult Blood Screening for Colorectal Cancer. Br. J. Surg. 2008, 95, 1029–1036. [Google Scholar] [CrossRef]
  24. Scholefield, J.H.; Moss, S.M.; Mangham, C.M.; Whynes, D.K.; Hardcastle, J.D. Nottingham Trial of Faecal Occult Blood Testing for Colorectal Cancer: A 20-Year Follow-Up. Gut 2012, 61, 1036–1040. [Google Scholar] [CrossRef] [PubMed]
  25. Shaukat, A.; Mongin, S.J.; Geisser, M.S.; Lederle, F.A.; Bond, J.H.; Mandel, J.S.; Church, T.R. Long-Term Mortality after Screening for Colorectal Cancer. N. Engl. J. Med. 2013, 369, 1106–1114. [Google Scholar] [CrossRef] [PubMed]
  26. Zheng, S.; Chen, K.; Liu, X.; Ma, X.; Yu, H.; Ph, D.; Chen, K.; Yao, K.; Zhou, L.; Wang, L.; et al. Cluster Randomization Trial of Sequence Mass Screening for Colorectal Cancer. Dis. Colon Rectum 2003, 46, 51–58. [Google Scholar] [CrossRef] [PubMed]
  27. Atkin, W.S.; Edwards, R.; Kralj-hans, I.; Wooldrage, K.; Hart, A.R.; Northover, J.M.A.; Parkin, D.M.; Wardle, J.; Duff, S.W. Once-Only Fl Exible Sigmoidoscopy Screening in Prevention of Colorectal Cancer: A Multicentre Randomised Controlled Trial. Lancet 2010, 375, 1624–1633. [Google Scholar] [CrossRef] [Green Version]
  28. Hoff, G.; Grotmol, T.; Skovlund, E.; Bretthauer, M.; Bmj, S.; Medical, B.; June, N.; Hoff, G.; Grotmol, T.; Skovlund, E.; et al. Risk of Colorectal Cancer Seven Years after Flexible Sigmoidoscopy Screening: Randomised Controlled Trial. BMJ 2020, 338, 1363–1366. [Google Scholar] [CrossRef] [Green Version]
  29. Schoen, R.E.; Pinsky, P.F.; Weissfeld, J.L.; Yokochi, L.A.; Church, T.; Laiyemo, A.O.; Bresalier, R.; Andriole, G.L.; Buys, S.S.; Crawford, E.D.; et al. Colorectal-Cancer Incidence and Mortality with Screening Flexible Sigmoidoscopy. N. Engl. J. Med. 2012, 366, 2345–2357. [Google Scholar] [CrossRef] [Green Version]
  30. Segnan, N.; Armaroli, P.; Bonelli, L.; Risio, M.; Sciallero, S.; Zappa, M.; Andreoni, B.; Arrigoni, A.; Bisanti, L.; Casella, C.; et al. Once-Only Sigmoidoscopy in Colorectal Cancer Screening: Follow-up Findings of the Italian Randomized Controlled Trial—SCORE. J. Natl. Cancer. Inst. 2011, 103, 13–15. [Google Scholar] [CrossRef] [Green Version]
  31. Bretthauer, M.; Kaminski, M.F.; Løberg, M.; Zauber, A.G.; Regula, J.; Kuipers, E.J.; Hernán, M.A.; McFadden, E.; Sunde, A.; Kalager, M.; et al. Population-Based Colonoscopy Screening for Colorectal Cancer: A Randomized Clinical Trial. JAMA Intern. Med. 2016, 176, 894–902. [Google Scholar] [CrossRef]
  32. Quintero, E.; Castells, A.; Bujanda, L. Colonoscopy versus Fecal Immunochemical Testing in Colorectal-Cancer Screening. Gastroenterol. Endosc. 2012, 54, 1510. [Google Scholar] [CrossRef] [Green Version]
  33. Gross, C.P.; McAvay, G.J.; Krumholz, H.M.; Paltiel, A.D.; Bhasin, D.; Tinetti, M.E. The Effect of Age and Chronic Illness on Life Expectancy after a Diagnosis of Colorectal Cancer: Implications for Screening. Ann. Intern. Med. 2006, 145, 646–653. [Google Scholar] [CrossRef]
  34. Mohile, S.G.; Dale, W.; Somerfield, M.R.; Schonberg, M.A.; Boyd, C.M.; Burhenn, P.S.; Canin, B.; Cohen, H.J.; Holmes, H.M.; Hopkins, J.O.; et al. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: Asco Guideline for Geriatric Oncology. J. Clin. Oncol. 2018, 36, 2326–2347. [Google Scholar] [CrossRef]
  35. Wildiers, H.; Heeren, P.; Puts, M.; Topinkova, E.; Janssen-Heijnen, M.L.G.; Extermann, M.; Falandry, C.; Artz, A.; Brain, E.; Colloca, G.; et al. International Society of Geriatric Oncology Consensus on Geriatric Assessment in Older Patients with Cancer. J. Clin. Oncol. 2014, 32, 2595–2603. [Google Scholar] [CrossRef] [Green Version]
  36. Decoster, L.; Van Puyvelde, K.; Mohile, S.; Wedding, U.; Basso, U.; Colloca, G.; Rostoft, S.; Overcash, J.; Wildiers, H.; Steer, C.; et al. Screening Tools for Multidimensional Health Problems Warranting a Geriatric Assessment in Older Cancer Patients: An Update on SIOG Recommendations. Ann. Oncol. 2015, 26, 288–300. [Google Scholar] [CrossRef]
  37. Abbasi, M.; Rolfson, D.; Khera, A.S.; Dabravolskaj, J.; Dent, E.; Xia, L. Identification and Management of Frailty in the Primary Care Setting. CMAJ 2018, 190, E1134–E1140. [Google Scholar] [CrossRef] [Green Version]
  38. Clegg. Europe PMC Funders Group Frailty in Older People. Lancet 2014, 381, 752–762. [Google Scholar] [CrossRef]
  39. Robinson, T.N.; Walston, J.D.; Brummel, N.E.; Deiner, S.; Brown, C.H., 4th; Kennedy, M.; Hurria, A. Frailty for Surgeons: Review of a National Institute on Aging Conference on Frailty for Specialists. J. Am. Coll. Surg. 2015, 221, 1083–1092. [Google Scholar] [CrossRef] [Green Version]
  40. Soubeyran, P.; Bellera, C.; Goyard, J.; Heitz, D.; Curé, H.; Rousselot, H.; Albrand, G.; Servent, V.; Jean, O.S.; van Praagh, I.; et al. Screening for Vulnerability in Older Cancer Patients: The ONCODAGE Prospective Multicenter Cohort Study. PLoS ONE 2014, 9, e115060. [Google Scholar] [CrossRef] [PubMed]
  41. Sternberg, S.A. The Vulnerable Elders Survey: A Tool for Identifying Vulnerable Older People in the Community. J. Am. Geriatr. Soc. 2003, 51, 139–140. [Google Scholar] [CrossRef] [PubMed]
  42. Church, S.; Rogers, E.; Rockwood, K.; Theou, O. A Scoping Review of the Clinical Frailty Scale. BMC Geriatr. 2020, 20, 1–18. [Google Scholar] [CrossRef] [PubMed]
  43. Yourman, L.C.; Lee, S.J.; Schonberg, M.A.; Widera, E.W.; Smith, A.K. Prognostic Indices for Older Adults. JAMA 2012, 307, 182. [Google Scholar] [CrossRef]
  44. Lee, S.; Smith, A.; Widera, E.; Yourman, L.; Schonberg, M.A.C. ePrognosis. Available online: https://eprognosis.ucsf.edu/leeschonberg.php (accessed on 26 October 2020).
  45. Saini, S.; Solomon, J. Should My Patient Get a Screening Colonoscopy: Colorectal Screening Decision Aid. Available online: http://screeningdecision.com/ (accessed on 26 October 2020).
  46. Hippisley-Cox, J.; Coupland, C. Development and Validation of Risk Prediction Algorithms to Estimate Future Risk of Common Cancers in Men and Women: Prospective Cohort Study. BMJ Open 2015, 5. [Google Scholar] [CrossRef]
  47. Maratt, J.K.; Calderwood, A.H.; Saini, S.D. When and How to Stop Surveillance Colonoscopy in Older Adults: Five Rules of Thumb for Practitioners. Am. J. Gastroenterol. 2018, 113, 5–7. [Google Scholar] [CrossRef] [Green Version]
  48. Ugolini, G.; Ghignone, F.; Zattoni, D.; Veronese, G.; Montroni, I.; Ugolini, G.; Ghignone, F.; Zattoni, D. Personalized Surgical Management of Colorectal Cancer in Elderly Population. World J. Gastroenterol. 2014, 20, 3762–3777. [Google Scholar] [CrossRef]
  49. Fox, J.; Gross, C.P.; Longo, W.; Reddy, V. Laparoscopic colectomy for the treatment of cancer has been widely adopted in the United States. Dis. Colon Rectum. 2012, 55, 501–508. [Google Scholar] [CrossRef]
  50. Keller, D.S.; Parikh, N.; Senagore, A.J. Predicting Opportunities to Increase Utilization of Laparoscopy for Colon Cancer. Surg. Endosc. 2017, 31, 1855–1862. [Google Scholar] [CrossRef] [PubMed]
  51. Colon Cancer Laparoscopic or Open Resection Study Group; Buunen, M.; Veldkamp, R.; Hop, W.C.; Kuhry, E.; Jeekel, J.; Haglind, E.; Påhlman, L.; Cuesta, M.A.; Msika, S.; et al. Survival after Laparoscopic Surgery versus Open Surgery for Colon Cancer: Long-Term Outcome of a Randomised Clinical Trial. Lancet Oncol. 2009, 10, 44–52. [Google Scholar] [CrossRef]
  52. Jayne, D.G.; Guillou, P.J.; Thorpe, H.; Quirke, P.; Copeland, J.; Smith, A.M.H.; Heath, R.M.; Brown, J.M. Randomized Trial of Laparoscopic-Assisted Resection of Colorectal Carcinoma: 3-Year Results of the UK MRC CLASICC Trial Group. J. Clin. Oncol. 2007, 25, 3061–3068. [Google Scholar] [CrossRef] [PubMed]
  53. Acuna, S.A.; Chesney, T.R.; Ramjist, J.K.; Shah, P.S.; Kennedy, E.D.; Baxter, N.N. Laparoscopic Versus Open Resection for Rectal Cancer: A Noninferiority Meta-Analysis of Quality of Surgical Resection Outcomes. Ann. Surg. 2019, 269, 849–855. [Google Scholar] [CrossRef] [PubMed]
  54. Liu, L.; Shen, X.; Zhu, J. Efficacy, Safety, and Overall Quality of Life of Endoscopic Submucosal Dissection for Early Colorectal Cancer in Elderly Patients. Gastroenterol. Res. Pract. 2017, 2017, 2386291. [Google Scholar] [CrossRef] [Green Version]
  55. Takahashi, Y.; Mizuno, K.I.; Takahashi, K.; Sato, H.; Hashimoto, S.; Takeuchi, M.; Kobayashi, M.; Yokoyama, J.; Sato, Y.; Terai, S. Long-Term Outcomes of Colorectal Endoscopic Submucosal Dissection in Elderly Patients. Int. J. Colorectal Dis. 2017, 32, 567–573. [Google Scholar] [CrossRef] [Green Version]
  56. Martin-Perez, B.; Andrade-Ribeiro, G.D.; Hunter, L.; Atallah, S. A Systematic Review of Transanal Minimally Invasive Surgery (TAMIS) from 2010 to 2013. Tech. Coloproctol. 2014, 18, 775–788. [Google Scholar] [CrossRef]
  57. Sa, L.; Jime, M. Laparoscopy-Assisted versus Open Colectomy for Treatment of Colon Cancer in the Elderly: Morbidity and Mortality Outcomes in 545 Patients. Surg. Endosc. 2014, 28, 3373–3378. [Google Scholar] [CrossRef]
  58. Law, W.L.; Edin, F.; Chu, K.W.; Edin, F.; Hiu, P.; Tung, M.; Edin, F. Laparoscopic Colorectal Resection: A Safe Option for Elderly Patients. J. Am. Coll. Surg. 2002, 7515, 768–773. [Google Scholar] [CrossRef]
  59. Troian, M.; Bellio, G.; Pasquali, A.; de Manzini, N. Laparoscopic vs Open Approach for PT3/PT4 Colorectal Cancer in the Elderly: Ten-Year Experience in a Single Center. Minerva. Chir. 2018, 73, 20e8. [Google Scholar]
  60. Iwashyna, T.J.; Lamont, E.B. Effectiveness of Adjuvant Fluorouracil in Clinical Practice: A Population-Based Cohort Study of Elderly Patients with Stage III Colon Cancer. J. Clin. Oncol. 2002, 20, 3992–3998. [Google Scholar] [CrossRef] [PubMed]
  61. Neugut, A.I.; Matasar, M.; Wang, X.; McBride, R.; Jacobson, J.S.; Tsai, W.Y.; Grann, V.R.; Hershman, D.L. Duration of Adjuvant Chemotherapy for Colon Cancer and Survival among the Elderly. J. Clin. Oncol. 2006, 24, 2368–2375. [Google Scholar] [CrossRef] [PubMed]
  62. Tournigand, C.; André, T.; Bonnetain, F.; Chibaudel, B.; Lledo, G.; Hickish, T.; Tabernero, J.; Boni, C.; Bachet, J.B.; Teixeira, L.; et al. Adjuvant Therapy with Fluorouracil and Oxaliplatin in Stage II and Elderly Patients (between Ages 70 and 75 Years) with Colon Cancer: Subgroup Analyses of the Multicenter International Study of Oxaliplatin, Fluorouracil, and Leucovorin in the Adjuvant Treatment of Colon Cancer Trial. J. Clin. Oncol. 2012, 30, 3353–3360. [Google Scholar] [CrossRef]
  63. McCleary, N.J.; Meyerhardt, J.A.; Green, E.; Yothers, G.; De Gramont, A.; Van Cutsem, E.; O’Connell, M.; Twelves, C.J.; Saltz, L.B.; Haller, D.G.; et al. Impact of Age on the Efficacy of Newer Adjuvant Therapies in Patients with Stage II/III Colon Cancer: Findings from the ACCENT Database. J. Clin. Oncol. 2013, 31, 2600–2606. [Google Scholar] [CrossRef]
  64. Haller, D.G.; O’Connell, M.J.; Cartwright, T.H.; Twelves, C.J.; McKenna, E.F.; Sun, W.; Saif, M.W.; Lee, S.; Yothers, G.; Schmoll, H.J. Impact of Age and Medical Comorbidity on Adjuvant Treatment Outcomes for Stage III Colon Cancer: A Pooled Analysis of Individual Patient Data from Four Randomized, Controlled Trials. Ann. Oncol. 2015, 26, 715–724. [Google Scholar] [CrossRef]
  65. Sargent, D.J.; Goldberg, R.M.; Jacobson, S.D.; Macdonald, J.S.; Labianca, R.; Haller, D.G.; Shepherd, L.E.; Seitz, J.F.; Francini, G. A Pooled Analysis of Adjuvant Chemotherapy for Resected Colon Cancer in Elderly Patients. N. Engl. J. Med. 2001, 345, 1091–1097. [Google Scholar] [CrossRef] [PubMed]
  66. Gerard, J.-P.; Chapet, O.; Ramaioli, A.; Romestaing, P. Long-term control of T2-T3 rectal adenocarcinoma with radiotherapy alone. Int. J. Radiat. Oncol. Biol. Phys. 2002, 54, 142–149. [Google Scholar] [CrossRef]
  67. Borstlap, W.A.A.; Coeymans, T.J.; Tanis, P.J.; Marijnen, C.A.M.; Cunningham, C.; Bemelman, W.A.; Tuynman, J.B. Systematic Review Meta-Analysis of Oncological Outcomes after Local Excision of PT1-2 Rectal Cancer Requiring Adjuvant (Chemo)Radiotherapy or Completion Surgery. Br. J. Surg. 2016. [Google Scholar] [CrossRef] [PubMed]
  68. Dossa, F.; Chesney, T.R.; Acuna, S.A.; Baxter, N.N. A Watch-and-Wait Approach for Locally Advanced Rectal Cancer after a Clinical Complete Response Following Neoadjuvant Chemoradiation: A Systematic Review and Meta-Analysis. Lancet Gastroenterol. Hepatol. 2017, 2, 501–513. [Google Scholar] [CrossRef]
  69. Chesney, T.R.; AlQurini, N.; Alibhai, S.M. Geriatric Surgical Oncology. In Surgical Oncology Manual; Springer: Toronto, ON, Canada, 2020; pp. 251–273. [Google Scholar]
  70. Montroni, I.; Rostoft, S.; Spinelli, A.; Van Leeuwen, B.L.; Ercolani, G.; Saur, N.M.; Jaklitsch, M.T.; Somasundar, P.S.; de Liguori Carino, N.; Ghignone, F.; et al. GOSAFE—Geriatric Oncology Surgical Assessment and Functional REcovery after Surgery: Early Analysis on 977 Patients. J. Geriatr. Oncol. 2020, 11, 244–255. [Google Scholar] [CrossRef] [Green Version]
  71. Fagard, K.; Leonard, S.; Deschodt, M.; Devriendt, E.; Wolthuis, A.; Prenen, H.; Flamaing, J.; Milisen, K.; Wildiers, H.; Kenis, C. The Impact of Frailty on Postoperative Outcomes in Individuals Aged 65 and over Undergoing Elective Surgery for Colorectal Cancer: A Systematic Review. J. Geriatr. Oncol. 2016, 7, 479–491. [Google Scholar] [CrossRef]
  72. Fagard, K.; Casaer, J.; Wolthuis, A.; Flamaing, J.; Milisen, K.; Lobelle, J.P.; Wildiers, H.; Kenis, C. Value of Geriatric Screening and Assessment in Predicting Postoperative Complications in Patients Older than 70 Years Undergoing Surgery for Colorectal Cancer. J. Geriatr. Oncol. 2017, 8, 320–327. [Google Scholar] [CrossRef]
  73. Weerink, L.B.M.; Gant, C.M.; Van Leeuwen, B.L.; De Bock, G.H.; Kouwenhoven, E.A.; Faneyte, I.F. Long-Term Survival in Octogenarians After Surgical Treatment for Colorectal Cancer: Prevention of Postoperative Complications Is Key. Ann. Surg. Oncol. 2018, 25, 3874–3882. [Google Scholar] [CrossRef] [Green Version]
  74. Bos, A.C.R.K.; Kortbeek, D.; van Erning, F.N.; Zimmerman, D.D.E.; Lemmens, V.E.P.P.; Dekker, J.W.T.; Maas, H.A.A.M. Postoperative Mortality in Elderly Patients with Colorectal Cancer: The Impact of Age, Time-Trends and Competing Risks of Dying. Eur. J. Surg. Oncol. 2019, 45, 1575–1583. [Google Scholar] [CrossRef]
  75. Day, L.W.; Kwon, A.; Inadomi, J.M.; Walter, L.C.; Somsouk, M. Adverse Events in Older Patients Undergoing Colonoscopy: A Systematic Review and Meta-Analysis. Gastrointest. Endosc. 2011, 74, 885–896. [Google Scholar] [CrossRef] [Green Version]
  76. Parker, M.A.; Robinson, M.H.E.; Scholefield, J.H.; Hardcastle, J.D. Psychiatric Morbidity and Screening for Colorectal Cancer. J. Med. Screen. 2002, 9, 7–10. [Google Scholar] [CrossRef] [PubMed]
  77. Lee, S.J.; Boscardin, W.J.; Stijacic-Cenzer, I.; Conell-Price, J.; Sarah, O.; Walter, L.C. Time Lag to Benefit after Screening for Breast and Colorectal Cancer: Meta-Analysis of Survival Data from the United States, Sweden, United Kingdom, and Denmark. BMJ 2013, 346, e8441. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  78. Costi, R.; Leonardi, F.; Zanoni, D.; Violi, V.; Roncoroni, L.; Costi, R.; Violi, V.; Roncoroni, L.; Leonardi, F.; Zanoni, D.; et al. Palliative Care and End-Stage Colorectal Cancer Management: The Surgeon Meets the Oncologist. World J. Gastroenterol. 2014, 20, 7602–7621. [Google Scholar] [CrossRef] [PubMed]
  79. Cooper, Z.; Scott, J.W.; Rosenthal, R.A.; Mitchell, S.L. Emergency Major Abdominal Surgical Procedures in Older Adults: A Systematic Review of Mortality and Functional Outcomes. J. Am. Geriatr. Soc. 2015, 63, 2563–2571. [Google Scholar] [CrossRef] [Green Version]
  80. Cho, H.; Klabunde, C.N.; Yabroff, K.R.; Wang, Z.; Meekins, A.; Lansdorp-Vogelaar, I.; Mariotto, A.B. Comorbidity-Adjusted Life Expectancy: A New Tool to Inform Recommendations for Optimal Screening Strategies. Ann. Intern. Med. 2013, 159, 667–676. [Google Scholar] [CrossRef]
  81. Saini, S.D.; Van Hees, F.; Vijan, S. Smarter Screening For Cancer: The Possibilities And Challenges Of Personalization Why Personalize Screening? HHS Public Access. JAMA 2014, 312, 2211–2212. [Google Scholar] [CrossRef] [Green Version]
  82. Lansdorp-Vogelaar, I.; Gulati, R.; Mariotto, A.B.; Schechter, C.B.; de Carvalho, T.M.; Knudsen, A.B.; van Ravesteyn, N.T.; Heijnsdijk, E.A.; Pabiniak, C.; van Ballegooijen, M.; et al. Personalizing Age of Cancer Screening Cessation Based on Comorbidity: Model Estimates of Harms and Benefits. Ann. Intern. Med. 2014, 161, 104–112. [Google Scholar] [CrossRef]
  83. Van Hees, F.; Saini, S.D.; Lansdorp-Vogelaar, I.; Vijan, S.; Meester, R.G.S.; De Koning, H.J.; Zauber, A.G.; Van Ballegooijen, M. Personalizing Colonoscopy Screening for Elderly Individuals Based on Screening History, Cancer Risk, and Comorbidity Status Could Increase Cost Effectiveness. Gastroenterology 2015, 149, 1425–1437. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  84. Van Hees, F.; Dik, J.; Habbema, F.; Meester, R.G.; Lansdorp-Vogelaar, I.; Van Ballegooijen, M.; Zauber, A.G. Should Colorectal Cancer Screening Be Considered in Elderly Without Prior Screening? A Cost-Effectiveness Analysis. Ann. Intern. Med. 2014, 160, 750–759. [Google Scholar] [CrossRef]
  85. Voelker, R. Finding the Right Words to Stop Cancer Screening in Older Adults. JAMA 2019, 322, 1339–1340. [Google Scholar] [CrossRef]
  86. Torke, A.M.; Schwartz, P.H.; Holtz, L.R.; Montz, K.; Sachs, G.A. Older Adults and Forgoing Cancer Screening: “I Think It Would Be Strange”. JAMA Intern. Med. 2013, 173, 526–531. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  87. Paladino, J.; Lakin, J.R.; Sanders, J.J. Communication Strategies for Sharing Prognostic Information with Patients: Beyond Survival Statistics. JAMA 2019, 322, 1345–1346. [Google Scholar] [CrossRef] [PubMed]
  88. Schoenborn, N.L.; Boyd, C.M.; Lee, S.J.; Cayea, D.; Pollack, C.E. Communicating about Stopping Cancer Screening: Comparing Clinicians’ and Older Adults’ Perspectives. Gerontologist 2019, 59, S67–S76. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  89. Schoenborn, N.L.; Lee, K.; Pollack, C.E.; Armacost, K.; Dy, S.M.; Bridges, J.F.P.; Xue, Q.L.; Wolff, A.C.; Boyd, C. Older Adults’ Views and Communication Preferences about Cancer Screening Cessation. JAMA Intern. Med. 2017, 177, 1121–1128. [Google Scholar] [CrossRef] [PubMed]
Table 1. Exclusion of older adults from studies used to inform guidelines about colorectal cancer screening recommendations [2,18,19,21].
Table 1. Exclusion of older adults from studies used to inform guidelines about colorectal cancer screening recommendations [2,18,19,21].
ReferenceStudy DesignTest Modality Primary OutcomeAges Included Mean Age of Included ParticipantsRationale for Age Cut Offs
Jorgensen et al., 2002 [22]RCTFOBTReduction in mortality from CRC45–7558.8 None provided
Lindholm et al., 2008 [23]RCTFOBTReduction in mortality from CRC60–64Not providedNone provided
Scholefield et al., 2011 [24]RCTFOBTReduction in CRC mortality and incidence45–74Not providedNone provided
Shaukat et al., 2013 [25]RCTFOBTReduction in CRC mortality50–8062.3 ± 7.8None provided
Zheng et al., 2003 [26]RCTFOBT and quantitative individual risk of colorectal cancerReduction in rectal and colon cancer mortality >30Mean not provided, 7% of individuals screened were aged 70 and over Occurrence age of colorectal cancer in Chinese populations is younger than Western populations
Atkin et al., 2010 [27]RCTFlexible sigmoidoscopyReduction of CRC incidence and mortality55–6460 ± 2.9 None provided
Hoff et al., 2009 [28]RCTFlexible sigmoidoscopyReduction in CRC incidence and mortality55–6459 None provided
Schoen et al., 2012 [29]RCTFlexible sigmoidoscopyReduction in CRC incidence and mortality55–74Not providedNone provided
Segnan et al., 2011 [30]RCTFlexible sigmoidoscopyReduction in CRC incidence and mortality55–6459.3 ± 4.4 None provided
Bretthauer et al., 2016 [31]RCTColonoscopyParticipation rate, adenoma yield, performance, adverse events55–6460.0 (median) None provided
Quintero et al., 2012 [32]RCTColonoscopy vs. FITCRC specific mortality 50–6959.2 ± 5.5 in colonoscopy group 59.3 ± 5.6 in FIT groupNone provided
RCT—randomized control trial, FOBT—faecal occult blood testing, CRC—colorectal cancer.
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Arora, A.; Chadi, S.A.; Chesney, T. What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older? Curr. Oncol. 2021, 28, 2540-2547. https://0-doi-org.brum.beds.ac.uk/10.3390/curroncol28040231

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Arora A, Chadi SA, Chesney T. What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older? Current Oncology. 2021; 28(4):2540-2547. https://0-doi-org.brum.beds.ac.uk/10.3390/curroncol28040231

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Arora, Anuj, Sami A Chadi, and Tyler Chesney. 2021. "What Should We Recommend for Colorectal Cancer Screening in Adults Aged 75 and Older?" Current Oncology 28, no. 4: 2540-2547. https://0-doi-org.brum.beds.ac.uk/10.3390/curroncol28040231

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