Let's Talk About Colorectal Screening After 75
I'm concerned lack of knowledge about the latest screening guidelines, coupled with pervasive ageism, may lead to poor screening decisions for some older adults
The recent increase in colorectal cancer incidence rates among adults under 50 continues to receive national attention. But this focus on younger adults overlooks the population at greatest risk for developing colorectal cancer, adults 76 and older. In fact, the incidence rate for colorectal cancer among adults between the ages of 75 and 79 is four times that of adults between 45 and 49.
Screening otherwise healthy adults for colorectal cancer can detect pre-cancerous polyps or early cancers that show no symptoms. Polyps can be removed when found to keep them from developing into cancer, and early cancers can be treated to avoid more serious illness and death.
It's time we took a hard look at the way we consider whether to screen older adults for colorectal cancer, particularly the growing number of adults over age 75.
Years before screening for colorectal cancer was recommended, my father suffered and died from late-stage colon cancer. Then I could only stand by, helpless and heartbroken. Now as a cancer epidemiologist, I know better use of screening tests could help more older adults and their loved ones escape a similar tragedy.
Lack of Knowledge About Guidelines
I'm concerned that lack of knowledge about the latest screening guidelines, coupled with pervasive ageism, may lead to poor screening decisions for some older adults. As a result, an opportunity to prevent debilitating illness and death from colorectal cancer might be missed.
It's time we took a hard look at the way we consider whether to screen older adults for colorectal cancer, particularly the growing number of adults over age 75. In 2022, there were 24 million adults in the U.S, age 75 and older. Most adults who survive the hazards of youth and midlife can look forward to many more birthdays. According to Social Security's Life Expectancy Calculator, a person in the U.S. who celebrates their 76th birthday in 2024 can expect to live, on average, well into their late 80s. Many will live even longer.
The latest guidelines for colorectal cancer screening, issued by a joint task force of three leading medical organizations, differ by age. Average-risk adults between the ages of 45 and 75 should be screened, and adults 86 and older should not. Between the ages of 76 and 85, the guidelines state that a decision on whether to screen someone should be specific to the person and made jointly with their provider. The U.S Preventive Services Task Force made similar recommendations.
After age 75, people who have not been screened in the past for colorectal cancer are the most likely to benefit from screening.
To be sure, screening for colorectal cancer, particularly colonoscopy, poses some risks, and the potential benefits of screening may not always outweigh potential harms for older adults. Although colonoscopy remains the most commonly used method for colorectal cancer screening, the use of alternatives to screening colonoscopy, such as stool DNA tests done at home, is increasing. The guidelines suggest a few factors to consider when making screening decisions for older adults.
After age 75, people who have not been screened in the past for colorectal cancer are the most likely to benefit from screening. In 2021, 17% of adults between the ages of 65 and 75 were not up-to-date with recommended colorectal cancer screening, suggesting many may still need to be screened after they reach age 76. Before the pandemic, about 1 in 6 adults between the ages of 76 and 84 had never been tested for colorectal cancer.
Life expectancy is another consideration, taking into account a person's overall health. Based on a person's gender, screening history and a measure of health status, an international team of researchers estimated that the appropriate age to stop screening for colorectal cancer, the point at which the risks of screening outweighed the benefits, could range anywhere from 66 to 90.
Other considerations for screening decisions include cancer risk, such as family history or personal history of polyps.
Other considerations for screening decisions include cancer risk, such as family history or personal history of polyps. And perhaps the most important consideration is patient preference, what the person wants. It is, after all, their body and their life.
The Effects of Ageism
The World Health Organization drew attention to the pervasive nature of ageism in health care in its 2021 Global Report on Ageism. Although meaningful biological differences exist among people by age, the latest guidelines say a decision not to screen based solely on age should be limited to adults over 85. A 2021 national survey of primary care physicians published last year found that less than half would continue electronic medical record reminders for colorectal cancer screening after age 75.
One approach to improve colorectal cancer screening for the growing population of older adults, so the right people are screened the right way, could be to increase support for shared decision-making between providers and patients. Older adults and their health care providers need adequate knowledge, tools and time for informed conversations about screening.
Greater public awareness about the latest screening recommendations after age 75 is also needed. When a health provider tells an adult over 75 that they're too old to be screened for colorectal cancer, or that it's time for a colonoscopy, an appropriate response could be, "Let's talk about that decision."
