A study published in the March 11 JAMA-Internal Medicine suggests that 23 percent of over-75-year-olds have colonoscopies that may be “potentially inappropriate” according to national guidelines which include an upper age limit, as well as how often negative colonoscopies should be repeated.

In a retrospective population study, University of Texas researchers looked at billings for 100 percent of colonoscopies performed in Medicare beneficiaries in Texas who were aged 70 years and older who had a colonoscopy in 2008 or 2009. They also examined a nationwide sample of 5% of Medicare claims. Colonscopies were classified as “screening” if records (including claims from 2000 to 2009) did not indicate a diagnosis, or any visits for related symptoms in the previous 3 months.

Colonoscopies were labeled “potentially inappropriate” based on patient age over 75, or because the procedure was done less than 10 years after a previously negative colonoscopy. (The study population did not include anyone with a history of colon cancer, inflammatory bowel disease, colon resection, or whose procedure was performed during a hospital admission or emergency room visit.)

Among Texas residents, overall percentages of potentially unnecessary colonoscopies were:

• Age 70-75: 9.9 % of procedures done
• Ages 76-85: 38.8%
• Aged 86-plus: 24.9%.

There was wide variation in geographic areas of Texas, plus among individual doctors doing the screening procedures. The researchers did note that reasons for doing a colonoscopy in an individual patient cannot be assumed from billing information alone. (In fact only 15% of the claims included a screening code, although experts believe about two-thirds of colonoscopies are for routine screening.) The authors noted that there might be poor communication between a primary care doctor and the gastroenterologist; there could be financial incentives to do the procedure, or doctors might disagree with the national guidelines.

What are the guidelines?

In fact, there are different sets of guidelines. The U.S. Preventive Services Task Force (and recently, the American College of Physicians) specify age limits. The USPSTF says “For adults aged 76 to 85 years, there is moderate certainty that the net benefits of screening are small….and [for] adults older than age 85 years, there is moderate certainty that the benefits of screening do not outweigh the harms.”

However, joint guidelines developed by the American Cancer Society, the U.S. Multi-Society Task force on Colorectal Cancer, and the American College of Radiology do not include age limits. Part of the problem is lack of evidence: experts note that far too few population studies and clinical trials include those over age 75, even though about 30% of colorectal cancers are diagnosed in those 75 or older.

Increased risks might outweigh benefits for colonoscopy in those over age 75

Although the USPSTF urges caution in any screening over age 75, colonoscopy itself carries higher risks to elderly patients. Both this study’s authors and guideline developers urge extra caution—especially in unnecessary procedures—in the elderly who face higher risks from the preparation (fluid imbalance, start of a diarrhea/constipation cycle, dizziness or a rush to bathroom causing falls) plus effects of anesthesia in elderly patients.

Some over 75 will benefit

A caveat common among the experts: Among those who have never been screened, a screening colonoscopy might be indicated—especially if the older person is healthy, active, has few other diseases, and has an expected lifespan of more than 7 years.

Another study in the March 5 2013 Annals of Internal Medicine showed that in four HMOs, screening among people aged 55 to 85 did reduced the risk of advanced colorectal cancer by 70% in average-risk adults. However, the study showed that annual stool samples in this population (particularly when reminders and stool-sample kits were mailed to people’s homes) were as effective as colonoscopy.

What to do?

Probably the Centers of Disease Control & Prevention says it best: “The decision to be screened after age 75 should be made on an individual basis. If you are older than 75, ask your doctor if you should be screened.”

Patient Take-Away

• All guidelines recommend a colonoscopy only every 10 years, unless you have symptoms, family history, or a previous removal of polyps or an adenoma. (In those cases, plan your “surveillance colonoscopy” with your doctor.)
• People aged 75 or older should pause to consider the need for a routine screening colonoscopy, especially if it’s less than 10 years since a previous negative colonoscopy. You can also consider other screening methods, such as a yearly stool sampling that is very effective at finding early cancer.
• Discussions about cancer (and other) preventive screening probably are best with your primary-care doctor, who knows all of your other health conditions, your general fitness level, etc.
• If you do have a colonoscopy, it’s best to get your own written record of the results, including number and type of any polyps. A common cause of getting too-frequent colonoscopies could be that a different doctor doesn’t know the results of your previous test(s).

As always, stay tuned for updates on both screening and colorectal cancer treatment in the elderly: As boomers age in, and hopefully more seniors are included in clinical and prevention studies, the science will get clearer.

For More information:

* CDC brief summary of guidelines

* Choosing Wisely: on colonoscopies

* Who is the USPSTF? “A Conversation with Dr. Virginia Moyer, Chair, U.S. Preventive Services Task Force, Nov. 27 2012 NCI Cancer Bulletin.

Sources:

“Potentially Inappropriate Screening Colonoscopy in Medicare Patients,” Kristin M. Sheffield, Ph.D. et al,  JAMA Internal Medicine, published online March 11, 2013

Other coverage of this study includes: “Seniors Getting Unnecessary Colonoscopies: Study,” Monday, Mar. 11 HealthDay News; and “Many Colonoscopies for Seniors May be Inappropriate,” Christian Nordqvist, 12 Mar. 2013 Medical News Today.

See previous Research News blogs, including the Feb. 14 2013 “Colorectal Cancer is (or Could Be) the Poster Child for Cancer Prevention” and
the May 16 2011 “Fight CRC Site Update: Some People Getting Colonoscopy Screening Too Often.”

Other recent articles about screening: “CRC Screening Tools—The Data and the Guidelines,” Linda Rabeneck, M.D., M.P.H., at January 2013 ASCO GI-Symposium; and  “Screening Colonoscopy and Risk for Incident Late-Stage Colorectal Cancer Diagnosis in Average-Risk Adults,” March 5 Annals of Internal Medicine .

Some people who go in for a routine screening colonoscopy (fully covered by most insurance) can end up with a surprise bill of several hundred dollars, if the doctor detected and removed one or more polyps.

Under current law, Medicare beneficiaries must pay a coinsurance when their screening colonoscopy also involves the removal of polyps or other tissue—because it is reclassified as a “treatment” procedure. Additionally, while current law also requires most private payers to cover colorectal cancer screenings without cost-sharing (copays/ coinsurance/ deductible), private payers have interpreted the rules differently. Some private payers waive cost- sharing when a screening involves the removal of polyps or other tissue; others do not.

Two weeks ago, we scored a partial victory. The Department of Health and Human Services issued a regulation change stating that private insurance companies cannot charge patients for the removal of a polyp during a screening colonoscopy. The HHS ruling this week was a result of a very productive meeting that we had at HHS last summer with a cooperative group of patient advocacy organizations and professional doctors’ associations.

This is progress, but this ruling doesn’t fix the Medicare policy—yet.

This is what Fight Colorectal Cancer does: Fight for you

For those of you who are new to Fight Colorectal Cancer, you’ll quickly learn that one of our strengths is being a respected, well-known voice in Congress and key federal agencies (e.g., National Cancer Institute, the FDA, Centers for Medicare and Medicaid Services, Dept. of Defense). Our staff and advocates monitor events 24/7 and work behind the scenes—often for months or years–on tedious details and complex issues with the decision makers. We’ve been partnering with other organizations since 2012 on this particular, knotty problem.

In last year’s Congress, Fight Colorectal Cancer was instrumental in the introduction of legislation in the House (H.R. 4120) that would correct Medicare law, and has lobbied the Department of HHS for a change in regulation.

We are working with our congressional allies to see if this HHS ruling may somehow spur the Medicare fix, while also continuing to work toward the reintroduction of a House bill (and a Senate bill) to get the job done in the 113^th Congress.

As soon as we get new House and Senate bill numbers for this year, we’ll issue an  Action Alert here so you can begin lobbying your congressional representatives.

What this means for patients:

• If you have private insurance, have a routine screening colonoscopy (not ordered to check out symptoms, or as a result of a positive stool blood test); and have precancerous polyps removed, your insurer cannot charge a copayment. (The HHS has ruled that removing precancerous polyps is an “integral part of a colonoscopy.” Under the Affordable Care Act, no copays can be charged for approved screening tests.)
• If you have private insurance, and your doctor determines that you are in a high-risk category (e.g., you have a family history of colorectal cancer) that is covered by screening guidelines, the same rules apply: No copayment for a screening colonoscopy that includes removal of precancerous polyps.
• If you have Medicare coverage, you may still be charged a copayment if a screening colonoscopy includes removal of a polyp.
• If you have either private or Medicare coverage, it appears that a followup colonoscopy ordered because of a positive FOBT (stool test for blood) is not considered a screening procedure, and is not covered by this rule change.

 Yes, it’s complicated. If you have questions or concerns, please call our Answer Line at 1-877-427-2111.

For more information:

* Click here for clarifications of Affordable Care Act coverage of screening, including colonoscopy:

* Read here about Fight Colorectal Cancer’s 2013 Legislative goals.

* For tools on making your voice heard, our 2012 Advocacy Handbook  is a great start. A 2013 version for this year’s Congress is in final production. Stay tuned.

Diagnosis and Treatment | CRC Symptoms | Diagnostic Tests | Staging | Stay in Touch with us

“Symptoms and Risks” fact sheet (PDF)
Available for free download right here!

People come to an initial medical work-up for colon or rectal cancer from different places. They may have had a suspicious polyp or cancer found during a routine screening. They may be experienced symptoms that might be caused by colorectal cancer. Getting an accurate diagnosis is critical because treatment for colorectal cancer depends on the diagnosis. For example, treatment for colon cancer is different than treatment for rectal cancer, and treatment for cancer which has spread outside of the colon is different than treatment for cancer which is limited to the colon. Getting an accurate diagnosis can take time and many different tests. It may require surgery, and examination of surgically-removed tissue to determine whether the cancer has spread. This process can involve several health professionals including:

• The gastroenterologist who will perform a colonoscopy if it has not been already done and remove tissue for biopsy. The gastroenterologist may remove suspicious polyps for pathology or, if they are large, leave them in place for later surgical removal.
• Pathologists who will examine biopsies under the microscope to identify precancerous cells or cancer (malignancy.)
• Radiologists who will perform CT-scans or other x-ray tests to see if the cancer has spread to other parts of your body.
• A general surgeon or colorectal surgeon who will give you a physical examination and ask about your medical history, order blood tests, review reports from gastroenterologist, radiologist, and pathology, and help decide on an initial treatment plan.
• If necessary, a medical oncologist who deals with chemotherapy treatment or a radiation oncologist may be involved at this point or they may join the treatment team after surgery. Specialized surgeons may also be called in to examine you if there is a possibility that the cancer has spread beyond your colon.

Choosing a medical team is an important initial step in getting an accurate diagnosis, especially if rectal surgery is involved. Work with your medical team to make sure that your evaluation, diagnosis, and staging are done carefully and thoroughly.. Get a second opinion if there is uncertainty about issues such as what tests are necessary, if surgery is the right first step, and whether staging is accurate. A second opinion at a large cancer center, particularly a National Cancer Institute designated cancer cancer or a member of the National Comprehensive Cancer Network can be valuable even early in the diagnostic process.

• Locate an NCI Cancer Center in your state.
• Locate an NCCN Comprehensive Cancer Center

Where Can You Go for More Information?

American Cancer Society How is Colorectal Cancer Diagnosed? Cancer.Net When the Doctor Says Cancer along with a podcast can help you learn questions to ask about your cancer and its diagnosis and how to understand and manage the information you get from your doctor.

New to Fight Colorectal Cancer?

Get monthly updates on colorectal cancer treatment options, research news and advocacy opportunities. We promise to not bombard you with email – just enough to keep you informed on how to fight colorectal cancer.