Skip to main content

Assessing the Impact of Screening Colonoscopy on Mortality in the Medicare Population

Abstract

Background

Some have recommended against routine screening for colorectal cancer (CRC) among patients ≥75 years of age, while others have suggested that screening colonoscopy (SC) is less beneficial for women than men. We estimated the expected benefits (decreased mortality from CRC) and harms (SC-related mortality) of SC based on sex, age, and comorbidity.

Objective

To stratify older patients according to expected benefits and harms of SC based on sex, age, and comorbidity.

Design

Retrospective study using Medicare claims data.

Participants

Medicare beneficiaries 67–94 years old with and without CRC.

Main Measures

Life expectancy, CRC- and colonoscopy-attributable mortality rates across strata of sex, age, and comorbidity, pay-off time (i.e. the minimum time until benefits from SC exceeded harms), and life-years saved for every 100,000 SC.

Key Results

Increasing age and comorbidity were associated with lower CRC-attributable mortality. Due to shorter life expectancy and CRC-attributable mortality, the benefits associated with SC were substantially lower among patients with greater comorbidity. Among men aged 75–79 years with no comorbidity, the number of life-years saved was 459 per 100,000 SC, while men aged 67–69 with ≥3 comorbidities had 81 life-years saved per 100,000 SC. There was no evidence that SC was less effective in women. Among men and women 75–79 with no comorbidity, number of life-years saved was 459 and 509 per 100,000 SC, respectively; among patients with ≥3 comorbidities, there was no benefit for either men or women.

Conclusions

Although the effectiveness of SC was equivalent for men and women, there was substantial variation in SC effectiveness within age groups, arguing against screening recommendations based solely on age.

This is a preview of subscription content, access via your institution.

Figure 1
Figure 2

References

  1. Force USPST. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;149(9):627–37.

    Google Scholar 

  2. Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J, van Ballegooijen M, Kuntz KM. Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(9):659–69.

    PubMed  Google Scholar 

  3. Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104(3):739–50.

    PubMed  Article  Google Scholar 

  4. American College of O, Gynecologists. ACOG Committee Opinion No. 384 November 2007: colonoscopy and colorectal cancer screening and prevention. Obstet Gynecol. 2007;110(5):1199–202.

    Article  Google Scholar 

  5. (CDC) CfDCaP. Behavioral Risk Factor Surveillance System Survey Data. Vol. 2009. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2009.

  6. Klabunde CN, Lanier D, Nadel MR, McLeod C, Yuan GG, Vernon SW. Colorectal Cancer Screening by Primary Care Physicians Recommendations and Practices, 2006–2007. Am J Prev Med. 2009;37(1):8–16.

    PubMed  Article  Google Scholar 

  7. Roy HK, Bianchi LK. Differences in colon adenomas and carcinomas among women and men: potential clinical implications. JAMA. 2009;302(15):1696–7.

    PubMed  Article  CAS  Google Scholar 

  8. Selby J, Friedman G, Quesenberry C, Weis N. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med. 1992;326:653–7.

    PubMed  Article  CAS  Google Scholar 

  9. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329(27):1977–81.

    PubMed  Article  CAS  Google Scholar 

  10. Muller AD, Sonnenberg A. Protection by endoscopy against death from colorectal cancer. A case-control study among veterans. Arch Intern Med. 1995;155(16):1741–8.

    PubMed  Article  CAS  Google Scholar 

  11. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750–6.

    PubMed  Article  CAS  Google Scholar 

  12. Ko CW, Sonnenberg A. Comparing risks and benefits of colorectal cancer screening in elderly patients. Gastroenterology. 2005;129(4):1163–70.

    PubMed  Article  Google Scholar 

  13. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. 1997;112(2):594–642.

    PubMed  Article  CAS  Google Scholar 

  14. Berg AO. Screening for colorectal cancer: recommendations and rationale. Am J Nurs. 2002;102(9):107–17.

    PubMed  Google Scholar 

  15. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin. 2003;53(1):27–43.

    PubMed  Article  Google Scholar 

  16. Yamokoski LM, Hasselblad V, Moser DK, et al. Prediction of rehospitalization and death in severe heart failure by physicians and nurses of the ESCAPE trial. J Card Fail. 2007;13(1):8–13.

    PubMed  Article  Google Scholar 

  17. Fox E, Landrum-McNiff K, Zhong Z, Dawson NV, Wu AW, Lynn J. Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. JAMA. 1999;282(17):1638–45.

    PubMed  Article  CAS  Google Scholar 

  18. Vigano A, Dorgan M, Bruera E, Suarez-Almazor ME. The relative accuracy of the clinical estimation of the duration of life for patients with end of life cancer. Cancer. 1999;86(1):170–6.

    PubMed  Article  CAS  Google Scholar 

  19. Warren JL, Harlan LC, Fahey A, et al. Utility of the SEER-Medicare data to identify chemotherapy use. Med Care. 2002;40(8 Suppl):IV-55–61.

    Google Scholar 

  20. Warren J, Klabunde C, Schrag D, Bach P, Riley G. Overview of SEER-Medicare data: content, research applictions, and generalizability to the United States elderly population. Medical Care. 2002;40(supp):IV-3–IV-18.

    Google Scholar 

  21. Lamont EB, Lauderdale DS, Schilsky RL, Christakis NA. Construct validity of medicare chemotherapy claims: the case of 5FU. Med Care. 2002;40(3):201–11.

    PubMed  Article  Google Scholar 

  22. Lamont EB, Herndon JE 2nd, Weeks JC, et al. Criterion validity of Medicare chemotherapy claims in Cancer and Leukemia Group B breast and lung cancer trial participants. J Natl Cancer Inst. 2005;97(14):1080–3.

    PubMed  Article  Google Scholar 

  23. Klabunde CN, Potosky AL, Legler JM, Warren JL. Development of a comorbidity index using physician claims data. J Clin Epidemiol. 2000;53(12):1258–67.

    PubMed  Article  CAS  Google Scholar 

  24. Potosky A, Riley G, Lubitz J, Mentnech R, Kessler L. Potential for cancer related health services research using a linked Medicare-tumor related database. Medical Care. 1993;31:732–48.

    PubMed  Article  CAS  Google Scholar 

  25. Hebert PL, Geiss LS, Tierney EF, Engelgau MM, Yawn BP, McBean AM. Identifying persons with diabetes using Medicare claims data. Am J Med Qual. 1999;14(6):270–7.

    PubMed  Article  CAS  Google Scholar 

  26. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8–27.

    PubMed  Article  CAS  Google Scholar 

  27. Cooper GS, Koroukian SM. Geographic variation among Medicare beneficiaries in the use of colorectal carcinoma screening procedures. Am J Gastroenterol. 2004;99(8):1544–50.

    PubMed  Article  Google Scholar 

  28. Gross CP, Andersen MS, Krumholz HM, McAvay GJ, Proctor D, Tinetti ME. Relation between Medicare screening reimbursement and stage at diagnosis for older patients with colon cancer. JAMA. 2006;296(23):2815–22.

    PubMed  Article  Google Scholar 

  29. Ko CW, Kreuter W, Baldwin LM. Effect of Medicare coverage on use of invasive colorectal cancer screening tests. Arch Intern Med. 2002;162(22):2581–6.

    PubMed  Article  Google Scholar 

  30. Inadomi JM, Sonnenberg A. The impact of colorectal cancer screening on life expectancy. Gastrointest Endosc. 2000;51(5):517–23.

    PubMed  Article  CAS  Google Scholar 

  31. Beck JR, Kassirer JP, Pauker SG. A convenient approximation of life expectancy (the "DEALE"). I. Validation of the method. Am J Med. 1982;73(6):883–8.

    PubMed  Article  CAS  Google Scholar 

  32. SEER Cancer Statistics Review: 1973–1993. In: Institute NC, ed. Vol. 2009. Bethesda, MD.

  33. Brenner H, Haug U, Arndt V, Stegmaier C, Altenhofen L, Hoffmeister M. Low risk of colorectal cancer and advanced adenomas more than 10 years after negative colonoscopy. Gastroenterology. 2010;138(3):870–6.

    PubMed  Article  Google Scholar 

  34. Brenner H, Chang-Claude J, Seiler CM, Sturmer T, Hoffmeister M. Does a negative screening colonoscopy ever need to be repeated? Gut. 2006;55(8):1145–50.

    PubMed  Article  CAS  Google Scholar 

  35. Brenner H, Arndt V, Sturmer T, Stegmaier C, Ziegler H, Dhom G. Long-lasting reduction of risk of colorectal cancer following screening endoscopy. Br J Cancer. 2001;85(7):972–6.

    PubMed  Article  CAS  Google Scholar 

  36. Newcomb PA, Storer BE, Morimoto LM, Templeton A, Potter JD. Long-term efficacy of sigmoidoscopy in the reduction of colorectal cancer incidence. J Natl Cancer Inst. 2003;95(8):622–5.

    PubMed  Article  Google Scholar 

  37. Singh H, Turner D, Xue L, Targownik LE, Bernstein CN. Risk of developing colorectal cancer following a negative colonoscopy examination: evidence for a 10-year interval between colonoscopies. JAMA. 2006;295(20):2366–73.

    PubMed  Article  CAS  Google Scholar 

  38. Pignone M, Rich M, Teutsch SM, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137(2):132–41.

    PubMed  Google Scholar 

  39. 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.

    PubMed  Article  CAS  Google Scholar 

  40. 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.

    PubMed  Article  CAS  Google Scholar 

  41. Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet. 1996;348(9040):1472–7.

    PubMed  Article  CAS  Google Scholar 

  42. Warren JL, Klabunde CN, Mariotto AB, et al. Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med. 2009;150(12):849–57. W152.

    PubMed  Google Scholar 

  43. Gatto NM, Frucht H, Sundararajan V, Jacobson JS, Grann VR, Neugut AI. Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. J Natl Cancer Inst. 2003;95(3):230–6.

    PubMed  Article  Google Scholar 

  44. Braithwaite RS, Fiellin D, Justice AC. The payoff time: a flexible framework to help clinicians decide when patients with comorbid disease are not likely to benefit from practice guidelines. Med Care. 2009;47(6):610–7.

    PubMed  Article  Google Scholar 

  45. Albertsen PC, Walters S, Hanley JA. A comparison of cause of death determination in men previously diagnosed with prostate cancer who died in 1985 or 1995. J Urol. 2000;163(2):519–23.

    PubMed  Article  CAS  Google Scholar 

  46. Hoffman RM, Stone SN, Hunt WC, Key CR, Gilliland FD. Effects of misattribution in assigning cause of death on prostate cancer mortality rates. Ann Epidemiol. 2003;13(6):450–4.

    PubMed  Article  Google Scholar 

  47. Regula J, Rupinski M, Kraszewska E, et al. Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N Engl J Med. 2006;355(18):1863–72.

    PubMed  Article  CAS  Google Scholar 

  48. Ransohoff DF. How much does colonoscopy reduce colon cancer mortality? Ann Intern Med. 2009;150(1):50–2.

    PubMed  Google Scholar 

  49. Baxter NN, Rabeneck L. Is the effectiveness of colonoscopy "good enough" for population-based screening? J Natl Cancer Inst;102(2):70–1.

  50. Baxter NN, Goldwasser MA, Paszat LF, Saskin R, Urbach DR, Rabeneck L. Association of colonoscopy and death from colorectal cancer. Ann Intern Med. 2009;150(1):1–8.

    PubMed  Google Scholar 

  51. Singh H, Nugent Z, Demers AA, Kliewer EV, Mahmud SM, Bernstein CN. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Gastroenterology;139(4):1128–37.

Download references

Acknowledgements

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

This work was supported by funding from by the National Institutes of Health (grant number 1 R21 HS017624-01).

Conflict of Interest

None disclosed.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Cary P. Gross MD.

Appendices

Appendix 1

Selection of cancer sample

figure a

Appendix 2

Decision rule figure for sensitivity analysis, assessing life-years saved for patients who had undergone a negative colonoscopy during 10–15 years prior

figure b

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Gross, C.P., Soulos, P.R., Ross, J.S. et al. Assessing the Impact of Screening Colonoscopy on Mortality in the Medicare Population. J GEN INTERN MED 26, 1441–1449 (2011). https://doi.org/10.1007/s11606-011-1816-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-011-1816-4

Key Words

  • screening colonoscopy
  • colorectal cancer screening
  • medicare