Colorectal Cancer Screening and Surveillance Colonoscopy in Older Adults

  • Jennifer K. Maratt
  • Audrey H. CalderwoodEmail author
Colon (JC Anderson, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Colon


Purpose of review

The purpose of this chapter is to highlight current recommendations regarding colorectal cancer (CRC) screening and post-polypectomy surveillance colonoscopy in older adults and to review the available literature in order to help inform decision-making in this age group.

Recent findings

Age is a risk factor for CRC; however, older adults with a history of prior screening are at lower risk for CRC compared to those who have never been screened. Decision-making for CRC screening and post-polypectomy surveillance colonoscopy in older adults is complex and several factors including age, screening history, comorbidities, functional status, bowel preparation, prior experiences, preferences, and barriers need to be considered when weighing risks and benefits. Recent guidelines have started to incorporate life expectancy and prior screening history into their recommendations; however, how to incorporate these factors into actual clinical practice is less clear.


There are limited data on the relative benefits of screening and surveillance in older adults and therefore, at this time, decision-making should be individualized and incorporate patient preferences in addition to medical factors.


Colon cancer Elderly Screening Surveillance 


Compliance with Ethical Standards

Conflict of Interest

Jennifer K. Maratt declares that she has no conflict of interest. Audrey H. Calderwood declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. 1.
    Noone AM, Howlader N, Krapcho M, et al. SEER Cancer Statistics Review, 1975–2015, National Cancer Institute. Bethesda, MD, Accessed 25 Oct 2018.
  2. 2.
    Lieberman DA, Holub J, Eisen G, Kraemer D, Morris CD. Utilization of colonoscopy in the United States: results from a national consortium. Gastrointest Endosc. 2005;62:875–83.CrossRefGoogle Scholar
  3. 3.
    Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844–57.CrossRefGoogle Scholar
  4. 4.
    Census Bureau US. Older people projected to outnumber children for first time in U.S. History. Accessed 25 Oct 2018.
  5. 5.
    Siegel RL, Miller KD, Fedewa SA, Ahnen DJ, Meester RGS, Barzi A, et al. Colorectal cancer statistics, 2017. CA A Cancer J Clin. 2017;67:177–93.Google Scholar
  6. 6.
    World Health Organization. World Report on Ageing And Health. Geneva, Switzerland: World Health Organization, 2015; 1–246.Google Scholar
  7. 7.
  8. 8.
    Day LW, Velayos F. Colorectal cancer screening and surveillance in the elderly: updates and controversies. Gut Liver. 2015;9:143–51.CrossRefGoogle Scholar
  9. 9.
    ••Tran AH, Man Ngor EW, Wu BU. Surveillance colonoscopy in elderly patients. JAMA Intern Med. 2014;174:1675–82 Large retrospective cohort of adults 50 years of age or greater undergoing surveillance colonoscopy for history of CRC or polyps showing a low incidence of CRC and a high rate of post procedure hospitalization among older adults (> 75 years).Google Scholar
  10. 10.
    Martínez ME, Baron JA, Lieberman DA, Schatzkin A, Lanza E, Winawer SJ, et al. A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy. Gastroenterology. 2009;136:832–41.Google Scholar
  11. 11.
    United States Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2008;149:627–37.Google Scholar
  12. 12.
    Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, et al. Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2018;149:659–69.Google Scholar
  13. 13.
    •• van Hees F, Habbema JDF, Meester RG, Lansdorp-Vogelaar I, van Ballegooijen M, Zauber AG. Should colorectal Cancer screening be considered in elderly persons without previous screening? Ann Intern Med. 2014;160:750–32 Microsimulation modeling study to determine age up to which to consider CRC screening. In unscreened older adults, screening found to be cost-effective up to age 86 in those without comorbidities, up to 83 in those with moderate comorbidities, up to 80 in those with severe comorbidities.CrossRefGoogle Scholar
  14. 14.
    •• Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2017;112:1016–30 The US Multi-Society Task Force recently updated guidelines to include that discontinuation of screening should be considered in individuals who are up to date with screening, who have prior negative screening, reach age 75, or have < 10 years of life expectancy. Also, individuals without prior screening should be considered for screening up to age 85, depending on their age and comorbidities. Finally, they concluded that the decision to continue surveillance should be individualized with consideration of benefit, risk, and comorbidities.CrossRefGoogle Scholar
  15. 15.
    Eckstrom E, Feeny DH, Walter LC, et al. Individualizing cancer screening in older adults: a narrative review and framework for future research. J Gen Intern Med. 2012;28:292–8.CrossRefGoogle Scholar
  16. 16.
    Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Helping patients decide: ten steps to better risk communication. JNCI J Natl Cancer Inst. 2011;103:1436–43.CrossRefGoogle Scholar
  17. 17.
    ••American Cancer Society. Updates on Colorectal Cancer Screening Guideline. Accessed 12 Nov 2018. The American Cancer Society states that adults between the ages of 76–85 should make decisions about pursuing screening with their medical provider, with consideration of their own preferences, life expectancy, overall health, and prior screening history. The also recommended against screening for those over the age of 85.
  18. 18.
    Cairns SR, Scholefield JH, Steele RJ, Dunlop MG, Thomas HJW, Evans GD, et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut. 2010 Apr 28;59(5):666–89.Google Scholar
  19. 19.
    European Colorectal Cancer Screening Guidelines Working Group. European guidelines for quality assurance in colorectal cancer screening and diagnosis. Nov. 2010;17:1–1426.Google Scholar
  20. 20.
    Saini SD, Vijan S, Schoenfeld P, Powell AA, Moser S, Kerr EA. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ. 2014;348:g1247.CrossRefGoogle Scholar
  21. 21.
    Mittal S, Lin YL, Tan A, et al. Limited life expectancy among a subgroup of Medicare beneficiaries receiving screening colonoscopies. Clin Gastroenterol Hepatol. 2014;12:443–50.CrossRefGoogle Scholar
  22. 22.
    Goodwin JS. Overuse of screening colonoscopy in the Medicare population. Arch Intern Med. 2011;171:1335–43.CrossRefGoogle Scholar
  23. 23.
    Kistler CE. Long-term outcomes following positive fecal occult blood test results in older adults. Arch Intern Med. 2011;171:1344–51.CrossRefGoogle Scholar
  24. 24.
    Cooper GS, Kou TD, Barnholtz Sloan JS, Koroukian SM, Schluchter MD. Use of colonoscopy for polyp surveillance in Medicare beneficiaries. Cancer. 2013;119:1800–7.CrossRefGoogle Scholar
  25. 25.
    Murphy CC, Lewis CL, Golin CE, et al. Underuse of surveillance colonoscopy in patients at increased risk of colorectal cancer. Am J Gastroenterol. 2014;110:633–41.CrossRefGoogle Scholar
  26. 26.
    Kahn B, Freeland Z, Gopal P, Agrawal D, Mayorga CA, Mithani R, et al. Predictors of guideline concordance for surveillance colonoscopy recommendations in patients at a safety-net health system. Cancer Causes Control. 2015;26:1653–60.Google Scholar
  27. 27.
    Lewis CL, Esserman D, DeLeon C, Pignone MP, Pathman DE, Golin C. Physician decision making for colorectal cancer screening in the elderly. J Gen Intern Med. 2013;28:1202–7.CrossRefGoogle Scholar
  28. 28.
    Cazares K, OConnor S, Calderwood AH. Older adults perspectives toward surveillance colonoscopy: a qualitative study. Am J Gastroenterology. 2018;113:S145.CrossRefGoogle Scholar
  29. 29.
    Schwartz LM, Woloshin S, Fowler FJ, et al. Enthusiasm for cancer screening in the United States. JAMA. 2004;291:71–8.CrossRefGoogle Scholar
  30. 30.
    Maratt JK, Lewis CL, Saffar D, et al. Veterans' attitudes towards de-intensification of surveillance colonoscopy for low-risk adenomas. Clin Gastroenterol Hepatol. 2018;17:345–52. Scholar
  31. 31.
    ••Calderwood AH, Anderson JC, Robinson CM, et al. Endoscopist specialty predicts the likelihood of recommending cessation of colorectal cancer screening in older adults. Am J Gastroenterol. 2018 Nov 2. [Epub ahead of print] Using the New Hampshire Colonoscopy Registry, 85% of adults 70-74 years of age with a normal screening colonoscopy were found to have a recommendation to return for screening (when they would be 80–84 years of age). Advanced age and absence of family history of CRC were associated with recommended to stop screening. Gastroenterologists were more likely to recommend screening cessation for patients of advanced age as compared to non-gastroenterology endoscopists.
  32. 32.
    Day LW, Walter LC, Velayos F. Colorectal cancer screening and surveillance in the elderly patient. Am J Gastroenterology. 2011;106:1197–206.CrossRefGoogle Scholar
  33. 33.
    Lin OS, Kozarek RA, Schembre DB, Ayub K, Gluck M, Drennan F, et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA. 2006;295:2357–65.Google Scholar
  34. 34.
    Calderwood AH, Holub JL, Robertson DJ, Greenwald DA. Practice patterns and yield of surveillance colonoscopy among older adults: an analysis of the GI Quality Improvement Consortium (GIQUIC). Gastrointest Endosc. 2018;87:AB100.CrossRefGoogle Scholar
  35. 35.
    Kumar A, Lin L, Bernheim O, Bagiella E, Jandorf L, Itzkowitz SH, et al. Effect of functional status on the quality of bowel preparation in elderly patients undergoing screening and surveillance colonoscopy. Gut Liver. 2016;10:569–73.Google Scholar
  36. 36.
    Ho JM-W, Juurlink DN, Cavalcanti RB. Hypokalemia following polyethylene glycol-based bowel preparation for colonoscopy in older hospitalized patients with significant comorbidities. Ann Pharmacother. 2010;44:466–70.CrossRefGoogle Scholar
  37. 37.
    Rex DK. Dosing considerations in the use of sodium phosphate bowel preparations for colonoscopy. Ann Pharmacother. 2007;41:1466–75.CrossRefGoogle Scholar
  38. 38.
    Lukens FJ. Colonoscopy in octogenarians: a prospective outpatient study. Am J Gastroenterol. 2002;97:1722–5.CrossRefGoogle Scholar
  39. 39.
    Cha JM, Kozarek RA, La Selva D, et al. Risks and benefits of colonoscopy in patients 90 years or older, compared with younger patients. Clin Gastroenterol Hepatol. 2016;14:80–6 e1.CrossRefGoogle Scholar
  40. 40.
    Reumkens A, Rondagh EJA, Bakker CM, et al. Post-colonoscopy complications: a systematic review, time trends, and meta-analysis of population-based studies. Am J Gastroenterol. 2016;111:1092–101.CrossRefGoogle Scholar
  41. 41.
    •• Le ST, Lash BR, Schroy PC III, et al. Physician perceptions of surveillance follow-up colonoscopy in older adults. J Am Board of Family Med. 2017;30:371–3 Survey-based study of primary care physicians (PCPs) and gastroenterologists that evaluated factors related to decision-making in surveillance for older adults. Factors that PCPs considered life expectancy (40%), gastroenterologists’ recommendations (28%), and patient preferences (12%) as the most important factors while gastroenterologists considered comorbidities (57%), findings on prior colonoscopies (27%), and risks of the procedure (10%) as the most important factors for decision-making.CrossRefGoogle Scholar
  42. 42.
    Maratt JK, Calderwood AH, Saini SD. When and how to stop surveillance colonoscopy in older adults: five rules of thumb for practitioners. Am J Gastroenterol. 2017;113:5–7.CrossRefGoogle Scholar
  43. 43.
    •• Preventive Services US, Task Force B-DK, Grossman DC, et al. Screening for colorectal cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315:2564–75 The US Preventive Services Task Force provides revised guidelines for older adults to include that the decision to screen those who are 76–85 years of age should be individualized. Overall, they concluded that the net benefit of screening individuals in this age group, who have previously been screened, is small and that those who have not been screened are more likely to benefit. They also concluded that screening is most appropriate for those who are healthy enough to undergo treatment and those without comorbid conditions that limit their life expectancy.CrossRefGoogle Scholar
  44. 44.
    Torke AM, Schwartz PH, Holtz LR, Montz K, Sachs GA. Older adults and forgoing cancer screening. JAMA Intern Med. 2013;173:526–31.CrossRefGoogle Scholar
  45. 45.
    May FP, Gupta S. When should screening stop for elderly individuals at average and increased risk for colorectal cancer? Clin Gastroenterol Hepatol. 2018;16:178–80 e1.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Gastroenterology and Hepatology, Department of Internal MedicineMichigan MedicineAnn ArborUSA
  2. 2.Veterans Affairs Ann Arbor Healthcare SystemAnn ArborUSA
  3. 3.Section of Gastroenterology, Department of MedicineDartmouth Geisel School of Medicine and the Dartmouth Institute for Health Policy and Clinical PracticeLebanonUSA

Personalised recommendations