Primary Care Clinician Decision-Making Around Surveillance Colonoscopies in Older Adults with Prior Adenomas

Abstract

Introduction: While guidelines recommend against routine colorectal cancer screening in adults >75 years and/or those with limited life expectancies, there is no clear guidance on when surveillance colonoscopies following prior adenoma detection should stop. How primary care clinicians weigh the potential risks and benefits of surveillance colonoscopies in older adults with prior adenomas is unknown.

Methods: We conducted semistructured in-person interviews with 30 primary care clinicians from 21 clinics in Maryland. We asked how clinicians decided whether to continue or stop surveillance colonoscopies in older adults (65+ years) with prior adenomas. Interview transcripts were independently coded by 2 investigators using qualitative content analysis.

Results: Participants described a range of decision-making approaches. Some deferred to specialists because they did not feel confident making decisions about stopping surveillance in light of the higher cancer risk involved. Some took a more active role and discussed the decision with patients and/or specialists. Other clinicians felt comfortable stopping surveillance colonoscopies and made these decisions based on patient age, comorbidities, or life expectancy.

Discussion: We found a range of decision-making approaches among primary care clinicians on whether to continue surveillance colonoscopies in older adults with prior adenomas. Separate bodies of evidence currently exist on how prior adenoma characteristics influence colorectal cancer risk and on how older age and declining health influence the benefit/harm balance of screening. Information is lacking on the benefits and harms of surveillance in older adults with prior adenomas. Developing the evidence to address this knowledge gap is critically needed to inform clinical decision making.

Keywords: Aging; Clinical Decision Making; Colonoscopy; Colorectal Cancer; Decision Making; Early Detection of Cancer; Life Expectancy; Maryland; Mass Screening; Primary Health Care; Qualitative Research; Risk Assessment.