Published online Sep 15, 2019. doi: 10.4251/wjgo.v11.i9.729
Peer-review started: March 15, 2019
First decision: June 5, 2019
Revised: June 7, 2019
Accepted: July 26, 2019
Article in press: July 29, 2019
Published online: September 15, 2019
Processing time: 184 Days and 16.8 Hours
In France, as in other countries, the Colorectal Cancer (CRC) Screening Program (CRCSP) does not include people aged ≥ 75 years, despite the high incidence of CRC after 74 years and the constant increase in life expectancy since 2000. Indeed, elderly patients aged at least 75 years old (Elderly_75), represent 45% of CRC incidence. To date, there is little evidence to justify stopping CRC screening at 74 years of age.
In this period of implementation of the proposals for reform of the National CRCSP, our motivation was to feed the debate on the problem of screening in the elderly, in order to alert the decision-making bodies. By noting that in each French district, the sporadic participation of Elderly_75, out of the national CRCSP’s recommendation, is recorded every year.
Our objective was to describe the sources and outcomes of these screening test performed out of recommendation. Indeed, in the absence of a CRC screening program involving this age group, the elderly and/or their attending physicians decide sporadic participation in the campaigns organized by the local cancer screening managing center. The analysis of these sources and outcomes could argue the need for the implementation of an experimental program on the benefits and risk of CRC screening after the age of 75 years.
The study concerned 18704 Elderly_75 residing in eleven French districts (Ain, Doubs, Essonne, Haute-Saone, Hauts-de-Seine, Jura, Seine-Saint-Denis, Territoire-de-Belfort, Val-de-Marne, Val-d'Oise, Yonne), having performed a CRC screening test between January 2008 and December 2017.
Of 18995 screening-tests were performed by these 18704 Elderly_75 at ages: 75 (83.5%), 76-80 (13.4%) and > 80 (3.1%) years old. Elderly_75 performed the screening test in a circumstance of delayed response to a solicitation from the local cancer screening managing center (71.9%) or following a recommendation by a General Practitioner or other provider ordered (28.1%). The proportion (3.7%) of positive tests remains significantly higher than that found (2.9) in these districts in the same period or that usually found (2.6%) in the CRCSP program. It’s obvious that the high risk of colonoscopy complication after 75 years is a barrier to screening CRC in the elderly. With a reported colonoscopy completion rate estimated at 81.3%, this study recorded no complications. On reminder, in the national program, reported colonoscopy completion rate after a positive test was 76.9% with approximately major incidents, including perforation in 3 in 1000 colonoscopies. The neoplasia (124 Low-risk-polyps, 159 High-risk-polyps, 13 Unspecified-polyps and 70 CRCs) detection rate was 19.3/1000 Elderly_75 screened and the CRC detection rate was 3.6/1000 Elderly_75 screened. In this population, CRC were diagnosed on average age at 77 years.
Despite a regulatory framework that is not favorable to their participation in CRCSP campaigns, a motivation to continue CRCSP after 74 years of age was observed. Considering these findings, it could be argued that extending the duration of CRCSP in healthy people up to 80 years, could allow the screening of the many cases that occur after the exclusion of the Elderly_75 from CRCSP.
We are confident that more in-depth studies on the feasibility of CRC screening in Elderly are needed to confirm or not, the current age limit of screening at 74 years. Our perspectives converge in this direction because a pilot project for the implementation of CRC-screening after the age of 75, is currently in the process of identifying strategic and financial partners. One of the main objectives of this study will be to assess the risk associated with performing colonoscopy. Awaiting the implementation of this project, we intend to open the debate in France with the results of this study.