Colorectal cancer screening is widely recommended for adults ages 45 to 75 with an average risk of developing the disease. However, many people don’t realize that the benefits of screening for this type of cancer aren’t always the same for older adults.
But what are the effects of personalizing screening in this population?
This question led Sameer Saini, M.D., M.S. and a multi-institutional, international team, including experts from the VA Ann Arbor Healthcare System, U-M, the University of Colorado, Memorial Sloan Kettering Cancer Center and Erasmus University Medical Center Rotterdam to conduct a VA-funded study to determine the effects of personalizing care on the appropriate use of colorectal cancer screening in older adults.
Their findings were recently published in JAMA Internal Medicine.
The study targeted individuals who fell into the age range of 70 to 75, and the team compared two different strategies of care in a cluster randomized trial involving 431 older adults of average risk for developing colorectal cancer.
“Each of our study participants were due for a colorectal cancer screening and had no family history of colorectal cancer or personal history of colon polyps,” Saini said. “Our control strategy was, in some ways, ‘usual’ care. But we did change a few things at the health system level, as well as at the physician level.”
Saini noted that the team made it possible for clinicians to stop screening patients within the control group without being penalized for doing so.
Another thing the team did, said Saini, was provide physicians with education about how screening benefits change throughout an individual’s lifespan, and how screening can potentially cause harm when “competing comorbidities” are present.
“In the intervention arm, physicians were also able to make more personalized decisions and were provided with education about screening benefits,” said Carmen Lewis, M.D., M.P.H., associate professor of internal medicine at University of Colorado and co-primary author of the study.
“But we also gave patients a personalized decision aid, which was a 30-page booklet with background information about screening, as well as personalized information about screening benefits and harms based upon their age, prior screening history, sex and whether they were healthy or sick at the time of the study.”
When the team compared the screening orders between the control arm and the intervention arm, they found no significant differences.
“In particular, we analyzed how orders for screening varied for patients who had low benefit versus high benefit for screening. And we found that individuals within the control arm who were least likely to benefit from screening got more screening orders than those in the intervention arm. In other words, the intervention reduced low value screening orders. In contrast, we found that those in the control arm who were most likely to benefit got fewer screening orders than those in the intervention arm. Therefore, the intervention increased high value screening orders,” Saini said.
Saini noted that not only was the intervention effective, but the control arm results also revealed that under usual care, colorectal cancer screenings were happening in excess in low benefit older adults, and not enough in high benefit older adults.
“When we looked at screening use, it was about 13% lower in the intervention arm when compared to the control arm, as fewer intervention arm patients used screening overall, likely reflecting a reduction in use of low value care.”