Monday, March 12, 2012

Colon cancer screening - not for 75 years olds?

The headline references one of the latest recommendations from the American College of Physicians (ACP).Seven members of the Clinical Guidelines Committee of the American College of Physicians have "determined" that consistent with the principle of cost conscious,high value care that "clinicians should not screen adults aged greater than equal to 75 years or those with substantial co-morbid conditions ..with a life expectancy of less than 10 years ."

The reference is "Screening for Colorectal cancer: A Guidance statement from the American College of Physicians. Annals of Internal Medicine 2012:156;378-386.

This is in contrast to the less rigid recommendation of the USPSTF which said:

USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support cancer screening in an individual patients.

Kudos to the USPSTF for allowing something that might at least pass for " patient centered care" to actually be centered on the patient and her concerns and her particular set of facts and to have those considered by her and her physician rather than having the option of colonoscopy categorically excluded by a general rule based on age. Further, the opposite of kudos to the ACP committee for their recommendation for not doing so.

ACP quotes a study in the Archives of Internal Medicine that "suggests that colonoscopy is overused in elderly patients including repeated screening at less than 10-years intervals and routine screening of patients older than 80 years."

The referenced article( see here for abstract) was an analysis of a large sample of Medicare patients who received colonoscopy exams for screening and around 45% received an second exam in less than 10 years. This is evidence than a number of patients received exams sooner than the 10 years recommendation for repeat exam so in that limited sense there was "overuse". The logical leap from that article to the recommendations of no screening past age 75 is unsupported by evidence or articulated reasoning expressed in the Annals article.

Why not age 73 or 76 or 80 or 65?

The age choice appears arbitrary and the absence of an articulated waiver based on individual circumstances is surprising and you have to wonder what evidence was used to reach their conclusion.You have to wonder because the article seemed bereft of any supporting evidence.

The print boiler plate disclaimer at the end of the article says:

"Clinical guidance statements are "guides" only and may not apply to all patients and all clinical situations.Thus,they are not intended to override clinicians' judgment."

But what will be remembered and quoted will be the 75 years cut point.

Page 385 of the Annals article has a table with the left hand column having a heading of "high-value,cost conscious care" across from the age related cutoff and their general screening recommendations.The implication is that the age recommendation is consistent with this "principle" of high-value,cost conscious care.

However,invoking the new magic words "High-value,cost-conscious care" (HVCCC) does not substitute for offering an analysis of the data regarding the outcomes of colonoscopy in older patients,e.g. complications, positive findings and ( here is something radical) how did the patients value the procedure.

I cannot help but worry that whatever righteous and rational reasoning and good intentions lead to the notion of HVCCC , it will become like the term "patient centered care" meaning whatever the authors of articles chose to have it mean. There are certain tactical advantages to have an elastic, ambiguous concept . I am preparing some comments on the notion of "value" as it is being applied to medical issues,particularly in regard to the difference between the use of the term by certain business consultant gurus and its questionable transfer to medical care and the standard
definition of value as explained in introductory economics texts.

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