Study Points to Increased Colorectal Cancer Screening Among Veteran’s Affairs Patients

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The rate of colorectal cancer screening appears to be increasing among Veterans Affairs (VA) patients, although the use of colonoscopy is less common than other screening procedures, according to a report in the November 13, 2006 issue of Archives of Internal Medicine. A second report in the same journal shows that younger veterans with other illnesses and reduced life expectancies may not necessarily benefit from such screening and may even be harmed, but continue to be screened at high rates.

Approximately 145,290 individuals in the United States developed colorectal cancer in 2005 and 56,290 died from the disease, according to background information contained in the first article. Screening for the disease has previously been shown to decrease illness and death and such methods include fecal occult blood testing (FOBT) and colonoscopy. Thus, Dr Hashem B. El-Serag of the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, and colleagues studied screening patterns in patients who received care in the Department of Veterans Affairs between 1998 and 2003.

By searching national inpatient and outpatient VA databases, the researchers identified all patients from age 49 to 75 who had undergone FOBT, colonoscopy, flexible sigmoidoscopy, or double contrast barium enema. A total of 5,125,938 screening tests for colorectal cancer were performed on 2,402,657 patients between 1998 and 2003, an average of 2.1 procedures per patient. The number of tests increased from 432,778 in 1998 to 1,179,764 in 2003. In that same time period, the proportion of FOBT tests increased from 81.7% to 90.4%; screening colonoscopy declined from 5.7% to 4.7%; flexible sigmoidoscopy declined from 8.3% to 3.6%; and double contrast barium enema declined from 4.1% to 1.3%.

Although the number of screening colonoscopies performed during this time increased from 24,955 to 55,199, the percentage of colonoscopies used for screening compared with the percentage used for diagnostic or other purposes increased only slightly, from 34.3% to 38.4%. “Although screening colonoscopy more than doubled in frequency, it still constitutes a small proportion of colorectal cancer screening,” the authors write. “Overall, there was no significant difference in the likelihood of undergoing screening colonoscopy between 1998 and 2003.”

“Apart from the advantages of colonoscopy, the effectiveness of an FOBT-based screening program in clinical settings (as opposed to clinical trials) is unclear,” the authors state. “The predominant use of FOBT for colorectal cancer screening in the VA, while strikingly different from other health care systems in the United States, may not necessarily lead to worse outcomes in terms of colorectal cancer-related incidence and mortality. It does, however, call for closer examination of the process and outcomes of this practice in VA settings.”

In terms of its policy for colorectal cancer screening, the Annals report notes that the VA recommends the following: “All eligible veterans at average or high risk for CRC need to be offered CRC screening. Given that each modality has advantages and disadvantages and that none has clearly been proven to be superior, the choice of specific screening strategy (absent medical contraindications to a particular method) needs to be based on patient preferences. The practitioner may recommend any one of the 5 screening options, but the veteran has the option of rejecting the recommended method and instead choosing one of the five alternatives, or none of the alternatives.”

In the second study, Shahnaz Sultan, MD, then at Duke University Medical Center and Durham Veterans Affairs Medical Center, North Carolina, and now at the University of Florida College of Medicine, Gainesville, and colleagues examined the relationship between colorectal cancer screening, health status, and other illnesses in 861 patients treated at a single VA Medical Center between 1996 and 2004. The participants were age 50–64 with no history of colorectal cancer or screening. Each patient completed 2 surveys about their health and comorbidity. Screening data were collected from hospital and individual medical records.

Within 5 years of their initial clinic visit, 395 (45.9%) of the veterans underwent screening for colorectal cancer, including 258 (65.3%) who had FOBT and 138 (34.9) who had colonoscopy. Researchers separated patients into groups by age and health status, with 3 groups for age (50–54, 55–59, and 60–64 years), 3 for comorbid diseases, and 4 for health status (1 being the worst and 4 being the best). High screening rates were observed for patients with poor health scores and coexisting illnesses. This included 84 (44.9%) of 187 of those with moderate illness and 55 (45.8%) of 120 of those with severe illness, as well as 88 (40.7%) of 216 of those with the worst health scores.

For a screening test to be beneficial, it must reduce the rates of patients who die from the disease they are screened for and prolong the life expectancy of those who are screened, the authors write. “In the context of colorectal cancer screening, if an individual’s life expectancy is anticipated to be fewer than 5 years, then screening may be of little benefit,” they continue. “In our study, 52 patients died during the 5-year follow-up period from non-colorectal cancer deaths, and of these patients, 71.2% had undergone colorectal cancer screening but had not derived any survival benefit. Most of these individuals had limited life expectancy based on their health status and co-morbidity score and may therefore have been inappropriately screened.” The authors conclude that future research “should focus on the development of appropriate decision tools to reduce potentially inappropriate colorectal cancer screening in severely chronically ill patients.”

For more details, see “The Use of Screening Colonoscopy for Patients Cared for by the Department of Veterans Affairs,” Arch Intern Med. 2006;166:2202–2208 and “Colorectal Cancer Screening in Young Patients With Poor Health and Severe Comorbidity,” 2209–2214.