Surveillance Colonoscopy May Be Deprioritized in Adults Aged 75 and Older, Study Finds

Although adults aged 75 and older with prior adenomas had slightly higher colorectal cancer (CRC) risk than those without, a recent JAMA study found non-CRC mortality far exceeded CRC incidence across frailty levels, suggesting surveillance colonoscopy may be deprioritized in this age group.¹

Uncertain Value of Surveillance Colonoscopy in Older Adults

Adults aged 75 years and older and their clinicians increasingly face difficult decisions about whether or not to continue cancer screening and surveillance, particularly for CRC. Although cancer risk rises with age, older adults also face competing risks of noncancer mortality, especially with higher levels of frailty, which may limit the net benefit of continued screening or surveillance.

This uncertainty is especially relevant for post-polypectomy CRC surveillance colonoscopies, which are commonly performed given high prior adenoma detection rates in screened populations. The incremental benefit of continued surveillance in older adults is unclear, and current guidelines offer no clear age- or frailty-based guidance on when to discontinue it. The researchers emphasized the need for such guidance, as colonoscopies remain frequently used even among individuals with limited life expectancy despite increasing procedural risks and costs with age and frailty.²

To address this evidence gap and better inform surveillance decisions, they conducted a retrospective cohort study using a large national cohort of older adults, comparing those with and without prior adenomas to assess risks of CRC, non-CRC mortality, and all-cause mortality.¹ The study included US veterans who underwent colonoscopy between January 1, 2006, and December 31, 2019, within the Department of Veterans Affairs (VA) health system.

Eligible individuals were aged 75 years or older and had undergone at least 1 colonoscopy between the ages of 65 and 75 years, with either confirmed adenoma detection or no adenoma found. The colonoscopy performed closest in time before each patient's 75th birthday was used to determine adenoma status.

Primary outcomes included incident CRC, CRC death, non-CRC death, and all-cause mortality, confirmed via the VA oncology registry and National Death Index data. In a secondary analysis, outcomes among those with adenoma were stratified by 5 frailty categories using the validated VA Frailty Index, ranging from nonfrail to severely frail. Between-group differences were assessed using the Gray test for CRC incidence and the log-rank test for all-cause mortality.

Low CRC Risk vs High Competing Mortality

Of 227,554 individuals initially identified, 91,952 met the inclusion criteria. The median age at the most recent qualifying colonoscopy was 71 years, and 98% of the cohort was male, reflecting the composition of the VA patient population.

Among the study population, 25,538 (27.8%) had adenoma detected at a prior colonoscopy, whereas 66,414 (72.2%) did not. Compared with those without adenoma, higher proportions of individuals with adenoma were slightly older, were Black and Hispanic, and were more likely to be classified as nonfrail. Additionally, advanced adenoma, defined as 10 mm or larger, with villous or tubulovillous features or high-grade dysplasia, was present in 10.8% of the adenoma group.

At the 10-year follow-up, the cumulative incidence of CRC was 1.1% (95% CI, 0.8%-1.3%) among individuals with prior adenoma vs 0.7% (95% CI, 0.5%-0.8%) among those without (P < .001). The cumulative incidence of CRC death was 0.5% vs 0.4%, respectively (P = .005).

However, these risks were substantially outweighed by the competing risk of non-CRC death. Among individuals with adenoma, the 10-year cumulative incidence of non-CRC death was 48.2%, which was more than 43 times the incidence of CRC in that group. Similarly, among those without adenoma, the corresponding figure was 46.9%.

This pattern held across all frailty levels. Among nonfrail individuals with adenoma, the 10-year cumulative CRC incidence was 1.7%, compared with a non-CRC death rate of 34.2%. Meanwhile, the CRC incidence among severely frail individuals was less than 1%, whereas non-CRC death rates reached 82.0%.

However, the researchers highlighted that no significant variation in CRC risk was found based on whether the adenoma was advanced or non-advanced, and the frequency of follow-up colonoscopy after age 75 years did not differ significantly between those who developed CRC and those who did not.

Implications for Reduced Surveillance Colonoscopy in Older Adults

The authors concluded by highlighting key limitations of their study, including that they studied a US veteran population that was 98% male, limiting the generalizability of findings to women; they noted that studies with higher female representation are needed to confirm the consistency of results. Still, the researchers expressed confidence in their findings.

“Adults 75 years of age or older with adenoma at prior colonoscopy were more likely to experience subsequent CRC and CRC death compared with those without adenoma, but cumulative risks were low and were far exceeded by competing risks for non-CRC death,” they wrote. “Older adults may consider deprioritizing surveillance colonoscopy relative to other health concerns.”

References

1. Gupta S, Liu L, Demb J, et al. Colorectal cancer and mortality risk among older adults with vs without adenoma on prior colonoscopy. JAMA. 2026;335(17):1499–1506. doi:10.1001/jama.2026.3414
2. Calderwood AH, Tosteson TD, Wang Q, Onega T, Walter LC. Association of life expectancy with surveillance colonoscopy findings and follow-up recommendations in older adults. JAMA Intern Med. 2023;183(5):426-434. doi:10.1001/jamainternmed.2023.0078