Discussing a Positive FIT Result with an 80-Year-Old Patient When Colonoscopy is Not Recommended
Based on current guidelines, it is appropriate to inform your 80-year-old patient that colonoscopy following a positive FIT test is not recommended due to their age, as the potential risks outweigh the benefits. 1
Rationale for Not Proceeding with Colonoscopy
Age-Based Recommendations
- The American Cancer Society (ACS) recommends that clinicians individualize CRC screening decisions for individuals aged 76-85 based on patient preferences, life expectancy, health status, and prior screening history 1
- The Canadian Task Force on Preventive Health Care (CTFPHC) explicitly recommends not screening adults aged 75 years and older for colorectal cancer 1
- For patients over 85, the ACS recommends that clinicians discourage individuals from continuing CRC screening 1
Risk-Benefit Analysis
- Colonoscopy in very elderly patients is associated with:
- Higher risk of incomplete procedures (88.2% completion rate in patients ≥90 years vs. 99.3% in younger elderly) 2
- Increased rate of inadequate bowel preparation (29.7% in patients ≥90 years) 2
- Higher incidence of cardiopulmonary events and overall adverse events 2
- Need for higher levels of sedation (more general anesthesia) or lower doses of moderate sedation 2
How to Have the Conversation
Step 1: Acknowledge the Positive Test
"I see that your FIT test came back positive. This means we found microscopic blood in your stool sample."
Step 2: Explain the Context of Screening
"Normally, a positive FIT test would lead to a colonoscopy to check for the source of bleeding. However, medical guidelines recommend we consider several factors before proceeding with colonoscopy in patients over 75 years of age."
Step 3: Present the Risk-Benefit Analysis
"At age 80, colonoscopy carries increased risks including complications from the bowel preparation, the procedure itself, and the sedation medications. These risks include dehydration, perforation, bleeding, and cardiac events. The guidelines recommend against routine colonoscopy at your age because these risks often outweigh the potential benefits."
Step 4: Discuss Alternative Approaches
"Instead of colonoscopy, we can:
- Monitor for any symptoms like visible blood in stool, abdominal pain, or changes in bowel habits
- Check for anemia with blood tests
- Consider less invasive imaging if symptoms develop
- Continue to focus on your overall health and quality of life"
Step 5: Personalize and Reassure
"This recommendation isn't about denying care—it's about providing the most appropriate care for you at this stage of life. The goal is to avoid procedures that might cause more harm than good."
Special Considerations
When to Consider Proceeding with Colonoscopy
Despite age-based recommendations, colonoscopy might still be considered if:
- The patient has concerning symptoms (visible rectal bleeding, unexplained weight loss) 1
- The patient has an excellent functional status and life expectancy >10 years 1
- There is no history of prior colorectal cancer screening 1
Addressing Patient Concerns
- If the patient expresses anxiety about the positive FIT result, acknowledge their concern while explaining that false positives are common in older adults
- Emphasize that the decision is based on established medical guidelines designed to protect patients from unnecessary harm
- Explain that the goal is to maximize quality of life rather than performing procedures with limited benefit
Remember that this conversation requires sensitivity and should acknowledge the patient's autonomy while providing clear medical guidance based on established recommendations for their age group.