Should an 84-year-old patient with no prior colon cancer screening undergo a Fecal Immunochemical Test (FIT) today?

Should You Perform FIT Testing on This 84-Year-Old Patient?

Yes, you should consider FIT testing for this 84-year-old patient who has never been screened, but only if they are healthy enough to undergo treatment for colorectal cancer if detected and have a life expectancy exceeding 10 years. 1

Age-Specific Screening Guidance for 76-85 Year-Olds

The decision to screen at age 84 falls into a nuanced category where guidelines consistently emphasize that never-screened individuals are more likely to benefit than those with prior negative screening 1. The key distinction is:

• Previously screened patients with negative results: Should generally stop screening at age 75 or when life expectancy falls below 10 years 1
• Never-screened patients: Should be considered for screening up to age 85, depending on comorbidities and overall health 1

The USPSTF provides a Grade C recommendation for adults aged 76-85, meaning the decision should be individualized, with adults who have never been screened more likely to benefit 1. The American College of Physicians specifically states that "persons without prior screening should be considered for screening up to age 85, depending on consideration of their age and comorbidities" 1.

Critical Assessment Required Before Screening

You must evaluate two essential criteria before proceeding:

1. Treatment Candidacy

• The patient must be healthy enough to undergo treatment if colorectal cancer is detected 1
• This includes ability to tolerate surgery (local excision, polypectomy, or surgical resection with anastomosis) 1
• Consider functional status and ability to withstand potential complications from treatment 2

2. Life Expectancy Assessment

• Life expectancy should exceed 10 years 1, 2
• For context: average 75-year-old men have 9.9 years life expectancy, while 75-year-old women have 12 years 1
• Patients with serious comorbidities (such as chronic renal failure) have significantly reduced life expectancy and are unlikely to benefit 1
• Online calculators can help estimate life expectancy based on age and comorbidities 2

Why FIT is Appropriate for This Patient

FIT is the preferred initial screening modality for this 84-year-old for several reasons:

• Lower risk profile: FIT is non-invasive and avoids the increased complications associated with colonoscopy in elderly patients 2
• Colonoscopy risks increase with age: Including perforation, bleeding, and cardiopulmonary complications from bowel preparation and sedation 1, 2
• FIT is a first-tier screening option: The U.S. Multi-Society Task Force recommends annual FIT as a first-tier option alongside colonoscopy 1, 3
• Proven mortality benefit: FIT has demonstrated reduction in CRC mortality and improved survival when used diagnostically 4

Important Caveats and Pitfalls

Do NOT Screen If:

• Patient is 86 years or older - guidelines recommend against screening at this age 1, 5
• Life expectancy is less than 10 years due to severe comorbidities 1
• Patient cannot tolerate treatment if cancer is detected 1
• Patient has conditions substantially limiting life expectancy (e.g., advanced heart failure, severe COPD, dementia) 1

If FIT is Positive:

• Colonoscopy will be required for diagnostic follow-up 2, 3
• Be aware that false-positive rates are higher in elderly patients 2
• Ensure the patient understands and accepts that a positive FIT necessitates colonoscopy before ordering the test 2

Screening Should Be Stopped If:

• Patient reaches age 85 without completing screening 5, 6
• Life expectancy falls below 10 years at any point 1
• Patient develops comorbidities that would preclude cancer treatment 1

The Bottom Line

For this never-screened 84-year-old, FIT testing is reasonable if they meet the health and life expectancy criteria outlined above. The lack of prior screening history means they lack the protective benefit of previous negative tests and may harbor undetected disease 1. However, this must be balanced against their ability to benefit from and tolerate subsequent interventions if screening is positive. The decision hinges on a realistic assessment of their functional status, comorbidities, and treatment candidacy - not simply their chronological age 1, 2.