Should an elderly African American male with no history of colonoscopy undergo a Fecal Immunochemical Test (FIT) kit for colorectal cancer screening?

Should an Elderly African American Male Complete a FIT Kit?

Yes, this patient should complete a FIT kit for colorectal cancer screening, particularly if he declines or cannot undergo colonoscopy, as FIT is a first-tier screening option that can reduce colorectal cancer mortality even in elderly patients who have never been screened. 1, 2

Age and Screening Considerations for Elderly Patients

The critical question here is defining "elderly" and determining if this patient can benefit from screening:

• For patients aged 50-75 years: Screening is strongly recommended regardless of prior screening history 1
• For patients aged 76-85 years: Screening decisions should be individualized, but never-screened individuals are more likely to benefit than those with prior negative screening 3, 2
• For patients ≥86 years: Screening is generally not recommended 2

The key determinant is whether life expectancy exceeds 10 years 1, 2. If this patient has good functional status and minimal comorbidities suggesting >10 year life expectancy, screening is appropriate even up to age 85 1, 2.

African American-Specific Considerations

This patient's African American ethnicity is particularly relevant:

• African Americans should begin screening at age 45 (5 years earlier than other populations) due to higher CRC incidence, earlier age at onset, and worse survival rates 1
• The fact that this patient has never had a colonoscopy makes screening even more important, as he has had no prior cancer prevention intervention 3, 2

FIT as the Appropriate Screening Method

FIT is designated as a first-tier screening option alongside colonoscopy by the U.S. Multi-Society Task Force 1, 4:

• Annual FIT reduces colorectal cancer mortality 1, 4
• FIT is particularly appropriate for elderly patients because it avoids the increased procedural risks of colonoscopy (perforation, bleeding, cardiopulmonary complications from bowel preparation and sedation) that escalate with age 2
• FIT should be offered to patients who decline colonoscopy in a sequential screening approach 1

Clinical Algorithm for This Patient

Step 1: Assess Life Expectancy

• If life expectancy >10 years and patient can tolerate cancer treatment if detected → Proceed to Step 2 2
• If life expectancy <10 years or age ≥86 years → Do not screen 2

Step 2: Offer Screening Options

• First choice: Colonoscopy every 10 years 1
• If colonoscopy declined or contraindicated: Annual FIT 1, 4

Step 3: If FIT is Chosen

• Perform annual FIT testing 1, 4
• If FIT positive: Patient must undergo colonoscopy for diagnostic evaluation 1, 2
• Critical caveat: Non-adherence to colonoscopy after positive FIT significantly increases CRC risk (6.64-fold higher) 5

Important Caveats and Pitfalls

Do NOT screen if:

• Patient is ≥86 years old 2
• Life expectancy <10 years due to severe comorbidities 1, 2
• Patient cannot tolerate cancer treatment (surgery, chemotherapy) if detected 2
• Patient has comorbidities that would preclude cancer treatment 2

Common pitfall to avoid:

• Ordering FIT without ensuring colonoscopy follow-up capacity for positive results is inappropriate and potentially harmful 5. The patient must understand that a positive FIT requires colonoscopy, and he must be willing and able to undergo this procedure 2.

Patient counseling points:

• FIT detects blood in stool and requires annual completion 1
• Approximately 50% of patients complete FIT "to please their doctor," which is acceptable motivation 6
• Some patients find stool collection uncomfortable or embarrassing (59.6%), but modifications like disposable gloves can help 6