Follow-Up in Older Adults after Fecal Occult Blood Test

Mortality rates from colorectal cancer can be reduced with utilization of fecal occult blood testing (FOBT). The low-risk test is only effective when patients who have an abnormal result are followed up with a complete evaluation with a colonoscopy or barium enema plus sigmoidoscopy, which has clinically significant risks. Guidelines recommend targeting FOBT to patients whose comorbidity and preferences would allow further evaluation of the colon in the case of abnormal results, but studies have found that FOBT screening is often performed in patients whose clinically significant comorbidities would be at increased risk for serious adverse events from follow-up procedures. Researchers recently conducted a prospective cohort study designed to determine whether lack of follow-up in older adults with abnormal results from an FOBT is due to screening patients whose comorbidity or preferences do not allow follow-up or failure to complete follow-up in healthy patients. They reported results in Archives of Internal Medicine [2011;171(3):249-256]. The primary outcome measure was receipt of follow-up within 1 year of the FOBT. The researchers used Veterans Affairs (VA) and Medicare claims, as well as medical chart reviews, to generate objective, real-world data that characterized the spectrum of screening FOBT results and type of follow-up received within 1 year among patients ≥70 years of age who were screened at 4 geographically diverse VA facilities. For patients who had abnormal results to the FOBT, the researchers determined the impact of age, comorbidity, and other factors on receipt of a complete colon evaluation within 1 year. They also identified documented reasons for lack of follow-up. The VA cohort included 2410 patients who were stratified according to the results of their FOBT result. Of the total cohort, 23% were ≥80 years of age, 98% were men, and 88% were white. Nine percent (n=212) had a positive FOBT result, 87% (n=2091) had a negative result, and 3% (n=83) had an incomplete result. Four percent (n=106) of patients died within 1 year of their screening FOBT. Of the 9% who had positive FOBT results, 42% (n=90) had a complete colon evaluation within 1 year; 22% (n=47) received an evaluation within 6 months. Only 33% (27/83) of patients who had an incomplete FOBT result had any follow-up within 1 year. The most common follow-up was repeat of the FOBT (24%). There was no significant association between receiving a complete colon evaluation within 1 year of a positive FOBT result and age, comorbidity, race/ethnicity, or socioeconomic status (P<.05). There was a significant association between complete colon evaluation follow-up and VA site, number of positive FOBT cards, and number of VA outpatient visits. The most common findings in the VA medical records among the 122 patients with a positive FOBT result who did not receive a complete followup colon evaluation were lack of any acknowledgment of the positive FOBT results in progress notes (43%) and patient refusal of colonoscopy (26%). Thirty-eight percent of these patients were classified as having been inappropriately screened when their clinicians documented the patient as refusing colonoscopy or having health problems or other issues that precluded complete colon evaluation. In conclusion, the researchers commented that “while follow-up after positive FOBT results was low regardless of age or comorbidity, screening patients in whom complete evaluation would not be pursued substantially contributes to lack of followup. Efforts to improve follow-up should address the full chain of decision making, including decisions to screen and decisions to follow up.”