Time had passed since the last colonoscopy for the patient, so Dr. Steven Itzkowitz, a gastroenterologist at the Icahn School of Medicine at Mount Sinai, determined she was eligible for another. She was in “reasonably good health,” with low risks associated with the procedure — things like bleeding and reactions to anesthesia. However, being 85, she would need to pause her blood thinners due to cardiac stents, which could complicate matters.
If this decision had come up five years ago, Dr. Itzkowitz would have proceeded without a second thought. Yet, new studies suggest that the benefits of a repeat colonoscopy are limited after the age of 75.
Now he finds himself wondering, “What are we really achieving here?”
He’s not alone. Many doctors and patients are reconsidering the risks and benefits of common medical screenings, as research highlights procedures that may be unnecessary at older ages.
Skin Lesions: To Remove or Not?
Investigations have also been exploring which skin lesions might be harmless and possibly don’t require removal. Commonly known as actinic keratoses, these red or rough patches arise from prolonged sun exposure and usually appear on areas like the face and hands.
Older patients frequently show these lesions; a significant study found that nearly 30 percent of Medicare beneficiaries were diagnosed with actinic keratosis within five years. So what’s next?
Dr. Allison Billi, a dermatologist from the University of Michigan, notes that most of the time, these lesions are removed through procedures like cryosurgery or topical treatments. The thinking is that, although unlikely, these patches could turn cancerous. However, she points out that for most patients, the risk of progression to skin cancer is less than 1 in 1,000. In fact, the lesions often clear up on their own.
Dr. Billi added that treatment can be more troublesome than the lesions themselves. The removal process can be very painful and might result in swelling, irritation, and permanent discoloration.
Moreover, these lesions likely come back or new ones arise since this is a chronic issue. Instead of jumping to removal, she suggests active monitoring. Primary care doctors could check for signs like bleeding or rapid growth as reasons to proceed with removal, but, she insists, it’s often unnecessary to act.
Of course, she still recommends sunscreen.
Levothyroxine: A Questionable Necessity
Levothyroxine is prescribed to patients whose thyroids don’t produce enough hormone. This condition, known as hypothyroidism, causes symptoms like weight gain and low energy.
There’s been a rising trend in prescribing it for a borderline condition known as subclinical hypothyroidism, which typically doesn’t show symptoms but can evolve into hypothyroidism.
Many patients end up taking the medication indefinitely, but does it have to be this way? Dr. Jacobijn Gussekloo’s research shows that for numerous older patients with subclinical hypothyroidism, hormone levels can normalize naturally.
Additionally, outcomes reveal that among older individuals with this condition, levothyroxine didn’t seem to improve symptoms or show clear benefits. Like other medications, it can have adverse effects, particularly interactions with commonly prescribed drugs for older patients, alongside demands for frequent lab monitoring.
To identify if some patients could safely stop taking levothyroxine, Dutch researchers developed a protocol to gradually reduce dosages over 30 weeks, combined with regular lab checks and consultations.
A year later, 25% of the 370 participants, all over 60, successfully discontinued the drug while maintaining proper thyroid function; many had started with lower doses.
Discontinuation must be monitored and carefully tapered off, cautions Dr. Papaleontiou. While some may always need the drug, “a select group of older adults might not need this lifelong treatment,” she noted.
Debating Colon Cancer Screening
The discussion around when older patients can safely stop colon cancer screenings has been ongoing. The United States Preventive Services Task Force provides colon cancer screening a C rating after age 76, stating the benefits as “small.”
Despite this, nearly 60% of older people with previous colonoscopies and limited life expectancies (under five years) are still advised to get another screening, as found in a 2023 study.
Dr. Samir Gupta, a gastroenterologist at the University of California, San Diego, regularly encounters this issue. “I know they have a low risk of colon cancer, yet I’m subjecting them to additional risks,” he reflected.
Risks of complications post-colonoscopy increase with age. A recent study highlighted that almost 7% of those over 75 may have an emergency room visit or hospitalization within a month after the procedure.
Dr. Gupta, who contributed to a study featuring almost 92,000 Veterans Affairs patients over the age of 75 with prior colonoscopies, discovered about 28% had an adenoma — a polyp that can be precancerous. While only a fraction may turn cancerous, gastroenterologists typically remove them.
Over ten years, veterans with prior adenomas were found to have a higher likelihood of developing colon cancer than those without; however, the overall rates were very low.
Notably, just 0.5% of those with adenomas died from colon cancer, compared to 0.4% in those without — a minuscule difference, as pointed out by Dr. Gupta.
Most veterans who eventually died in that timeframe did so from other causes, highlighting how rare these scenarios are.
“Even if the procedure is successful, you’re either going to find nothing or discover something that won’t significantly impact your longevity,” remarked Dr. Itzkowitz, a co-author of an editorial linked to this study.
Yet, many patients who have had polyps prefer to keep having colonoscopies.
It’s challenging to change established medical practices. Efforts to “deprescribe” medications often face resistance from both patients and healthcare providers.
Numerous older women continue getting mammograms beyond the point where it’s proven effective, while older men often proceed with prostate screenings past the suggested age.
Given the unpleasant nature of colonoscopies, some older patients might welcome skipping them. “The likelihood of dying from colon cancer is so minimal compared to other risk factors you could face,” Dr. Itzkowitz stated.
So he informed his 85-year-old patient that she could forgo the next colonoscopy, and she seemed relieved.
