The reality of any cancer screening at any age is that benefits accrue to the few at the expense of the many. Benefits include longer life expectancy and less morbidity, while expenses include the risks of false-positive test results and cancer overdiagnosis, the burdens and risks of downstream tests and treatments, monetary costs to both individual patients and the health care system, and lost opportunity costs from diverted resources. This tension crescendos in the case of colorectal cancer (CRC) screening in elderly persons. On the one hand, the dramatic increases in CRC incidence and mortality appeal directly to our sense of responsibility as clinicians to detect and eradicate it with the goal of improving the quality and quantity of life; on the other hand, several realities interfere with this logic, such that the mission of “detect and eradicate” may not translate into improving either quantity or quality of life. Older patients have less life expectancy to save. Many elderly persons have comorbid conditions that further dilute the benefits of screening. Elderly adults incur more burdens and complications from colonoscopy and its downstream tests and treatments.1- 4 Given the tension between the benefits and burdens of CRC screening, it behooves clinicians to find the right balance—explicitly and quantitatively if possible—for each patient.
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