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INTRODUCTION

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Oh, and one more thing: it is now time for you to get another colonoscopy,” Dr Brown said to his patient Mrs Mary Moore, as she was packing up her purse and getting ready to leave the exam room. “We recommend that everyone gets a colonoscopy every 5 to 10 years, so I will have my nurse call you to set-up an appointment for you with the gastroenterologist here in town. Okay?”

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“Umm, okay, sure,” Mrs Moore, an 86-year-old widowed woman with severe congestive heart failure, hesitantly answered.

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“Great! It is always a pleasure seeing you Mrs Moore, thanks for coming today. See you at your next appointment,” Dr Brown smiled as he left.

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Dr Brown has known Mrs Moore for more than 30 years. He has helped her through difficult times over the years such as the death of her spouse, and has taken care of her chronic hypothyroidism and more recently her worsening congestive heart failure. Mrs Moore truly respects Dr Brown and is thankful for their therapeutic relationship.

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A colonoscopy involves inserting a small camera on a telescope-like instrument through the rectum in order to examine the interior of a person's large bowels. In general, the goal of a screening colonoscopy is to discover and remove polyps that can be precursors to cancer. But since progression from a polyp in the colon to a cancer is a slow process, it takes many years for patients to realize benefits from a colonoscopy procedure.1 Also the procedure is expensive, preparation can be uncomfortable because of the need to take powerful laxatives in order to remove the fecal matter from the bowel, and there are risks of damaging the intestines during the procedure. Therefore, the US Preventive Services Task Force (USPSTF) advises against routine colon cancer screening in patients over 75 years and any screening in patients over 85.2 Nevertheless, Medicare pays for routine screening colonoscopies regardless of age, paying doctors more than $100 million for nearly 550,000 screening colonoscopies in 2009, with around 40% of those for patients over 75.3 But the cost is not only monetary: life-threatening complications such as perforating the bowel significantly increase with advancing age.4 Therefore, an 86-year-old patient with a life-limiting disease like congestive heart failure is more likely to suffer from the risks of a colonoscopy than to ever see the potential downstream benefits.

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Overscreening patients for disease is a massive and growing problem in the United States. Elderly patients, often with multiple life-limiting diseases and/or advanced dementia, frequently undergo screening testing that will never benefit them.5 Approximately 50% of woman older than 80 years continue to receive breast cancer screening, and more than half of patients older than 75 years report that their physicians continue to recommend routine screening.6

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For younger patients, colonoscopies may also present a personal monetary hurdle. ...

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