Should We Continue Colonoscopy surveillance After 75?: JAMA | April 2026

Introduction

Colorectal cancer (CRC) screening and surveillance have significantly reduced cancer-related mortality. However, in adults aged ≥75 years, clinical decision-making becomes complex. While cancer risk increases with age, competing risks—particularly non-cancer mortality and frailty—also rise substantially. Current guidelines provide limited clarity on when to stop surveillance colonoscopy, especially in patients with prior adenomas, where the perceived cancer risk often drives continued procedures despite uncertain benefit.

Problem Statement

In older adults ≥75 years, it is unclear whether the risk of colorectal cancer justifies continued surveillance colonoscopy, particularly when competing risks of mortality are high.

Summary

This large Veterans Affairs cohort study of over 90,000 older adults provides important clarity. Over a 10-year follow-up, the risk of CRC remained low—even in those with prior adenomas (1.1% incidence, 0.5% CRC mortality)—and only marginally higher than those without adenomas. In stark contrast, non-CRC mortality approached nearly 50%, far exceeding cancer-related risks across all frailty levels.

Even among high-risk groups (prior adenoma, increasing frailty), the likelihood of dying from non-cancer causes was substantially higher than developing or dying from CRC. These findings highlight that the benefit of continued surveillance colonoscopy diminishes significantly with age and comorbidity burden.

Clinically, this study supports a paradigm shift—from routine surveillance to individualized decision-making. In many older adults, especially those with frailty, it may be more appropriate to deprioritize colonoscopy and focus on overall health, quality of life, and management of comorbid conditions.