LAUSR

Colonoscopy, the current “gold standard” for colorectal cancer and precancer detection and removal, is generally recommended for the screening of adults aged 50–75. Through recommendations and guidelines such as the 80% screening rate by 2018 set by the National Colorectal Cancer Roundtable [1], its use has nearly doubled over the past two decades [2]. Colonoscopy also carries the risk of major complications such as hemorrhage, perforation, and cardiopulmonary events [3], for which the incidence remains low, although its growing use will increase the number of patients experiencing adverse events. Moreover, it may be of limited benefit in a subset of older patients. A method for determining the patients in which the risk of colonoscopy outweighs its benefit has the potential to help clinicians improve the procedural risk/benefit. This issue of Digestive Diseases and Sciences features a study by Taleban and colleagues which addresses the problem of risk stratification by using frailty as a predictor of complications associated with colonoscopy [4]. Frailty is a state of decreased physiologic capacity and reserve in which patients are more vulnerable to acute stressors such as surgery. This is often associated with sarcopenia. As the authors point out, it can be used to predict outcomes following a variety of procedures. In patients undergoing elective surgery, for example, frailty is an independent predictor of postoperative complications, length of hospital stay, and discharge to a nursing facility [5]. While frailty has now been successfully used to risk-stratify patient risk across a wide range of surgeries, to our knowledge the current study is the first time it has been used as a screening instrument for colonoscopy risk. This prospective cohort study divided the patients into two groups—prefrail/frail and non-frail—using an easily administered upper-extremity frailty test. In this test, participants wear motion sensors and flex and extend their dominant elbow as many times as possible in 20s. The authors then recorded adverse events associated with colonoscopy, reporting that frailty and American Society of Anesthesiologists (ASA) status were significantly associated with colonoscopy-associated adverse events, with 70% of patients in the prefrail/frail group experiencing an adverse event compared to 41% of non-frail patients. We commend the authors on their novel application of frailty as a screening tool for colonoscopy risk. Not only are frail patients at increased risk of colonoscopy complications, they are also less likely to derive any real benefit given the association of frailty with shorter life expectancy [6]. Therefore, determining a patient’s frailty index could significantly inform the decision to pursue colonoscopy to screen for colorectal cancer. Another strength of this study is the practicality of its application. There are several methods by which to determine a patient’s frailty index. Although there is no “gold standard” for diagnosing frailty, several methods rely on determining factors such as weight loss, exhaustion with activity, level of physical activity, and physical weakness and slowness. This often involves a lengthy evaluation and interview process. Such a robust evaluation process may have strengthened the conclusions of this paper, but readers would be left wondering how best to implement this. By using a validated strength test that takes under a minute to administer, the authors greatly enhance the ease of test application and the scalability of their results. Frailty diagnosis may also be useful given the ongoing debate that often surrounds the use of screening * David Machado-Aranda [email protected]