All right, so let’s talk
about colorectal cancer
screening and I personally
think it’s a real shame
that colorectal cancer
screening doesn’t get the
attention that it deserves
in the United States.
I’ve been in practice now for
20 years, I mostly see older
adults who should receive
colorectal cancer screening
and I can’t remember once where the
first thing that a patient told me
when they came in is, “I’m here to
get colorectal cancer screening.”
Not once, thousands and
thousands of patients.
And that makes sense
because if you look at
who should be screened
in the United States,
less than half of those individuals
who should be up-to-date on their
colorectal cancer screening are
up-to-date on their screening.
So we have a long way to go.
Let’s talk about some of
the modalities that can be
used and screening intervals
that are recommended.
And so we’re going to do a
case to illustrate this issue.
We’ve got a 51-year-old man, who is at
average risk for colorectal cancer.
Based on recommendations from the United
States Preventive Services Task Force,
what screening modality
is acceptable for him?
Is it a FIT test, a Fecal
Immunochemical Test alone,
or FIT plus sigmoidoscopy, or
colonoscopy, or D, all of the above?
There are options here
and there are options based on where your
patient is coming from, what they want out of
screening, and therefore,
you should be ready to
discuss all these options
with your patients.
But what’s incontrovertible is
that colorectal cancer is the
third most common cancer in the
US among both women and men.
There is a significant number of
colorectal cancer deaths in the
United States every year, but that
number is getting better over time.
And always think about modifiable
risk factors for colorectal cancer.
So it’s not just a
family history, smoking
increases the risk, obesity
increases the risk.
And those, you can’t do much
about your family history,
you can certainly do something
about those latter two issues.
So when to start and stop
colorectal cancer screening?
The American College of Gastroenterology
recommends screening at
age 45 for higher risk individuals,
that includes Black adults,
and certainly patients with
higher risk, with the familial
polyposis syndrome, maybe
screened even earlier than that.
For most adults, the vast
majority, other adults,
the screening should begin
at 50 years of age.
When to stop?
There’s insufficient evidence to
recommend screening beyond 74 years.
Again, that might be something where you
want to use shared decision-making.
Look at your patient in terms
of their quality of their life,
their general life expectancy,
and choose what you want to do.
How to screen?
So as I mentioned, USPSTF
recommends FIT annually.
FIT annually, in and of itself, can reduce
the risk of death due to colorectal cancer.
Flexible sigmoidoscopy has also
been widely studied in its
effects on colorectal cancer
detection as well as mortality
and it is effective as well,
and it’s usually combined
with a FIT test every several
years or even annually.
And then the other option is
the colonoscopy, which is the
more complete test but the more
expensive test every 10 years.
So in a way it’s maybe confusing because
there are options that might be acceptable.
In another way this allows
you a menu that you
can give to your patients
and say, “Okay, pick
one of these,” because
doing something is at
least better than
nothing, that’s for sure.
So the American Gastroenterological
Society prefers colonoscopy,
they recommend the alternative
to colonoscopy as an annual FIT,
and there’s another option,
which is CT colonography
and that can be acceptable every
five years as an alternative.
So let’s look at a patient who went through
the colonoscopy and then has some results.
So the patient we
he goes through a colonoscopy, he’s
diagnosed with two tubular adenomas,
they’re both greater than 1
centimeter in the descending colon
Now, when should you schedule
his next colonoscopy?
And this kind of a challenging
question because there are a lot of
different options but we’re going to
go through those options in a second.
The answer is three years,
and that has to do more with
the size of his adenomas
versus the type of adenomas.
Tubular adenomas, the
most common adenoma,
they comprise about 80%
of adenomas and they
really have the lowest
but at the same time, his adenomas were
greater than a centimeter in size.
Size does matter in terms of
the risk of future cancer,
and therefore, he
got an advanced --
this patient is getting an advanced
screening in only three years.
So as I mentioned in normal exams, and we
need to do our job, by the way, in sticking
to these screening intervals and these
recommendations, so do pay attention.
interval is 10 years.
Hyperplastic polyps less than
10 millimeters don’t really
have any malignant potential,
therefore, 10 years.
One to two tubular adenomas that
are smaller, 5 to 10 years.
A sessile serrated polyp less than 10
millimeters, serrated polyps associated with a
higher malignant potential that’s still
small, no evidence of dysplasia, five years.
A larger number of tubular adenomas up to 3
or 10 is a three-year screening interval.
And when the tubular adenoma
or serrated polyp is larger,
that also mandates automatically
a three-year screening interval.
Villous adenoma, these have a
higher malignant potential,
or any finding of high-grade
dysplasia, three years.
That serrated polyp with
dysplasia, three years.
And larger serrated
adenomas though that aren’t
sessile can be screened
every 5 to 10 years.
Many, many adenomas,
that’s kind of a judgment
call but it’s going to
be under three years.
If there is an attempt to
do a piecemeal resection
of a large adenoma, the
screening interval should
be less -- is generally less
than one year, but again,
that’s going to be up
to the operator again.
And status post a curative resection
for a colorectal cancer, screening
at one year, and then three, and
then five years after detection.
And it’s worth noting that the risk of
developing polyps in a lifetime is about 70%.
So it’s normal for somebody, most patients
actually will fall somewhere on this list,
but it’s usually going to
be on this list with a
more benign type of polyp
or more benign adenoma.
All right, moving on.
That’s really what I
wanted to impart today.
Just understand that we are underusing
colorectal cancer screening
because even -- something that’s
fairly simple and straightforward
such as FIT testing on an
annual basis can be effective.
And for those patients who obviously
have a positive screening on FIT,
then you really have to advocate for them
strongly to get a colonoscopy because
their risk for some type of colorectal
cancer or advanced polyp are much higher.
But recommend something
and really engage your
patients as to what their
preferences might be,
and then we will have
success in finding more
preventing more deaths.