Case Study: You are in the middle of clinic, when you see that one of your longtime patients has scheduled a visit for “colonoscopy follow-up.” Irene is a 60-year-old woman with a history of obesity, hypertension, and a distant history of cigarette smoking. She has seen you in the past with complaints about knee pain and for antibiotics for the occasional bacterial sinusitis, but you are curious about this follow-up visit. When you walk into the room, you greet Irene and ask her how she is feeling these days. She replies, “I’m doing well, but they found something on my regular colonoscopy visit. Is it cancer?”
Surprised that no one has followed up with her, you take the report and photographs out of the chart and show them to her. The report says that the gastroenterologist removed a 15 mm sessile polyp, and no other abnormalities were found in the patient’s colon. You tell Irene that you are happy to report that the gastroenterologist did not find cancer, however she will have to follow up with another colonoscopy in 3 years instead of the standard 10 years because of the type of polyp the gastroenterologist found and removed. You ask Irene if she had any symptoms that required her to have a colonoscopy at this time. She says, “No. It was routine screening. My mother had colon cancer when she was 85 years old, but I started getting colonoscopies with everyone else since I was 50. Was that too late?”
The majority of patients who are diagnosed with colorectal cancer are asymptomatic and cancer is found during routine screening. If patients do present with symptoms, the most common symptoms are abdominal pain, blood in the stool, and/or changes in stool consistency. You think back to the wide array of screening recommendations published by organizations like the U.S. Preventive Services Task Force and the American Cancer Society. In order to determine when she should have started getting colonoscopies, you ask Irene if any other relatives have had colon cancer or if there is a family history of intestinal polyps or other GI malignancies. She tells you that only her mother had colon cancer, and it was caught early – her mother is alive and doing well. So you tell her that current recommendations are to start at 50 years old for patients without a family history or with one first-degree relative who had colon cancer after age 60. However, if she had at least two first-degree relatives with colon cancer or one who developed it before age 60, then she would have had to start screening when she was 10 years younger than the youngest person in her family to be diagnosed. The American College of Gastroenterology also recommends that people who self-identify as African American start screening at age 45. Irene’s mother was older than 60 when she was diagnosed, and Irene is Hispanic. She has average risk of developing colon cancer, and so it was appropriate to start screening at age 50.
What are the next steps for Irene?
There are several ways to monitor patients for colorectal cancer, including colonoscopy, flexible sigmoidoscopy, fecal immunochemistry test (FIT), guaiac-based fecal occult blood tests, and multitargeted stool DNA tests. These tests are administered in different combinations and at different frequencies depending on the guidelines and recommendations selected. However, Irene will be following up with a colonoscopy in 3 years because the large sessile polyp that was found on her most recent colonoscopy must be closely monitored. If she develops any new symptoms such as abdominal pain, blood in her stool, or changes in stool consistency, she will have to undergo screening sooner.
March is National Colorectal Cancer Awareness Month. The Colorectal Cancer Alliance’s 2019 public awareness campaign is “Don’t Assume”. The goal is to challenge assumptions and misconceptions about colorectal cancer by dispelling myths, raising awareness, and connecting people across the country with information and support.
How can you support this campaign in your practice?
Wilkins T, McMechan D, and A Talukder. “Colorectal Cancer Screening and Prevention.” American Family Physician. 97(10): 658-665. 2018.
For more Information, visit the American Society of Colon and Rectal Surgeons (ASCRS)
Dr. V. Silverstein
Published on 3/6/19