By Shardul A. Nanavati, M.D., Advanced Gastroenterology of Naples –
The ACP (American College of Physicians) came up with 4 specific recommendations. We will review these guidelines. Guidelines for Screening
1) Adults should receive screening recommendations based on personalized cancer risk profiles (with screening starting at 50 years for average risk patients). This is unchanged and in concordance with all of the other guidelines with the exception for average-risk African Americans for whom the American College of Gastroenterology recommends colonoscopy screening to begin at age 45. African Americans can have an earlier and more aggressive form of colon cancer; if the screening is negative, they are followed at the standard interval.
2) People should undergo screening at age 50, or, if they are deemed to be at high risk, at age 40 (or 10
years younger than the age at which the youngest relative was diagnosed). “High risk” according to the ACP means a patient with a first-degree relative with colon cancer or adenomatous polyps.
The average adenoma detection rate should be in the range 30-35% on the screening colonoscopy. Therefore, an inordinate number of people are going to have small polyps, now declaring “high risk” for their family members.
3) Patients should undergo a screening: the options for screening currently include stool occult blood test or fecal immunohistochemical testing (which is really the preferred strategy), optical colonoscopy, and flexible sigmoidoscopy. Barium enema was removed from the most recent screening guidelines. CT colonography is not an approved method for screening by the ACG nor ACP. Optical colonoscopy was recommended in high-risk patients as a preferred strategy.
4) Screening should be stopped after the age of 75. The USPSTF suggests that in patients over the age of 75, the value of screening diminishes, and that a decision to screen should be individualized. The USPSTF recommends that screening be stopped at age 85.
The Decision to Stop Screening
The other guidelines do not mention age as a variable in the decision to stop screening. The decision to stop screening should be individualized based on the patient and their comorbidities. If they have significant cardio-pulmonary or other systemic disease, it may well be ill-advised to continue screening regardless of age. The 10-year rule is pretty reasonable, but stopping at 75 seems to be an arbitrary assumption. We have a longevity on average of age 82-87 years in the U.S. and therefore our 75 year old patient with good functional capacity should not be lessened the opportunity for colorectal cancer screening just on the basis of age. The decision should be based not solely on age but on the patient profile using the 10-year rule of expected survival.
Regardless, 40% or more of the population has not been screened. It is the responsibility of the patient and their physicians to assure appropriate screening recommendations are followed. Colon cancer is still the second most common cause of cancer related death.
Advanced Gastroenterology of Naples
3439 Pine Ridge Road Naples, FL
Shardul A. Nanavati, MD
239.593.9599 | agnpmc@gmail.com