Colorectal Cancer Screening

The case study and answers to the following questions on screening for colorectal cancer are based on the recommendations of the current U.S. Preventive Services Task Force (USPSTF), part of the Put Prevention into Practice program of the Agency for Healthcare Research and Quality (AHRQ). This recommendation was released in 2002 and is an update of the 1996 recommendations contained in the Guide to Clinical Preventive Services, second edition. More detailed information on this subject is available in the Systematic Evidence Review, Summary of the Evidence, and USPSTF Recommendations and Rationale on the AHRQ Web site (www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse (www.guideline.gov).

Answers appear below.

This case study is part of AFP's CME. See "Clinical Quiz" on page 29.

Case Study

MB is a 51-year-old woman who visits you for a refill of her antihypertensive medication. You review her chart to deliver recommended clinical preventive services and learn that her screenings for lipids, breast cancer, and cervical cancer are current.

Noticing that she has not been screened for colorectal cancer, you inquire about her family history and conduct a pertinent review of systems, both of which are unremarkable.

Case Study Questions

1. According to the U.S. Preventive Services Task Force (USPSTF), which one of the following statements reflects the most appropriate plan to screen MB for colorectal cancer?
	A.	Offer MB a diagnostic test to evaluate for colorectal cancer because she is at high risk.
	B.	Offer MB screening because she is older than 50.
	C.	Offer MB screening at regular intervals until age 70.
	D.	Do not offer screening until MB turns 65.
	E.	Do not offer screening because MB has no risk factors for colorectal cancer.
2. Which of the following methods is recommended by the USPSTF to screen for colorectal cancer?
	A.	Periodic fecal occult blood testing.
	B.	Flexible sigmoidoscopy.
	C.	Colonoscopy.
	D.	Double-contrast barium enema.
	E.	All of the above methods are acceptable.

Answers

1. The answer is B: Colorectal cancer is the fourth most common cancer in the United States and the second leading cause of cancer death.¹ The USPSTF strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer. In persons at high risk (e.g., those with a first-degree relative who is diagnosed with colorectal cancer before age 60), initiating screening at an earlier age is reasonable. The appropriate age at which colorectal cancer screening should be discontinued is not known. Yield of screening should increase in older persons (because of higher incidence of colorectal cancer), but benefits may be limited as a result of competing causes of death. Discontinuing screening is therefore reasonable in patients whose age or comorbid conditions limit life expectancy.

2. The answer is E: The USPSTF found fair to good evidence that several screening methods are effective in reducing mortality from colorectal cancer. Options include fecal occult blood testing (FOBT), flexible sigmoidoscopy, the combination of FOBT and flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema. However, the quality of evidence, magnitude of benefit, and potential harms vary with each method. The USPSTF found good evidence that periodic FOBT (use of guaiac-based test cards prepared at home by patients from three consecutive stool samples) reduces mortality from colorectal cancer^2-4 and fair evidence that sigmoidoscopy alone or in combination with FOBT reduces mortality.^5,6 The USPSTF found no direct evidence that screening colonoscopy is effective in reducing colorectal cancer mortality but did find compelling supportive evidence.^7,8 It is not certain whether the potential added benefits of colonoscopy relative to screening alternatives are enough to justify the added risks and inconvenience for patients. Double-contrast barium enema offers an alternative means of examining the entire colon, but the USPSTF found no direct evidence that it reduces mortality. Neither digital rectal examination (DRE) nor the testing of a single stool specimen obtained during DRE is recommended as a screening strategy. Studies have not yet examined clinical outcomes with computed tomographic colography (virtual colonoscopy). The optimal interval for screening depends on the test, and direct evidence exists only for FOBT every one to two years.^2,4 Other recommended screening intervals include 10 years for colonoscopy and five years for both sigmoidoscopy and double-contrast barium enema. According to the USPSTF, there are insufficient data to determine which strategy provides the best balance of benefits and potential harms. Studies indicate that screening is likely to be cost effective, regardless of the strategy chosen.⁹

BHUPESH MANGLA, M.D.
Final-year resident
Yale University-Griffin Hospital Combined Internal Medicine and Preventive Medicine residency program
Yale University School of Medicine

KENNETH FINK, M.D., M.G.A., M.P.H.
Kerr White visiting scholar
Center for Practice and Technology Assessment
Agency for Healthcare Research and Quality
and
Assistant professor
Department of Family Medicine
University of North Carolina at Chapel Hill School of Medicine

REFERENCES

1. Ries LA, Wingo PA, Miller DS, Howe HL, Weir HK, Rosenberg HM, et al. The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer. Cancer 2000; 88:2398-424.
2. Mandel JS, Bond JH, Church TR, Snover DC, Bradley GM, Schuman LM, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993;328:1365-71.
3. Hardcastle JD, Chamberlain JO, Robinson MH, Moss SM, Amar SS, Balfour TW, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996;348:1472-7.
4. Mandel JS, Church TR, Ederer F, Bond JH. Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood. J Natl Cancer Inst 1999;91:434-7.
5. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med 1992;326:653-7.
6. Newcomb PA, Norfleet RG, Storer BE, Surawicz TS, Marcus PM. Screening sigmoidoscopy and colorectal cancer mortality. J Natl Cancer Inst 1992;84:1572-5.
7. Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993;329:1977-81.
8. Muller AD, Sonnenberg A. Protection by endoscopy against death from colorectal cancer. A case-control study among veterans. Arch Intern Med 1995;155:1741-8.
9. Pignone M, Saha S, Hoerger T, Mandelblatt J. Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:96-104.