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ABSTRACT: Colorectal cancer is a significant contributor to morbidity and mortality in the United States. Studies published in the early 1990s, showing that screening for colorectal cancer can reduce colorectal cancer-related mortality, led many organizations to recommend screening in asymptomatic, average-risk adults older than 50 years. Since then, however, national screening rates remain low. Several important studies published over the past four years have refined our understanding of existing screening tools and explored novel means of screening and prevention. The most important new developments, which are reviewed in this article, include the following: Additional trial results support the effectiveness of fecal occult blood testing in reducing the incidence of, and mortality from, colorectal cancer. New studies document the sensitivity of fecal occult blood testing, sigmoidoscopy, and double-contrast barium enema compared with colonoscopy. Cost-effectiveness models show that screening by any of several methods is cost-effective compared to no screening. Randomized trials show that calcium is effective but fiber is not effective in preventing reoccurrence of adenomatous polyps. Preliminary data suggest that nonsteroidal anti-inflammatory drugs may prevent adenomatous polyps and that DNA stool tests and virtual colonoscopy may show promise as screening tools. This new information provides further support for efforts to increase the use of colorectal cancer screening and prevention services in adults older than 50 years.
Serum Tumor Markers - Article
ABSTRACT: Monoclonal antibodies are used to detect serum antigens associated with specific malignancies. These tumor markers are most useful for monitoring response to therapy and detecting early relapse. With the exception of prostate-specific antigen (PSA), tumor markers do not have sufficient sensitivity or specificity for use in screening. Cancer antigen (CA) 27.29 most frequently is used to follow response to therapy in patients with metastatic breast cancer. Carcinoembryonic antigen is used to detect relapse of colorectal cancer, and CA 19-9 may be helpful in establishing the nature of pancreatic masses. CA 125 is useful for evaluating pelvic masses in postmenopausal women, monitoring response to therapy in women with ovarian cancer, and detecting recurrence of this malignancy. Alpha-fetoprotein (AFP), a marker for hepatocellular carcinoma, sometimes is used to screen highly selected populations and to assess hepatic masses in patients at particular risk for developing hepatic malignancy. Testing for the beta subunit of human chorionic gonadotropin (beta-hCG) is an integral part of the diagnosis and management of gestational trophoblastic disease. Combined AFP and beta-hCG testing is an essential adjunct in the evaluation and treatment of nonseminomatous germ cell tumors, and in monitoring the response to therapy. AFP and beta-hCG also may be useful in evaluating potential origins of poorly differentiated metastatic cancer. PSA is used to screen for prostate cancer, detect recurrence of the malignancy, and evaluate specific syndromes of adenocarcinoma of unknown primary.
ABSTRACT: This article describes a joint update of guidelines by the American Cancer Society and the U.S. Multi-Society Task Force on Colorectal Cancer delineating evidence-based surveillance recommendations for patients after polypectomy and colorectal cancer resection. Although there are some qualifying conditions, the following general guidelines apply: after colonoscopic polypectomy, patients with hyperplastic polyps should be considered to have normal colonoscopies, and subsequent colonoscopy is recommended at 10 years. Patients with one or two small (less than 1 cm) tubular adenomas, including those with only low-grade dysplasia, should have their next colonoscopy in five to 10 years. Patients with three to 10 adenomas, any adenoma 1 cm or larger, or any adenoma with villous features or high-grade dysplasia should have their next colonoscopy in three years. Following curative resection of colorectal cancer, patients should undergo a colonoscopy at one year, with subsequent follow-up intervals determined by the results of this examination. Adoption of these guidelines will have a dramatic impact on the quality of care provided to patients after a colorectal cancer diagnosis, will assist in shifting available resources from intensive surveillance to screening, and will ultimately decrease suffering and death related to colorectal cancer.
ABSTRACT: Flexible sigmoidoscopy is an important screening procedure because of its ability to detect early changes in the distal colon. The 60-cm flexible sigmoidoscope provides excellent visualization with minimal discomfort to patients. Successful sigmoidoscopy requires adequate patient preparation, proper equipment and an experienced examiner who can recognize both normal and abnormal findings. Complications arising from sigmoidoscopy are rare, but patients may experience some cramping, gas or watery stools. Screening and primary preventive measures, including regular exercise and increased dietary fiber intake, can lower the morbidity and mortality associated with colorectal cancer.
ABSTRACT: Spurred by mounting evidence that the detection and treatment of early-stage colorectal cancers and adenomatous polyps can reduce mortality, Medicare and some other payors recently authorized reimbursement for colorectal cancer screening in persons at average risk for this malignancy. A collaborative group of experts convened by the U.S. Agency for Health Care Policy and Research has recommended screening for average-risk persons over the age of 50 years using one of the following techniques: fecal occult blood testing each year, flexible sigmoidoscopy every five years, fecal occult blood testing every year combined with flexible sigmoidoscopy every five years, double-contrast barium enema every five to 10 years or colonoscopy every 10 years. Screening of persons with risk factors should begin at an earlier age, depending on the family history of colorectal cancer or polyps. These recommendations augment the colorectal cancer screening guidelines of the American Academy of Family physicians. Recent advances in genetic research have made it possible to identify persons at high risk for colorectal cancer because of an inherited predisposition to develop this malignancy. These patients require aggressive screening, usually by lower endoscopy performed at an early age. In some patients, genetic testing can guide screening and may be cost-effective.
Update on Colorectal Cancer - Article
ABSTRACT: An estimated 129,400 new cases of colorectal cancer occurred in the United States during 1999. The lifetime risk of developing this cancer is 2.5 to 5 percent in the general population but two to three times higher in persons who have a first-degree relative with colon cancer or an adenomatous polyp. Between 70 and 90 percent of colorectal cancers arise from adenomatous polyps, whereas only 10 to 30 percent arise from sessile adenomas. Tumors or polyps that develop proximal to the splenic flexure carry a poorer prognosis than those that arise more distally, in part because of delayed diagnosis secondary to later development of symptoms. The Dukes system is the classic staging method for colorectal cancer; the TNM staging system is more detailed and therefore more useful for surgical purposes. Although screening guidelines vary, most agree that colorectal cancer screening should begin at 50 years of age in patients without a personal or family history of colorectal cancer.
When Is the Right Time to Repeat Colonoscopy? - Editorials
ABSTRACT: Menopause is the permanent cessation of menstruation resulting from the loss of ovarian and follicular activity. It usually occurs when women reach their early 50s. Vasomotor symptoms and vaginal dryness are frequently reported during menopause. Estrogen is the most effective treatment for management of hot flashes and night sweats. Local estrogen is preferred for vulvovaginal symptoms because of its excellent therapeutic response. Bone mineral density screening should be performed in all women older than 65 years, and should begin sooner in women with additional risk factors for osteoporotic fractures. Adequate intake of calcium and vitamin D should be encouraged for all postmenopausal women to reduce bone loss. Coronary artery disease is the leading cause of death in women. Postmenopausal women should be counseled regarding lifestyle modification, including smoking cessation and regular physical activity. All women should receive periodic measurement of blood pressure and lipids. Appropriate pharmacotherapy should be initiated when indicated. Women should receive breast cancer screening every one to two years beginning at age 40, as well as colorectal cancer screening beginning at age 50. Women younger than 65 years who are sexually active and have a cervix should receive routine cervical cancer screening with Papanicolaou smear. Recommended immunizations for menopausal women include an annual influenza vaccine, a tetanus and diphtheria toxoid booster every 10 years, and a one-time pneumococcal vaccine after age 65 years.
ABSTRACT: Colorectal cancer causes significant morbidity and mortality in the United States. The incidence of colorectal cancer can be reduced with increasing efforts directed at mass screening of average-risk adults 50 years and older. Currently, fecal occult blood test and flexible sigmoidoscopy have the highest levels of evidence to support their use for colorectal cancer screening. Colonoscopy does not have a proven colorectal cancer mortality benefit, but it does have the greatest single-test accuracy, and it is the final test in the pathway to evaluate and treat patients with other abnormal screening tests. Double-contrast barium enema has sparse data of effectiveness. Computed tomographic colonography, fecal DNA testing, and Pillcam Colon are promising tests that need further study before they can be recommended for widespread screening. Routine screening should continue until 75 years of age. There is good evidence that fiber and antioxidants are not effective for primary prevention of colorectal cancer; they should not be recommended for chemoprevention. There is good evidence that aspirin, nonsteroidal antiinflammatory drugs, and cyclooxygenase-2 inhibitors are effective for decreasing the risk of colorectal cancer and adenomatous polyps, but increased risks, such as gastrointestinal bleeding, limit their usefulness. There is fair evidence that obesity is associated with colorectal cancer. Additional studies are needed on decreased fat intake and red meat consumption, and the use of calcium, vitamin D, and statins before these can be recommended for primary prevention of colorectal cancer.
Colorectal Cancer Screening WorksIf We Do It - Editorials