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less than 50% of patients have undergone screening of any kind Discussion and encouragement by the primary care provider are the most important factors in achieving patient compliance with screening programs The potential for harm from screening must be weighed against the likelihood of benefit, especially in elderly patients with comorbid illnesses and shorter life expectancy
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A Fecal Occult Blood Test or Multitarget DNA Assay
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Most colorectal cancers and some large adenomas result in increased chronic blood loss that may be detectable A variety of tests have been developed that have varying sensitivities for fecal occult blood, some of which are in clinical testing A guaiac-based test (Hemoccult II) has undergone the most extensive testing and has had the greatest clinical use Two slides must be prepared from three consecutive bowel movements To reduce the likelihood of false-positive tests, patients should abstain from aspirin (in doses greater than 325 mg/d), NSAIDs, red meat, poultry, fish, and vegetables with peroxide activity (turnips, horseradish) for 72 hours Vitamin C may cause a false-negative test Slides should be developed within 7 days after preparation The World Health Organization recently endorsed another guaiac test for FOBT, Hemoccult Sensa, because it has higher sensitivity than the Hemoccult II test; however, data from large clinical trials with this test are lacking When FOBT is administered to the general population as part of a screening program, 2-6% of tests are positive Patients with positive tests should undergo colonoscopy accompanied by removal of any polyps identified If colonoscopy reveals no colorectal neoplasm, further screening for colorectal cancer can be deferred for 10 years Of those with positive tests, 5 18% have colorectal cancer, more likely to be at an earlier stage (Dukes A or B) Adenomatous polyps are identified in 25 50% of patients with positive tests Finding these polyps is somewhat fortuitous since most are less than 1 cm in size and unlikely to cause occult bleeding The estimated sensitivity of a one-time guaiac-based FOBT for colorectal cancer is only 13%; however, sensitivity is increased in patients who undergo annual or biannual testing In several large prospective studies, FOBT has been demonstrated to reduce mortality from colorectal cancer by 30 40% among those who are compliant with regular testing An immunochemical FOBT that detects human globin is available The test is positive in 3 6% of asymptomatic patients and has a sensitivity of 65% for detection of colorectal cancer and 28% for all advanced neoplasms A fecal DNA assay (Pre-Gen Plus) is commercially available for screening for colorectal neoplasia The test analyzes fecal DNA for point mutations in the APC, K-ras, and p53 genes, microsatellite instability, and a marker of abnormal apoptosis However, in a recent study performed in a large asymptomatic screening population, the fecal DNA panel detected only one-half of cancers and only 18% of all advanced neoplasms The low sensitivity of FOBT and DNA tests for advanced neoplasia makes them a less attractive choice for populationbased screening than endoscopic or radiographic tests At present, they are most suitable in settings where health care
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Table 39 5 Recommendations for colorectal cancer screening1
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Average-risk individuals 50 years old2 Annual fecal occult blood testing Flexible sigmoidoscopy every 5 years Annual fecal occult blood testing and flexible sigmoidoscopy every 5 years Colonoscopy every 10 years Barium enema every 5 years Individuals with a family history of a first-degree member with colorectal neoplasia3 Single first-degree relative with colorectal cancer diagnosed at age 60 years: Begin screening at age 40 Screening guidelines same as average-risk individual; however, preferred method is colonoscopy every 10 years Single first-degree relative with colorectal cancer diagnosed at age < 60 years, or multiple first-degree relatives: Begin screening at age 40 or at age 10 years younger than age at diagnosis of the youngest affected relative, whichever is first in time Recommended screening: colonoscopy every 5 years For recommendations for families with inherited polyposis syndromes or hereditary nonpolyposis colon cancer, see 14 2 Colorectal cancer screening and surveillance: clinical guidelines and rationale Gastroenterology 2003 Feb;124(2):544 60 3 Screening Recommendations of American College of Gastroenterology Am J Gastroenterol 2000 Apr;95(4):868 77
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