David S. Weinberg, MD, MSc; Robert E. Schoen, MD, MPH
CME Objective: To review current evidence for prevention, screening, and practice improvement of screening for colorectal cancer.
Funding Source: American College of Physicians.
Disclosures: Drs. Weinberg and Schoen, ACP Contributing Authors, have disclosed the following conflicts of interest: Payment for manuscript preparation: Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0799.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
With the assistance of additional physician writers, Annals of Internal Medicine editors develop In the Clinic using resources of the American College of Physicians, including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program).
Weinberg D., Schoen R.; Screening for Colorectal Cancer. Ann Intern Med. 2014;160:ITC5-1. doi: 10.7326/0003-4819-160-9-201405060-01005
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Published: Ann Intern Med. 2014;160(9):ITC5-1.
Colorectal cancer (CRC) is the third leading cause of cancer death among men and women in the United States (1), but its incidence has been decreasing in the United States by 2%–3% per year over the past 15 years (2). Ample evidence shows that screening with any of several available strategies significantly decreases CRC incidence and mortality. Although still not optimal, screening rates in average-risk populations continue to increase, now exceeding 60% of the eligible population (3).
The lifetime risk for CRC in men and women in the United States is approximately 6%. About 93% of diagnoses are in patients older than 50 years, with the remaining 7% in those aged 40–50 years. CRC before 40 years of age is rare. Women are at modestly lower age-related risk for the disease than men but have an equivalent lifetime risk given their longer average life spans. Data suggest different relationships between age and disease incidence by sex and ethnic group, but these differences are generally not considered large enough to warrant specific, targeted screening recommendations (4, 5).
Joseph D. Feuerstein
Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School
May 15, 2014
There is more to timing the follow up colonoscopy than just the polyp pathology
I read the article by Drs. Weinberg and Schoen with great interest and commend the authors for a thorough review on colorectal cancer screening.1 While the authors published a very nice table (table 1) summarizing the recommended follow up surveillance intervals after a baseline screening colonoscopy, comments regarding the quality of the preparation and technique of the polypectomy is unfortunately missing.1 In its current state, it implies that an internist can just review the type and size of the polyp to determine the follow up interval for the next colonoscopy. The quality of the bowel preparation and how the polyp was removed (e.g. in one piece or piecemeal) is critical in determining the appropriate follow up colonoscopy interval.
As the authors mention, many interval cancers are believed to be secondary to inadequate bowel preparations.1 The current multi-society guideline on colon cancer screening as approved by the American Gastroenterological Association, American College of Gastroenterology and American Society of Gastrointestinal Endoscopy indicates that if a bowel preparation is poor then the colonoscopy should be repeated within 1 year, and if the preparation is only fair then the procedure should be repeated in a five year interval.2 Even a fair bowel preparation is associated with a high rate of missed adenomas. A recent study indicated a miss rate upwards of 28% when the procedure was repeated in three years. When a preparation is graded as poor or fair, a ten year interval is not appropriate if the endoscopist is unable to fully visualize the mucosa even if no adenomas were identified.2, 3 Based on the summary of the evidence and table provided by Drs. Weinberg and Schoen, a clinician reviewing the current recommendations may make a critical error in opting to wait ten years if there is no adenoma identified but the preparation was not adequate.
Similarly, the guidelines recommend that if a large adenomatous polyp is removed piecemeal, the multi-society task force recommends that the colonoscopy be repeated within 1 year to assess if there is any residual adenoma.2 Studies indicate that 19-27% of interval cancers develop in areas of incomplete polypectomy resections.4-6
Ultimately, the success of an adequate screening colonoscopy program to prevent cancer, is hinged on the program providing high quality colonoscopy with recommendations that are consistent with current practice guidelines. I commend the authors on summarizing the evidence nicely, but feel it is critical that the authors clarify the importance of the bowel prep and technique of the polypectomy in determining the timing of a follow up colonoscopy.
1. Weinberg DS, Schoen RE. Screening for Colorectal Cancer. Annals of Internal Medicine 2014;160:ITC5-1.
2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844-57.
3. Adler A, Wegscheider K, Lieberman D, et al. Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12 134 examinations (Berlin colonoscopy project 3, BECOP-3). Gut 2013;62:236-241.
4. Robertson DJ, Greenberg ER, Beach M, et al. Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology 2005;129:34-41.
5. Farrar WD, Sawhney MS, Nelson DB, et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006;4:1259-64.
6. Robertson DJ, Lieberman DA, Winawer SJ, et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut 2013.
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Gastroenterology/Hepatology, Hematology/Oncology, Cancer Screening/Prevention, Colonoscopy/Sigmoidoscopy, Gastrointestinal Cancer.
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