The best approach hinges on the number, degree, and age of relatives diagnosed with colorectal cancer (CRC) or adenomatous polyps (AP). Screening should begin at 40 years of age for patients with a family history of CRC or AP in at least 1 first-degree relative or CRC in at least 2 second-degree relatives (strength of recommendation [SOR]: B, extrapolation from systematic reviews)

Nelson, Roxanne M.

Wiltz, Scott A.

University of Missouri: MOspace

Evidence-based answers from the Family Physicians Inquiries Network176 THE JOURNAL OF FAMILY PRACTICE  |   MARCH 2010  |   VOL 59, NO 3 What’s the most eff ective way to screen patients with a familyhistory of colon cancer?EVIDENCE-BASED ANSWERA the best approach hinges on  the number, degree, and age of relatives diagnosed with colorectal can-cer (CRC) or adenomatous polyps (AP). Screening should begin at 40 years of age for patients with a family history of CRC or AP in at least 1 fi rst-degree relative or CRC in at least 2 second-degree relatives (strength of recommendation [SOR]: B, extrapolation from systematic reviews).Patients at highest risk—who have 1 fi rst-degree relative diagnosed with CRC or AP before 60 years of age or multiple fi rst-degree relatives diagnosed at any age—should begin screening with colonoscopy at 40 years of age or 10 years younger than the earliest aff ected relative and undergo a repeat colonoscopy every 5 years (SOR: C, consensus guidelines). Patients who have a fi rst-degree rela-tive diagnosed with CRC or AP after 60 years of age or 2 or more second-degree relatives with CRC should start screening at 40 years of age, with routine options and follow-up intervals (SOR: C, consensus guidelines). (Routine options and follow-up intervals include any of the following 3 regimens: annual high-sensitivity fecal occult blood testing, sigmoidoscopy every 5 years com-bined with high-sensitivity fecal occult blood testing every 3 years, or screening colonoscopy every 10 years.1) Evidence summaryProspective studies and systematic reviews show increased risk for CRC in people with a signifi cant family history. Little or no data are available regarding outcome improvements or head-to-head comparisons of the eff ects of diff erent screening methods. Recommenda-tions for screening rest largely on inference and consensus opinions.Family history=higher risk at lower ageTh e US Preventive Services Task Force (USPSTF) recommends CRC screening start-ing at 50 years of age for patients with average risk, based on a 5.6% lifetime risk of develop-ing CRC and good evidence that screening reduces morbidity and mortality.1 Patients with a family history of CRC or AP have a risk of CRC at 40 years of age that approximates average risk at 50 years.2 Right-sided colonic lesions are also more likely in patients with a family history of CRC (relative risk [RR]=2.25; 95% confi dence interval [CI], 1.96-2.59).3 Risk increases with number of affected fi rst-degree relativesMoreover, systematic reviews show the RR of CRC to be 1.99 (95% CI, 1.55-2.55) in patients with a single fi rst-degree relative with AP, 2.25 (95% CI, 2.00-2.53) with a single fi rst-degree relative with CRC, and 4.25 (95% CI, 3.01-6.02) with 2 or more fi rst-degree relatives with CRC.3 Younger age at diagnosis also increases riskTh e eff ect of the relative’s age at diagno-Begin screening at 40 years of age for patients with a history of colorectal cancer or polyps in at least 1 fi rst-degree relative or colorectal cancer in at least 2 second-degree relatives.Scott A. Wiltz, MD, MPHEglin Air Force Base Family Medicine Residency, Eglin Air Force Base, FlaRoxanne M. Nelson, MSLISMedical Library and Peyton T. Anderson Learning Resources Center, Mercer University School of Medicine, Macon, Ga177JFPONLINE.COM VOL 59, NO 3  |  MARCH 2010  |  THE JOURNAL OF FAMILY PRACTICEScreen the highest-risk patients with colonoscopy starting at 40 years, or 10 years younger than the earliest affected relative.sis of CRC is demonstrated by an RR of 3.87 (95% CI, 2.40-6.22) if diagnosed at younger than 45 years, 2.25 (95% CI, 1.85-2.72) if diag-nosed at 45 to 59 years, and 1.82 (95% CI, 1.47-2.25) if diagnosed at 60 years or older.3 Recommendations Colonoscopy is the preferred screening op-tion for most patients with family histories that put them at increased risk of CRC and right-sided colonic lesions.4,5 Th e American Cancer Society (ACS) and the American Gas-troenterological Association (AGA) recom-mend that patients with a fi rst-degree relative diagnosed before the age of 60 years or 2 or more fi rst-degree relatives with CRC are at highest risk and should undergo colonoscopy at age 40, or 10 years before the earliest rela-tive’s age at diagnosis; colonoscopy should be repeated every 5 years.4,5 Patients with a fi rst-degree relative di-agnosed with CRC or AP at 60 years or older or multiple second-degree relatives with CRC have an increased risk, but lower than the high-risk group.4 Such patients may start screening early, at 40 years, but using the same options as patients at average risk (see the Evidence-Based Answer).4 Th e TABLE summarizes these screening recommen-dations. Notably, the ACS recommends no screening change (from patients with aver-age risk) for patients with CRC in second-degree relatives because of the modest in-crease in risk.5 Th e American Society for Gastroin-testinal Endoscopy (ASGE) recommends screening colonoscopy for patients with a fi rst-degree relative who was older than 60 when diagnosed with adenomas but notes that the timing of initial colonoscopy hasn’t been established and should be individual-ized. Th e interval for follow-up colonoscopy in these patients should be the same as for average-risk patients. Patients with a second- or third-degree relative with colonic neopla-sia should adhere to average-risk screening recommendations.6 Otherwise, the ASGE rec-ommendations agree with the ones described previously. Th e most recent joint guidelines of the US Multisociety Task Force (USMSTF) on Colorectal Cancer, the American College of Radiology, and the ACS, released in 2008, make no recommendations regarding pa-tients with a family history.7 Th e USMSTF de-fers to guidelines from the ACS and the AGA described earlier.                                                     JFPTABLEACS and AGA guidelines for screening patients with a family history of colorectal cancer Risk factor Screening method Age to start SurveillanceCRC or AP in 1 fi rst-degree relative diagnosed at <60 yr or multiple fi rst-degree relatives Colonoscopy 40 yr, or 10 yr before earliest age at diagnosis of an affected relativeRepeat every 5 years1 fi rst-degree relative with CRC diagnosed at 60 yr or 2 second-degree relatives with CRC Same as average-risk screening*40 yr Same as average-risk screening 1 second-degree or any more distant relatives with CRCSame as average-risk screeningSame as average-risk screeningSame as average-risk screening*The ACS recommends screening these patients as average risk, meaning that screening should occur at age 50 and can use other recommended screening methods besides colonoscopy. ACS, American Cancer Society; AGA, American Gastroenterological Association; AP, adenomatous polyps; CRC, colorectal cancer.Adapted from: Winawer S et al. Gastroenterology. 20034 and Smith RA et al. CA Cancer J Clin. 2003.5CONTINUED178 THE JOURNAL OF FAMILY PRACTICE  |   MARCH 2010  |   VOL 59, NO 3 1.  US Preventive Services Task Force. Screening for colorectal can-cer. Rockville, MD: Agency for Healthcare Research and Quality; July 2002. Available at: www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed June 11, 2008.  2.  Fuchs CS, Giovannucci EL, Colditz GA, et al. A prospective study of family history and the risk of colorectal cancer. N Engl J Med. 1994;331:1669-1674.  3.  Johns LE, Houlston RS. A systematic review and meta-analysis of fa-milial colorectal cancer risk. Am J Gastroenterol. 2001;96:2992-3003.  4.  Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screen-ing and surveillance: clinical guidelines and rationale—update based on new evidence. Gastroenterology. 2003;124:544-560.  5.  Smith RA, Cokkinides V, Eyre HJ, American Cancer Society. American Cancer Society guidelines for the early detection of cancer, 2003. CA Cancer J Clin. 2003;53:27-43. Available at: http://caonline.amcancersoc.org/cgi/content/full/53/1/27. Accessed June 11, 2008.  6.  Davila RE, Rajan E, Baron TH, et al. ASGE guideline: colorec-tal cancer screening and surveillance. Gastrointest Endosc. 2006;63:546-557.  7.  Levin B, Lieberman DA, McFarland B, et al. Screening and sur-veillance for the early detection of colorectal cancer and ad-enomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008;58:130-160. Available at: http://caonline.amcancersoc.org/cgi/content/full/58/3/130. Accessed on June 11, 2008. ReferencesACKNOWLEDGEMENTSThe opinions and assertions contained herein are the private views of the authors and not to be construed as offi cial, oras refl ecting the views of the US Air Force Medical Service or the US Air Force at large.Online at jfponline.comGet answers to these Clinical Inquiries by going to jfponline.com and clicking on “Online Exclusives” in the left-hand navigation bar.•  Do intercontraction intervals predict when a woman at term should seek evaluation of labor? •  What’s the best way to monitor low-risk patients with a history of diff erentiated thyroid cancer?•   Which interventions are best for alleviating nipple pain in nursing mothers?•  Do OTC remedies relieve cough in acute URIs?•  When is it OK for children to start drinking fruit juice?•  Does group prenatal care improve pregnancy outcomes?•  What measures relieve postherpetic neuralgia?•   Menstrual disturbances in perimenopausal women: What’s best?•  What’s the most practical way to rule out adrenal insuffi  ciency?

What's the most effective way to screen patients with a family history of colon cancer?

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