Don't skip CRC screening

Family physicians should be encouraged to advise colorectal cancer (CRC) screening for all appropriate patients. CRC is not only the No. 2 cause of cancer death in the United States, it is also responsible for more than one-half of the malpractice litigation filed against primary care physicians for gastrointestinal complaints.

"You absolutely want to make colorectal cancer screening a high priority," said John Pope, MD, professor of clinical family practice, Louisiana State University Health Sciences Center in Shreveport. "If your patient comes up with colorectal cancer, the lawyers are gunning for you. You have to screen and you have to document that you screen. We are at risk."

The good news is that approximately 90% of CRC can be prevented with appropriate screening, Dr Pope said at an early morning session of the American Academy of Family Physicians on Wednesday, Oct. 3, 2007. And although patients generally dislike the prospect of CRC screening, most are willing to undergo some form of screening if recommended by the physician.

"This is not a procedure that people line up at your door and demand," he said. "But it is something that almost everyone will do if you recommend it. The data show that physicians just are not very good at recommending screening and even worse at following up appropriately."

In the general population, more than 90% of CRC occurs in individuals over age 50, according to Dr Pope. Based on this statistic, the general recommendation is that CRC screening begin at age 50. Yet only 44% of the eligible population is actually screened.

"The appropriate test was never recommended for the vast majority of these people," he said. "There are very few folks who do not accept some sort of screening. But the physician has to recommend it."Many patients are unhappy with the prospect of a colonoscopy or a flexible sigmoidoscopy, but nearly all accept an annual fecal occult blood test (FOBT). An annual FOBT for 10 years detects up to 93% of colorectal cancers, which compares favorably with the 95% detection rate for colonoscopy performed at the recommended interval of 10 years. Annual FOBT has the added advantage of picking up the relatively rare cases of fast-growing CRC that an FOBT performed once every decade might miss.Because CRC is associated with advancing age, screening average risk patients who are younger than age 50 is not cost effective, Dr Pope noted. This average risk population has a 6% lifetime risk of CRC after the age of 50.

But patients who have a first-degree relative diagnosed with CRC at age 60 or older have double the risk for CRC. Screening for these higher risk patients should begin at age 40. Patients with a first-degree relative diagnosed with CRC at less than age 60 have three to six times the typical risk for developing CRC.

These high-risk patients should be screened first at age 40 or 10 years younger than the age at which the first-degree relative was diagnosed. For example, if a first-degree relative was diagnosed at age 50, the patient should be screened starting at age 40. But if the first-degree relative was diagnosed at age 43, Dr Pope noted, the patient should begin screening at age 33."Screening is the standard of care," Dr Pope said.