HOW TO TREAT 27
ausdoc. com. au 11 APRIL 2025
HOW TO TREAT 27
Box 3. Indications for colonoscopy allowable on MBS item 32222 or 32223
• Positive FOBT.
• Anaemia or iron deficiency.
• Symptoms suggestive of colonic pathology.
• Imaging indicating abnormality of the colon.
• First examination after surgery for CRC.
• For pre-operative evaluation.
• Previous colonoscopy with inadequate bowel preparation.
• Management of inflammatory bowel disease.
• Patient with moderate risk family history( Category 2) or higher.
Source: MBS Online 8
affected. Include questions regarding a family history of colorectal cancer in a patient’ s annual systems review and update their records.
Educate patients to be vigilant for interval symptoms between screening investigations, including rectal bleeding, change in bowel habits, unexplained abdominal pain or weight loss.
There is a general consensus that 100mg of aspirin a day is likely beneficial in the prevention of colorectal cancer. 6 It takes at least 10 years for the benefit to be seen, and the duration of treatment should not be less than 2.5 years. Studies suggest that taking aspirin for a longer duration may not bring about a higher reduction in colorectal cancer risk. 9 However, this data should be viewed with caution. All the trials were originally designed for cardiovascular risk, and most of the trials were in men.
Although the Cancer Council of Australia has made a recommendation to consider aspirin, the USPSTF only recommends this in patients who have at least 10 % cardiovascular risk.
Aspirin carries a risk of gastric ulceration, bleeding and renal impairment, so consider these risks carefully during a full and frank discussion with each patient.
Management of patients who have had adenomatous polyps
Detection of polyps on colonoscopy may alter the advice given regarding future screening strategies. With the MBS changes making colonoscopy more difficult to access, it has become very important that the initial screening colonoscopy is of high quality. The guidelines for follow-up investigation after removal of polyps are outlined in table 2.
Each polyp should be judged on its merits. A hyperplastic polyp in the rectum is unlikely to increase
the risk of colorectal cancer, and therefore the patient remains at the same risk as before the colonoscopy. Adhere to the various screening intervals in table 1. While recommendations from national guidelines are important, always tailor the individual patient advice to the specific needs of the patient.
Polyps can generally be removed colonoscopically. The traditional techniques of polypectomy, including the use of hot biopsy forceps and an electro-cautery snare, have now augmented with more advanced techniques, including endoscopic mucosal resection.
There is a general consensus that 100mg of aspirin a day is likely beneficial in the prevention of colorectal cancer.
The newer techniques of colonoscopic polypectomy allow for the removal of most polyps without the need for abdominal surgery; however, complete colonoscopic removal is not possible in a small number of patients, and some highgrade dysplastic polyps PAGE 30
Table 2. Guidelines for follow-up investigation after removal of polyps
Risk category |
When to test |
Recommended |
|
|
test( s) |
People with small rectal hyperplastic polyps
People with 1-4 small( less than 1cm) tubular adenomas with low-grade dysplasia or sessile serrated lesions without dysplasia( see figures 2 and 3)
People with 5-9 adenomas, or a large( at least 1cm) polyp( hyperplastic, adenomatous or sessile serrated), or any adenomas with high-grade dysplasia or villous features, or sessile serrated lesions with dysplasia
People with more than 10 adenomas on a single examination
People with adenomas that are removed in pieces
Source: Cancer Council Australia 6
Same age as those at average risk
5-10 years after the polyps are removed
Three years after the polyps are removed
FOBT at the prescribed screening intervals
Colonoscopy
Colonoscopy
Comments
Figure 2. Adenoma.
Figure 3. A sessile serrated lesion.
Those with hyperplastic polyposis syndrome are at increased risk for adenomatous polyps and cancer and require more intensive follow-up
Time between tests is based on other factors such as prior colonoscopy findings, family history, and patient and doctor preferences
Adenomas must have been completely removed If the colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia, future colonoscopies can be done every five years
One year Colonoscopy Consider a possible genetic syndrome
2-6 months after adenoma removal
Colonoscopy
If entire adenoma has been removed, further testing should be based on doctor’ s judgement