32 HOW TO TREAT: COLORECTAL CANCER: DIAGNOSIS
32 HOW TO TREAT: COLORECTAL CANCER: DIAGNOSIS
11 APRIL 2025 ausdoc. com. au
Figure 8. Endoscopic picture of hepatic flexure cancer.
colonoscopy but is told to return if his symptoms recur. The GP carefully documents this discussion in James’ medical record.
Case study two
Rose, a fit and well 37-year-old, presents to her GP complaining of rectal bleeding. She reports that the bleeding is bright red, but inspection of the photos on her phone reveal that the bleeding is maroon in colour. She also reports that her bleeding has happened without a bowel motion. Rose does not have any other symptoms and there is no family history of bowel cancer.
Examination, including rectal examination, is normal. Her GP is concerned about the bleeding and refers Rose to a colorectal surgeon for further workup. The specialist
How to Treat Quiz.
1. Which THREE statements regarding CRC are correct? a FOBT is recommended every year for those aged 45-74. b CRC is on the rise in those aged under 50. c Screening rates increase with the intervention of GPs and other health professionals. d Survival from CRC now stands at 70 %.
2. Which THREE are symptoms of large bowel cancer or other significant large bowel pathology? a Blood in the faeces. b Persistent or unusual abdominal pain. c Nausea and vomiting. d Persistent and unusual change in bowel habit lasting more than two weeks.
3. Which TWO are features of bleeding from a benign perianal cause? a Blood mixed in with the faeces. b Bleeding accompanies a bowel motion. c Dark blood and clots. d Bleeding is associated with perianal symptoms such as pain or a lump.
4. Which TWO are indicated in those at or slightly above average risk for CRC? a FOBT at least every two years from the age of 45. b Colonoscopy every five years starting at 45, or at an age 10 years younger than the age of youngest CRC diagnosis in the family, whichever comes first. c Consideration of colonoscopy if patients develop symptoms of CRC. d Referral to a family genetics clinic.
5. Which THREE are risks of colonoscopy? a Risk of perforation of the small bowel. b Risk of bleeding after removal of polyps or biopsies. c General risks of anaesthesia. d Risks of bowel preparation.
6. Which TWO statements are correct regarding the asymptomatic patient at normal risk? a Colonoscopy and FOBT are equally accurate in detecting CRC in the asymptomatic patient. b In Australia, FOBT is used as a
Changes to the MBS have made it difficult for patients to have a colonoscopy solely for screening purposes.
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population screening tool. c MBS item number 32228, applicable only once a lifetime, allows for a colonoscopy without a stated reason. d It is never appropriate to proceed to colonoscopy in asymptomatic patients.
7. Which THREE interventions have evidence for reducing the risk of CRC? a Maintaining a BMI of
20-25kg / m 2. b Consuming highly soluble fibre. c Avoiding smoking. d Reducing consumption of lean red meats.
8. Which TWO statements regarding follow-up after removal of polyps are correct? a Consider a possible genetic syndrome in people with more than 10 adenomas on a single examination. b Most polyps require abdominal surgery for removal. c People with small rectal hyperplastic polyps require
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COLORECTAL CANCER: DIAGNOSIS
advises Rose to have a colonoscopy because of the unusual pattern of bleeding. At colonoscopy a sigmoid cancer is found, and subsequent staging does not show evidence of metastatic disease. She has a successful laparoscopic anterior resection, removing the sigmoid. Her final staging is stage I, meaning that no chemotherapy is required. In conjunction with her GP, Rose undergoes careful
FOBT at the prescribed screening intervals. d A hyperplastic polyp in the rectum significantly increases the risk of colorectal cancer.
9. Which THREE statements regarding other screening methods for CRC are correct? a Blood cancer screening tests are not currently approved in Australia. b A patient with a positive CT colonography does not need colonoscopic confirmation. c Stool DNA studies appear to have a high false-positive rate. d Testing is available for some specific syndromes associated with inherited bowel cancer.
10. Which THREE statements regarding colonoscopy are correct? a Colonoscopy is the gold standard for diagnosis of colorectal cancer. b Advanced colonoscopic techniques allow for the resection of polyps larger than 1cm. c The risks for the removal of small and large polyps colonoscopically are the same. d Proceduralists who perform colonoscopy now require recertification. surveillance and is also referred to a familial cancer genetics clinic because of her young age. She is closely surveyed for the next five years.
Case study three
John, 48, presents to his GP requesting colonoscopy. His mother, aged 70, has recently undergone a right hemicolectomy for colon cancer. The GP takes a detailed history that reveals John does not have any symptoms to suggest colonic pathology, and his mother is the only affected relative. Physical examination is normal. Despite John’ s family history, he is only at slightly above average risk. Therefore, FOBT is usually indicated. Nonetheless, he is adamant about colonoscopy and is referred to a gastroenterologist. The gastroenterologist discusses the possible benefits and harms of colonoscopy and explains that John can have a colonoscopy without a specific indication, but only once in his lifetime. John decides to go ahead. His subsequent colonoscopy is normal, and he is counselled to continue with a biannual FOBT.
CONCLUSION
COLORECTAL cancer remains the second highest cause of cancer-related death in Australia. Screening plays a vital role in reducing this death rate, especially because patients can remain asymptomatic even with advanced metastatic disease.
Consider whether further investigation with colonoscopy is appropriate in any patient aged over 30 who has rectal bleeding or other suspicious symptoms.
RESOURCES
• Gastroenterological Society of Australia list of proceduralists who have undergone recertification recert. gesa. org. au
• Cancer Council Australia Clinical practice guidelines for the prevention, early detection and management of colorectal cancer bit. ly / 3Ng5LI3
References Available on request from howtotreat @ adg. com. au