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from page 22
Case study two Hazel , 45 , presents to a GP requesting colonoscopy because her 72-year-old mother has recently undergone surgical resection of a colorectal cancer . On taking a thorough history , the GP determines Hazel has no risk factors or family history to suggest autosomal-dominant inheritance .
Her mother is the only affected relative and the patient herself has no symptoms to suggest neoplasia — specifically , no bleeding , no change in bowel habit and no unexplained abdominal pain or weight loss . Under these circumstances , Hazel fulfils NHMRC category 2 risk for bowel cancer . The indicated screening investigation is one-to-two-yearly FOBT from the age of 50 or screening at an age 10 years younger than the youngest affected relative , whichever is first .
She would only be regarded as fulfilling category two risk if the affected relative had been 55 or younger at the time of presentation . Hazel is reassured that no immediate intervention is required and that screening should start at 50 .
However , two dilemmas may arise for GPs . First , patients will
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regularly question the differentiation between category 1 and category 2 risk when a first-degree relative has been affected , on the basis of a nominal age of 55 . Some patients will ‘ demand ’ colonoscopy under these circumstances .
Given that patients have often seen a close relative go through the
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process of treatment for colorectal cancer , it is reasonable to discuss the option of colonoscopy under these circumstances , provided the risks and benefits of colonoscopy versus FOBT are carefully outlined and documented .
The second dilemma is even though screening is recommended
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to start at age 50 in these circumstances , patients of a recently affected relative will often demand action be taken now . Again , it is reasonable under these circumstances to offer starting FOBT at the patient ’ s current age , selffunded and outside of the NBCSP if they wish to undertake this . |
Summary
Colorectal cancer is extremely common in Australia , affecting one in 20 adults .
Screening is recommended for all average-risk adults over 50 , with FOBT every two years . This will not be covered in the National Screening Program until 2020 , and therefore , all GPs should screen their patients for their risk of bowel cancer .
A careful history and examination can help determine the risk that a patient may have a sinister cause for their symptoms and thus their need for further referral and investigation .
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1 . Which TWO statements regarding cancer of the colon are correct ? a ) Cancer of the colon is more common in women than in men . b ) There is unequivocal level-one evidence supporting population-based stratified screening for bowel cancer in Western society . c ) Colon cancer generally manifests as an adenocarcinoma . d ) Community-based FOBT is ideally suited to those regarded as being of high risk .
2 . Which THREE are risk factors for colon cancer ? a ) Diet b ) Family history c ) Lactose intolerance d ) Lifestyle factors
3 . Which THREE are risks of colonoscopy ? a ) There is a risk of bleeding after removal of polyps or biopsies . b ) There is a risk of perforation of the large bowel , approximately one in 5000 . c ) If perforation is to occur , then there is a significant likelihood that the patient will require abdominal surgery plus or minus stoma formation . d ) Sedation / Anaesthesia
4 . Which THREE are classically features of bleeding of benign perianal origin ?
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a ) Bright blood b ) Blood mixed in with the faeces or melaena stool c ) Blood on the toilet paper d ) Local perianal symptoms , such as the presence of a lump or local pain
5 . Which TWO statements regarding the patient with rectal bleeding are correct ? a ) Every patient with rectal bleeding requires colonoscopy . b ) The vast majority of cases with rectal bleeding are due to a distal colonic malignancy . c ) All adults who present with rectal bleeding should initially be evaluated for symptoms suggestive of proximal pathology . d ) All adult patients with rectal bleeding should have an informed discussion , including the option of colonoscopy tailored to their symptoms .
6 . Which THREE statements regarding the National Bowel Cancer Screening Program ( NBCSP ) are correct ? a ) The NBCSP is tailored for low-to-average risk patients . b ) Under current arrangements in 2016 , repeat colonoscopy is performed every five years in some patients with NHMRC category-two risk . c ) All patients over 50 should have a clear documented discussion regarding whether
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they are appropriate for inclusion in the NBCSP , whether they have performed the test sent to them , the importance of screening and assessment for symptoms . d ) Current community uptake of FOBT when offered under the NBCSP is about 55 %.
7 . Which TWO statements regarding lifestyle changes to manage the risk of colorectal cancer are correct ? a ) Restricting alcohol intake may be protective against colorectal cancer . b ) Unless otherwise contraindicated , NSAIDs should be commenced in all those with an NHMRC category-three risk as soon as this risk is determined . c ) Eating five or more portions of fruit and vegetables a day all year round may reduce the risk of colorectal cancer . d ) Patients at high risk of colorectal cancer should consume soluble cereal fibres , for example , wheat bran .
8 . Which THREE statements regarding polyps are correct ? a ) All polyps are of equal significance . b ) Polyps can generally be removed colonoscopically . c ) With colonoscopic polypectomy , the vast majority of polyps can be removed without resorting to abdominal surgery . d ) While recommendations from national guidelines are important , advice needs to
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be tailored to the individual needs of the patient .
9 . Which TWO statements regarding investigations are correct ? a ) CT colonography is gaining popularity in Australia as a community-screening tool for colorectal cancer . b ) Despite being regarded as an old investigation now , barium enema still has value in a small number of patients . c ) The majority of colorectal cancers in Australia are diagnosed at colonoscopy , even though many are initially prompted by FOBT . d ) CT abdomen and pelvis is a viable first-line investigation in patients who are reluctant to undergo colonoscopy .
10 . Which THREE statements regarding inherited bowel cancer are correct ? a ) In patients with hereditary non-polyposis colon cancer ( HNPCC ), the lesions in bowel cancer have specific features . b ) Immunohistochemistry for HNPCC is cheap and quick and can be performed on minimal volume tissue samples . c ) In familial adenomatous polyposis ( FAP ), polyps are only located in the colon . d ) Consider a diagnosis of FAP in families where there is a strong genetic predisposition towards colorectal cancer or other FAP-type cancers , or where more than 10 adenomas are found on colonoscopy .
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