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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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