The American Cancer Society and Colorectal Cancer Screening

Colorectal cancer is the fourth most common cancer with 140,000 diagnoses in the nation annually. It causes 50,000 deaths per year and is the number two cause of death due to cancer.

Colorectal cancer screening guidelines have called for digital rectal examinations beginning at age 40 and colonoscopies at age 50 in low risk individuals. An aggressive public awareness campaign has resulted in a marked decrease in deaths from this disease in men and women over age 65.

The same cannot be said for men and women younger than 55 years old where there is an increased incidence of colorectal cancer by 51% with an increased mortality of 11%. Experts believe the increase may be due to lifestyle issues including tobacco and alcohol usage, obesity, ingestion of processed meats and poorer sleep habits.

To combat this increase, the American Cancer Society has changed its recommendations on screening suggesting that at age 45 we give patients the option of:

  • Fecal immunochemical test yearly
  • Fecal Occult Blood High Sensitivity Guaiac Based Yearly
  • Stool DNA Test (e.g., Cologuard) every 3 years
  • CT Scan Virtual Colonoscopy every 5 years
  • Flexible Sigmoidoscopy every 5 years
  • Colonoscopy every 10 years.

Their position paper points out that people of color, American Indians and Alaskan natives have a higher incidence of colon cancer and mortality than other populations.  Therefore, these groups should be screened more diligently. They additionally note that they discourage screening in adults over the age of 85 years old. This decision should be individualized based on the patient’s health and expected independent longevity.

As a practicing physician these are sensible guidelines. The CT Virtual Colonoscopy involves a large X irradiation exposure and necessitates a pre- procedure prep. Cologuard and DNA testing misses few malignancies but has shown many false positives necessitating a colonoscopy. Both CT Virtual Colonoscopy and Cologuard may not be covered by your insurer, and they are expensive, so consider the cost in your choice of screening.

I still believe Flexible Sigmoidoscopy must be combined with the Fecal Occult Blood High Sensitivity Testing and prepping.  Looking at only part of the colon makes little sense to me in screening.

Colonoscopy is still the gold standard for detecting colorectal cancer.

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American Cancer Society Issues Prostate Cancer Survivor Guidelines

Prostate CancerThe American Cancer Society issued guidelines on how prostate cancer should be followed once treatment has been provided with the bulk of the responsibility falling on primary care providers. There are 240,000 new prostate cancer diagnoses in United States each year. Most of these malignancies are localized or regional disease in older men with five year survivals approaching 100%. The guidelines are quite simple. Prostate cancer survivors should have a PSA measured every six months for the first five years after treatment. After five years an annual PSA level is considered sufficient. If the PSA is increasing a referral should be made to a specialist either a urologist skilled in treatment of prostate cancer or an oncologist. An annual digital examination should be part of the regimen of all survivors of prostate carcinoma. These new guidelines are consistent with recommendations made by the Institute of Medicine and the National Comprehensive Cancer Network.

As treatment of cancer becomes more successful we can expect to see more guidelines on how to medically screen and follow survivors. The recommendation that the responsibility fall on the shoulders of primary care physicians comes at a time when the nation faces a shortage of future primary care physicians. At the same time that recommendations call for PSA evaluation every six months for the first five years in prostate carcinoma survivors, there are no recommendations to screen healthy males for prostate cancer with PSA measurements. That is a separate and distinct controversial issue.