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The

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clinical practice

Screening for Colorectal Cancer
David A. Lieberman, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinicalrecommendations.

A healthy 76-year-old woman presents as a new patient for primary care. She reports having one daily bowel movement and no rectal bleeding. She has no family history of colorectal cancer. She reports having negative stool card tests during gynecologic examinations, most recently at 65 years of age. Would you advise this patient to undergo colon-cancer screening, and if so, whattest would you recommend?

The Cl inic a l Probl em
Colorectal cancer is the second leading cause of death from cancer in the United States. This year, it is estimated that there will be 147,000 newly diagnosed cases of colo­ rectal cancer and nearly 50,000 deaths associated with this disease.1 The age­adjusted incidence of colorectal cancer in the United States is 61.2 cases per 100,000 popula­tion among men and 44.8 per 100,000 population among women.1 These rates have been slowly decreasing since 1985. There is considerable evidence that screening of asymptomatic persons who are at average risk can detect cancers at an early and curable stage, resulting in a reduc­ tion in mortality.2-4 Furthermore, some screening tests may also detect cancer­pre­ cursor lesions, which, if removed,may result in a reduced incidence of colorectal cancer.5 There are several different screening tests, each with advantages and limita­ tions (Table 1); differences among strategies in terms of the sensitivity and speci­ ficity of the tests, their complexity, and the associated risk complicate the process of informed decision making.
From the Division of Gastroenterology and Hepatology, OregonHealth and Science University, Portland. Address reprint requests to Dr. Lieberman at the Department of Medicine, Oregon Health and Science University, Mail Code L461, 3181 S.W. Sam Jackson Park Rd., Portland, OR 97239, or at lieberma@ohsu.edu. N Engl J Med 2009;361:1179-87.
Copyright © 2009 Massachusetts Medical Society.

S t r ategie s a nd E v idence
Identification of High-Risk Persons

Themost common indicator of high risk is a first­degree relative with colorectal cancer. If the first­degree relative had colorectal cancer before 50 years of age, there should be suspicion of hereditary syndromes such as familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer syndrome, and MutY homolog (MUTYH) polyposis. Such patients require special screening and should be referredto a special­ ist with expertise in these hereditary syndromes to obtain a complete family history, consider genetic counseling and testing, and determine appropriate timing for endo­ scopic surveillance. If a first­degree relative had colorectal cancer at 50 years of age or older, the lifetime risk of colorectal cancer nearly doubles among his or her family members. Colonoscopy is the preferredscreening test in these persons, and screening should be initiated either when they are 40 years old or when they are 10 years younger than the age at which the family member received a diagnosis of colorectal cancer, whichever comes first.9 Patients with chronic ulcerative colitis or colitis due to Crohn’s disease are at increased risk for colorectal cancer and should undergo surveillance withcolonoscopy, generally beginning 8 to 10 years after diagnosis.
n engl j med 361;12 nejm.org september 17, 2009

An audio version of this article is available at NEJM.org

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The New England Journal of Medicine Downloaded from nejm.org at Hinari Phase 1 sites -- comp on June 28, 2012. For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society....