Patient will present as → a 65-year-old male with several months of weight loss, vague right upper quadrant pain, and thin-caliber stools. His medical history is notable for 50-pack-years of smoking and obesity. On exam, he appears chronically ill and has firm hepatomegaly. His labs reveal a hemoglobin of 10.7 g/dL and mildly elevated ALT and AST.
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Progression of adenomatous polyp into malignancy (adenocarcinoma) usually occurs within 10-20 years - Colon CA is the third leading cause of cancer death after lung cancer and skin cancer
- Risk factors include age > 45 y/o, inflammatory bowel disease, polyps, low fiber, high animal fat diet, smoking, ETOH
- Presents as painless rectal bleeding and a change in bowel habits
- Selectively screen adults aged 76 to 85 years for colorectal cancer:
- There is adequate evidence that the benefits of detection and early intervention decline after age 75 years
- Discuss together with patients the decision to screen, taking into consideration the patient’s overall health status (life expectancy, comorbid conditions), prior screening history, and preferences.
Recommended intervals for colorectal cancer screening tests include:
Stool tests:
- High-sensitivity gFOBT or FIT every year
- sDNA-FIT every 1 to 3 years
CT colonography every 5 years
-
- (1 additional individual per 1000 would develop cancer in his or her lifetime due to radiation exposure)
Flexible sigmoidoscopy every 5 years or flexible sigmoidoscopy every 10 years + FIT every year
- (Serious complications occur in approximately 3.4 per 10,000 procedures)
Colonoscopy screening every 10 years
-
- Perforation of the colon occurs in an estimated 3.8 per 10,000 procedures
- Serious complications—including perforation, major bleeding, diverticulitis, severe abdominal pain, and cardiovascular events occur in an estimated 25 per 10,000 procedures
USPSTF colorectal cancer screening guidelines
**When adequate screening colonoscopy is accomplished, intercurrent stool tests (i.e., between colonoscopy examinations) are not necessary. In addition, for patients who have had a negative colonoscopy and have been recommended to have routine screening in 10 years, screening with FIT or other screening tests is not indicated prior to the end of the 10-year period.
"Hereditary factors are believed to contribute to up to 30% of colorectal cancers. Relative risk is 3.8 times if the family member's cancer was diagnosed at less than 45 years of age. Recommended screening in a single first-degree relative with colorectal cancer diagnosed before age 60 is beginning colonoscopy at age 40 or ten years younger than the age at diagnosis of the youngest affected first-degree relative. Then if negative, every 5 years."
Treatment is surgical resection and chemotherapy for nodal involvement
- 5FU is mainstay of chemotherapy
- Monitor CEA with treatment
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Colorectal cancer is the third most common cancer in both men and women with the majority of cases being adenocarcinoma. Risk factors include a family history of colorectal cancer, personal history of inflammatory bowel diseases such as ulcerative colitis or Crohn’s disease, a diet high in red meat, obesity, alcohol consumption greater than four drinks per week, and cigarette smoking. Clinical manifestations of early-stage colorectal cancer are usually non-specific, while manifestations of late-stage colorectal cancer include hepatomegaly, peritonitis, and abdominal pain. Patients aged 45 and older should undergo a colonoscopy once every 10 years to assess for polyps and/or the presence of cancer.
Play Video + QuizQuestion 1 |
complete blood count (CBC) Hint: See D for answer | |
fecal occult blood samples Hint: See D for answer | |
air-contrast barium enema Hint: See D for answer | |
colonoscopy |
Question 2 |
irritable bowel syndrome | |
lactose intolerance | |
adenocarcinoma of the pancreas | |
adenocarcinoma of the colon |
Question 3 |
total colectomy Hint: See B for explanation | |
surgical removal of the mass | |
removal of the appendix Hint: See B for explanation | |
abdominoperineal resection of the rectum Hint: See B for explanation |
Question 4 |
an adenomatous polyp | |
an inflammatory polyp Hint: See A for explanation | |
a hyperplastic polyp Hint: See A for explanation | |
a benign lymphoid polyp Hint: See A for explanation |
Question 5 |
5% Hint: See D for explanation | |
10% Hint: See D for explanation | |
15% Hint: See D for explanation | |
25% |
Question 6 |
There is good evidence to include stool-based testing in screening asymptomatic patients older than 45 years for colorectal carcinoma | |
There is fair evidence to include stool-based testing in screening asymptomatic patients older than 45 years for colorectal carcinoma | |
There is insufficient evidence to include or to exclude stool-based testing testing as an effective screening test for colorectal cancer in asymptomatic patients older than 45 years | |
None of the above |
Question 7 |
CEA is a cost-effective screening test for colorectal cancer Hint: See B for explanation | |
elevated preoperative CEA levels correlate well with postoperative recurrence rate in colorectal cancer | |
CEA is a sensitive test for colorectal cancer Hint: See B for explanation | |
CEA is a specific test for colorectal cancer Hint: See B for explanation | |
CEA has no value in predicting recurrence in colorectal cancer
Hint: See B for explanation |
List |
References: Merck Manual · UpToDate