CRC Guidelines- What’s New and What to Do?

Colon cancer remains a significant healthcare issue with nearly 145,000 new cases per year and 48,000 related deaths in the U.S. annually. Everyone is at risk – even without a family history.

Although there is clear evidence that colon cancer screening saves lives and can effectively in most patients prevent the development of colon cancer, the rates for colon cancer screening remain far less than other very effective programs such as breast cancer or cervical cancer (PAP smears).

New guidelines have been released by the American College of Gastroenterology (ACG) and there are some important issues to highlight for patients to understand and bring up with their health care provider.

Colonoscopy every 10 years beginning at age 50 remains the preferred strategy for colorectal cancer screening. This test is cancer preventative if precancerous polyps can be identified and removed and the patient kept in a follow-up surveillance schedule. This test remains the most cost effective test for prevention of colon cancer.

The new guidelines suggest that the older tests (Hemoccult) be abandoned and replaced with another stool test which involves a chemical test which detects human blood and is much more specific for blood in the stool (which may suggest colon cancer or advanced large colon polyps). The dietary restrictions prior to the Hemoccult test (e.g. avoidance of red meats, leafy vegetables) are not needed with the newer fecal immunohistochemical tests (FIT).

CT Colonography (also known as “virtual” colonoscopy) done every 5 years is endorsed in the updated ACG guideline as an alternative to every 10 years for patients who decline a traditional endoscopic exam. Compared to a traditional colonoscopy, the CT Colonoscopy is not as sensitive for detection of polyps or colon cancer. It is important for patients to understand that this test does involve the same bowel preparation for cleaning the colon that is used for colonoscopy. Additionally, a tube is inserted into the rectum to inflate gas into the colon. In contrast to a traditional colonoscopy, sedation is not used for this procedure. Also if a polyp is seen, the patient will have to be referred for colonoscopy. Typically this means scheduling an appointment on another day and therefore enduring another colon cleansing preparation! Additionally, there is recent evidence about the cancer causing effects that radiation from x-rays (like CAT scans) can create- in particular if patients have repeated scans over their life.

Due to a lack of data to show this technology is a benefit in the updated guideline, the ACG removed this test from the current menu of options for screening.

The updated guideline includes a new recommendation for African Americans to begin colorectal cancer screening earlier, at age 45, because of the high incidence of colorectal cancer and a greater prevalence of right sided (higher up in the colon) polyps and cancerous lesions in this population.

Changes were made as to when to begin screening in family members.

Begin at age 40 or ten years earlier than the age of the patient when they developed colon cancer. These patients should have a traditional colonoscopy every 5 years thereafter.

Recommended screening: Same as average risk (colonoscopy every 10 years beginning at age 50 years).

Recommended screening: colonoscopy every 5 years beginning at age 40 or 10 years younger than age at diagnosis of the youngest affected relative.

The guidelines highlight some patients who in particular may be at even higher risks for colon polyps and cancer.

Literature review reveals that people who have smoked for more than 20 years have over 2 to 3 times the risk for precancerous colon polyps as non-smokers. There is as much as a 30% increased risk for colon and rectal cancer for both male and female smokers as well as an increase of up to 50% in deaths from colorectal cancer. It also has been observed that the risk of colorectal cancer and mortality may be increased after 20 pack years or less of smoking exposure. The impact of quitting is as yet unclear but it appears that the risk may continue to increase, perhaps as long as 20 years after smoking cessation.

Evidence supports the prediction that both overweight and obese status are associated with increased risk of CRC. The risk of both precancerous polyps as well as colon cancer is increased approximately 2 to 3 times for obese compared to nonobese patients.

Colon cancer screening should be a top priority. This disease is treatable, beatable and preventable! With well informed patients asking good questions to their health care providers, together we can make a meaningful difference in this deadly disease!