One of difficulties that we face in providing advice to patients, relates to advising those who are asymptomatic and therefore fit within the framework of the NHMRC guidelines, verses those who present with active symptoms. I'd now like to present a series of case studies, which highlight these differences and how we can apply this framework on a day to day basis in a clinical setting.
In case study 1 we present a 58 year old woman who attends her GP to discuss mammography and cervical screening. In addition to her stated goals, as part of her regular workup, the following should be included:
- A systems review including GI symptoms
- Assessment of her family history of bowel and other cancers
- Enquiry about whether or not she is participating in the NBCSP.
If this woman is asymptomatic and has a negative family history, then she should be advised to participate in the National Bowel Cancer Screening Program when next invited, and preferably to commence biennial screening outside of the program now.
It is important to note that if not already participating, it is likely that she won't be invited for up to 2 years from now, when she turns 60, and really should be tested in the interim. Personally, I would refer her to a private FOB provider in the interim to prevent a 2 year delay in her being screened
Let's just say that this woman tells you that she has already undergone colonoscopy 4 years ago and the result was normal. She indicated that she was going to be invited for a repeat scope in another year. Under these circumstances, there is no formal indication for her to have a repeat scope, and she should be educated regarding the national guidelines and the option of FOBT. It is important that she makes an informed decision regarding the option of either continuing colonoscopic screening, including discussion of the risk of 1/1500 of colonoscopic perforation and its consequences including potential surgery and a stoma, versus the option of FOB testing. There is also the added inconvenience of bowel preparation and at least two days off work. In this setting I would offer her immediate self-funded FOB testing, and then she can participate in the national program when it is offered to her if she wishes. It is worth highlighting here that in 2015, the program has not yet been fully rolled out to offer biennial FOB testing, so it is entirely reasonable for Australians to screen with FOB testing outside the Program in the interim.
Importantly this woman should be reassessed at future consults to ensure that she has commenced screening for bowel cancer along the lines suggested and that she understands the importance of biennial FOBT, and vigilance for interval symptoms, as well as guidance regarding primary prevention.
In case study 2, we present the story of a 35 year old man who presents to his doctor requesting a referral for colonoscopy, as his grandfather has just been diagnosed with bowel cancer at the age of 79. The young man has no symptoms and is otherwise well. No other relatives have been affected.
This is a common scenario where we see young relatives of an older affected patient referred, requesting immediate investigation.
In this particular circumstance, urgent investigation is not required. This young man fulfils the criteria for level one risk under the NHMRC guidelines, the guidelines are clear in suggesting that he does not require screening until he turns 50 as his family history does not currently, significantly affect his personal risk of bowel cancer. Having said that, there will often be pressure to 'take action' in this setting, so there are a number of options to offer this patient.
The guidelines would suggest that he requires screening at either age 50, or ten years younger than the youngest affected relative, and as his grandfather was over 55 at diagnosis, colonoscopy is not indicated, but rather FOBT.
The recommendation relating to the age of diagnosis of the affected relative is perhaps the most contentious aspect of the guidelines and many patients simply refuse to accept this recommendation. This is not difficult to understand of course as the experience of seeing a relative suffer from advanced colorectal cancer is distressing regardless of their age, and likely to evoke an emotive response from the patient's family.
Under these circumstances, there are a number of options that can be offered.
Firstly the young man should be educated regarding the status of the current guidelines, that is that he should commence FOBT at age 50 and he should be educated about vigilance for interval symptoms, and primary prevention.
If he does feel the need to act now, then it is very reasonable to offer him the option of commencing FOBT now, outside of the National Bowel Cancer Screening Program. The kit can then be purchased online from the Cancer Council Victoria website, from some pharmacies or from other third party providers. All GPs should be familiar with these options.
When he turns 50, he can then again discuss the role of colonoscopy vs FOBT, and of course whatever other option may be available in 14 years' time when that deadline arrives.
For the time being however, I would counsel him against up front colonoscopy, as in this setting the likely very low yield is probably outweighed by the risk of perforation associated with the scope itself, days off work and potential out of pocket costs. FOBT alone should provide him with adequate reassurance if he wishes.
In case 3 we present a 55 year old woman who presents to her general practitioner with 3 weeks of bright rectal bleeding. It is important to identify up front that this patient is symptomatic, and hence not eligible for the national program, which applies to asymptomatic patients.
Her family history is negative, systems review was unremarkable with no symptoms of proximal pathology, specifically
- no change in bowel habit,
- weight loss,
- abdominal pain, and
- the blood has always been bright.
She has never undergone colonoscopy.
She was recently sent the National Bowel Cancer Screening Program kit in the mail, has ignored it for 5 months, but now wants to know if she should do the test.
In this setting, there is really no value in her undertaking the test at this point in time. She has reported macroscopic bleeding and does not need this confirmed with an FOBT.
In this setting there are a number of options, but importantly this patient is currently symptomatic and not eligible for screening.
If her bleeding is minor, resolving and she does not need surgical treatment of her haemorrhoids, then I would encourage her to undergo a one off colonoscopy.
In this setting, she is bleeding and over the age of 50 and even though the yield is likely to be low, the risk of the scope is almost certainly outweighed by its benefit.
If her scope is normal, then there is no indication for her to repeat her colonoscopy in the future unless her family history changes, or she develops recurrent symptoms, or returns a positive FOBT.
I would then advise her to undergo regular FOBT after the scope, and reassess her compliance at each subsequent visit.
If she has ongoing bleeding that is worrying her, then it is also reasonable in this setting to undertake conservative management of her haemorrhoids for about 4 to 6 weeks, with fibre bulking and avoiding straining, and then to reassess.
At that point, I would recommend colonoscopy, and if her symptoms have not settled then she could undergo surgical treatment of her haemorrhoids at the time of the scope.
If she refuses a scope, and has not bled after the original consult, then it may be reasonable to advise FOBT at that time, but ensuring that colonoscopy occurs should the follow up test in 4 to 6 weeks be positive.
In case 4, we present a 48 year old male who presents with rectal bleeding for a short period of time. He has no symptoms of proximal pathology specifically no change in bowel habit, unexplained abdominal pain or weight loss and his family history is negative for colorectal cancer. The bleeding sounds to be haemorrhoidal in nature and is associated with straining at stool, but rectal examination and proctoscopy in the office reveal innocuous, small haemorrhoids only.
In summary, this man is symptomatic so, again, is not eligible for the National Bowel Cancer Screening Program. On assessing him clinically, it sounds very much as though the bleeding is perianal in origin, however, in any adult with rectal bleeding, the option of further investigation should be considered, discussed with the patient and that discussion documented. In this particular circumstance, I'd be inclined to offer him, as he is currently bleeding, 4 to 6 weeks of fibre bulking, to see if the bleeding can be symptomatically resolved, and I would organise an FBE and iron studies, at the first consultation, with instructions to the patient to check the results with me 48 hours afterwards. Assuming the bloods are okay and he has a reasonable symptomatic response to the fibre bulking at review consultation, even though this is sounding more and more like bleeding of perianal origin, I would however discuss with him the option of investigation with colonoscopy, carefully outlining the risks and benefits of this, including discussion of the 1 in 1500 risk of perforation associated with the colonoscopy, and its consequences. At that stage, the patient will either opt for colonoscopy or otherwise. If they opt for colonoscopy, I'd facilitate that for them. If they don't opt for colonoscopy, I would ensure that I have clearly documented the discussion and the option of the scope being offered. In addition, I would then suggest to the patient the alternate option of performing a faecal occult blood test at that time, just to ensure there is no evidence of ongoing bleeding at a microscopic level. Obviously, if the FOB test was positive, then a colonoscopy would be mandated. If the patient has not responded to Metamucil after 4 to 6 weeks of fibre bulking, then that patient definitely should be encouraged to undergo further investigation and the option of rubber band ligation of haemorrhoids at the time of the scope. Regardless of the outcome here, whilst the patient, after completion of their treatment, is still too young to be considered for the National Program, it would be reasonable to offer them the option of ongoing faecal occult blood testing, self-funded, if they wish.
Case 5 involves a 42 year old male presenting for discussion regarding screening options on the basis of his mother having been diagnosed with bowel cancer at the age of 47. The male patient currently is asymptomatic and has no other major comorbidities. It's important to note that under the NHMRC Clinical Guidelines, this patient fulfils Category 2 level risk and hence, faecal occult blood testing is not appropriate for him. This patient should be referred for five yearly colonoscopy, commencing at an age 10 years younger than the youngest affected relative, should be warned about the importance of ongoing surveillance and should, as with all patients, be educated about primary prevention.
Case 6 is a 54 year old woman who presents for advice regarding colonoscopic screening. She's asymptomatic. Her family history is significant. Her mother developed uterine cancer at the age of 35 and subsequently died from the disease. Her maternal uncle developed bowel cancer at the age of 42 and his own son developed a small bowel tumour at the age of 54. The patient herself underwent a colonoscopy for low level symptoms about 5 years ago.
Under these circumstances, this woman fulfils Category 3 level risk. Her family history is suggestive of the possibility of an underlying autosomal dominant syndrome such as Lynch syndrome or HNPCC, as more than three relatives on the same side of the family have been diagnosed with HNPCC associated malignancies at an early age. Under these circumstances, this woman requires not just colonoscopy, but referral to a family cancer centre for formal assessment and counselling for the family. She may well require genetic testing and/or specialised gynaecological surveillance.
Case 7 is a 65 year old woman who's received notification from the National Program that she is eligible for FOB testing and has been sent a kit and instructions. This woman has no symptoms that she can attribute to her bowel, has had no family members affected by bowel cancer, and her husband has previously thrown out his kit when it was sent to him. Later that year, during a routine consultation with her local doctor for an unrelated matter, she mentions to her that she has received and ignored the kit.
Her GP has significant interest in preventative medicine and screening, and has thorough knowledge of the National Program. She takes a clinical history and determines that the patient fulfils NHMRC category one and hence is appropriate for inclusion in the National Bowel Cancer Screening Program. She spends time educating this woman about her lifetime risk of bowel cancer, and the evidence supporting her participating in the program. In particular she emphasises that her risk of bowel cancer is considerably higher than her risk of cervical cancer. Armed with this information, the patient then promptly completes the FOB test, which is positive.
At follow up colonoscopy, she is identified as having a 2.5cm sessile lesion in her sigmoid colon. This is removed by a colorectal surgeon using endoscopic mucosal resection at the time of her colonoscopy, as a day case. Histopathology indicates that this was an adenomatous polyp, with moderate dysplasia.
At subsequent follow up with her GP, she indicates to the patient that now that she has a personal history of a significant adenoma, she should consider repeat colonoscopy in the future as guided by the NHMRC guidelines. The patient is booked for a recall colonoscopy in 3 years. In addition, her GP educates her about the importance of her family history, and suggests the importance of her first degree relatives undertaking screening. As it transpires, as a result of this advice, the patient's brother obtains an FOB kit from his GP. The result was positive, and he was harbouring an asymptomatic stage 2 carcinoma of the right colon.