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Most colorectal cancers and some large adenomas result in increased chronic blood loss that may be detectable A variety of tests have been developed that have varying sensitivities for fecal occult blood, some of which are in clinical testing A guaiac-based test (Hemoccult II) has undergone the most extensive testing and has had the greatest clinical use Two slides must be prepared from three consecutive bowel movements To reduce the likelihood of false-positive tests, patients should abstain from aspirin (in doses greater than 325 mg/d), NSAIDs, red meat, poultry, fish, and vegetables with peroxide activity (turnips, horseradish) for 72 hours Vitamin C may cause a false-negative test Slides should be developed within 7 days after preparation The World Health Organization recently endorsed another guaiac test for FOBT, Hemoccult Sensa, because it has higher sensitivity than the Hemoccult II test; however, data from large clinical trials with this test are lacking When FOBT is administered to the general population as part of a screening program, 2-6% of tests are positive Patients with positive tests should undergo colonoscopy accompanied by removal of any polyps identified If colonoscopy reveals no colorectal neoplasm, further screening for colorectal cancer can be deferred for 10 years Of those with positive tests, 5 18% have colorectal cancer, more likely to be at an earlier stage (Dukes A or B) Adenomatous polyps are identified in 25 50% of patients with positive tests Finding these polyps is somewhat fortuitous since most are less than 1 cm in size and unlikely to cause occult bleeding The estimated sensitivity of a one-time guaiac-based FOBT for colorectal cancer is only 13%; however, sensitivity is increased in patients who undergo annual or biannual testing In several large prospective studies, FOBT has been demonstrated to reduce mortality from colorectal cancer by 30 40% among those who are compliant with regular testing An immunochemical FOBT that detects human globin is available The test is positive in 3 6% of asymptomatic patients and has a sensitivity of 65% for detection of colorectal cancer and 28% for all advanced neoplasms A fecal DNA assay (Pre-Gen Plus) is commercially available for screening for colorectal neoplasia The test analyzes fecal DNA for point mutations in the APC, K-ras, and p53 genes, microsatellite instability, and a marker of abnormal apoptosis However, in a recent study performed in a large asymptomatic screening population, the fecal DNA panel detected only one-half of cancers and only 18% of all advanced neoplasms The low sensitivity of FOBT and DNA tests for advanced neoplasia makes them a less attractive choice for populationbased screening than endoscopic or radiographic tests At present, they are most suitable in settings where health care.

Average-risk individuals 50 years old2 Annual fecal occult blood testing Flexible sigmoidoscopy every 5 years Annual fecal occult blood testing and flexible sigmoidoscopy every 5 years Colonoscopy every 10 years Barium enema every 5 years Individuals with a family history of a first-degree member with colorectal neoplasia3 Single first-degree relative with colorectal cancer diagnosed at age 60 years: Begin screening at age 40 Screening guidelines same as average-risk individual; however, preferred method is colonoscopy every 10 years Single first-degree relative with colorectal cancer diagnosed at age < 60 years, or multiple first-degree relatives: Begin screening at age 40 or at age 10 years younger than age at diagnosis of the youngest affected relative, whichever is first in time Recommended screening: colonoscopy every 5 years For recommendations for families with inherited polyposis syndromes or hereditary nonpolyposis colon cancer, see 14 2 Colorectal cancer screening and surveillance: clinical guidelines and rationale Gastroenterology 2003 Feb;124(2):544 60 3 Screening Recommendations of American College of Gastroenterology Am J Gastroenterol 2000 Apr;95(4):868 77

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You can define common distribution channels and divisions using the following menu paths, as shown in Figure 2-8

Like colonoscopy, barium enema permits examination of the entire colon Barium enema has been an attractive screening technique because it was widely available, relatively inexpensive, and safe However, it is being rapidly supplanted by colonoscopy and CT colonography A recent multicenter trial demonstrated that the sensitivity of barium enema is only 50% for polyps 1 cm and 55 85% for early-stage cancers when compared with colonoscopy At present, barium enema may be recommended when screening of the entire colon is desired and the patient is unable or unwilling to undergo colonoscopy, and expertise in CT colonography is unavailable

resources are limited or in patients who desire a noninvasive method of screening If FOBT screening is to be used, immunochemical tests may be preferred

Use of a 60-cm flexible sigmoidoscope permits visualization of the rectosigmoid and descending colon It requires no sedation and in many centers is performed by a nurse specialist or physician s assistant Adenomatous polyps are identified in 10 20% and colorectal cancers in 1% of patients (For management of adenomatous polyps identified at sigmoidoscopy, see 14) Case-control studies suggest that screening sigmoidoscopy programs lead to a 60% reduction in colorectal cancer mortality The risk of serious complications (perforation) associated with flexible sigmoidoscopy is less than 1:10,000 patients However, approximately 50% of advanced neoplasms (cancer, adenomas 1 cm in size, polyps with villous histology, or high-grade dysplasia) are proximal to the splenic flexure, ie, above the reach of a flexible sigmoidoscopic examination Up to 60% of such patients do not have an adenomatous polyp distal to the splenic flexure at sigmoidoscopy Therefore, if patients found on screening sigmoidoscopy to have an adenoma of any size subsequently undergo colonoscopy, approximately 70% of all advanced colonic neoplasms will be identified; however, using such a strategy means that 30% of patients with advanced colonic neoplasia located only in the proximal colon will be overlooked

E CT Colonography (Virtual Colonoscopy)

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