Colorectal Neoplasms: Screening and Surveillance After Polypectomy
Screening for colorectal cancer in average-risk individuals begins at age 50 and may continue to age 75. Screening intervals vary according to personal and family history. A number of screening modalities now exist, though colonoscopy remains the gold sta
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Key Concepts • Screening can reduce colorectal mortality. • Screening recommendations are based upon risk for polyp/ cancer development (family history of cancer or polyps, personal history cancer/polyps, genetic syndromes (FAP, MYH, and HNPCC), and inflammatory bowel disease). • Surveillance after polypectomy depends on the histology of polyp and the completeness of its resection. • The decision to perform colectomy for a polyp that contains cancer depends on the extent of invasion (Haggitt staging for pedunculated polyp and Kikuchi classification for sessile polyp).
Introduction Colorectal cancer is the second leading cause of cancer-related deaths in the United States in men and women combined [1]. In 2014, the National Cancer Institute (NCI) estimated 96,000 new colon cancer and 40,000 new rectal cancer cases, and the estimated number of deaths for both colon and rectal cancer combined was 50,310. The fortunate news is that the death rate from colorectal cancer has been decreasing over the last 20 years. This reduction in the number of new cancer cases and cancer-related deaths is a consequence of current screening programs [2, 3]. The rationale for the above is that adenomatous polyps are considered precursors to cancer, and through their early endoscopic removal, carcinoma can be prevented. In addition to the therapeutic roles of colonoscopy, it also allows for the identification of individuals at higher risk for accelerated carcinogenesis (e.g., multiple polyps, unfavorable histology, dysplasia, and large polyps (≥1.0 cm)), who may benefit from more frequent screening. Of further interest and consideration is that upon following current routine screening recommendations, the potential to identify large groups of patients with adenomatous polyps
also exists. This creates a huge burden on the healthcare system (costs, risks, and resources) in terms of surveillance of these patients.
Recommended Screening Guidelines Guidelines from the American Cancer Society (ACS), the American Society of Colon and Rectal Surgeons (ASCRS), and the American Gastroenterological Association (AGA) all recommend that colorectal cancer screening begin at the age of 50 for both men and women with average risk (i.e., no family history of colorectal cancer, no personal history of inflammatory bowel disease, and asymptomatic) [4–6]. These accepted guidelines are based on joint efforts set forth in 2008 by the ACS, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology (ACR) [7]. Screening regimens can be divided into two categories: fecal testing and structural examinations. While structural examinations are designed to detect both polyps and cancer, fecal testing primarily detects already established cancers or possibly advanced adenomas. It is the opinion of the above organizations that the goal of colorectal cancer screening should be that of prevention. There are various screening options for asymptomatic individuals. The recommended time intervals are listed below and will be further evaluate
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