I disagree with statements made in “What’s the most effective way to screen patients with a family history of colon cancer?” (Clinical Inquiries, J Fam Pract. 2010;59:176-178). Patients with a first-degree relative diagnosed with colorectal cancer (CRC) or adenomatous polyps (AP) after the age of 60 have an increased risk and should start screening at 40 years of age, the article recommends.
That recommendation is at odds with the most recent colorectal screening guidelines from the American College of Gastroenterology (ACG), issued in 2008, which state: “Individuals with a single first-degree relative with CRC or advanced adenomas diagnosed at ≥60 years can be screened like average-risk persons.”1 The guidelines further note that a family history of small tubular adenomas in a first-degree relative is not associated with an increase in risk—a statement that applies even to patients whose family member had a tubular adenoma before the age of 60.
This is an important distinction. We should not be pushing people to have colonoscopies, which are invasive and expensive, without providing the most current recommendations from a specialty organization whose members include the doctors who make money from performing this procedure. Presenting this as an “evidence-based answer,” I believe, is dangerous and misleading.
Larry Novik, MD
Fairfield, Conn
1. Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2008. Am J Gastroenterol. 2009;104:739-750.
The author responds:
The referenced ACG guidelines are the only guidelines that do not recommend early screening for patients with a relative older than 60 with CRC or AP. It is also important to note that the authors of the ACG guidelines state that there is evidence of increased risk in this population. But presumably—in their view—the increased risk is not large enough to warrant early screening.
Other guidelines, specifically from the American Society of Gastrointestinal Endoscopists (ASGE)1 and the US Multi-Society Task Force (USMSTF),2 do recommend screening at age 40 for such patients. Interestingly, the USMSTF guidelines were published just 1 year prior to the ACG guidelines, and the USMSTF is composed of a broad range of organizations—including the ACG, the American Gastroenterological Association, the ASGE, the American College of Radiology, and the American Cancer Society. What’s more, 2 of the authors of the ACG guidelines were also primary authors of the USMSTF guidelines. Such contradictory recommendations highlight the fact that there is limited solid evidence to guide practitioners.
With regard to the level of evidence, there are a limited number of randomized controlled trials addressing this question, especially regarding the circumstance of relatives over the age of 60 with CRC or AP. Most of the recommendations, which are primarily based on consensus, suggest screening early.
Moreover, many gastroenterologists do not closely adhere to published guidelines for surveillance intervals; they often recommend more frequent or aggressive surveillance. Under the circumstances, the argument in favor of changing screening recommendations is shaky at best.
Scott A. Wiltz, MD, MPH
Eglin Air Force Base, Fla