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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

9.2 Colorectal cancer

Please note that Section 9.2 was updated in August 2018

Average risk

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

High risk

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

Biennial faecal occult blood test (FOBT) can reduce colorectal cancer (CRC) mortality by 16%.17 The original trials of FOBT screening used the guaiac-based FOBT, but this has been superseded by the more sensitive and specific faecal immunochemical test (ie iFOBT). Organised screening by iFOBT is recommended for the asymptomatic (average risk) population from 50 years of age every two years (A) until 74 years of age with repeated negative findings.18,19

In November 2017, the National Health and Medical Research Council (NHMRC) endorsed a new national guideline on CRC prevention and screening. Screening recommendations, which used to be determined solely on lifetime risk of CRC, now also account for absolute risk of cancer in the short term.109 Risk assessment should include determining the number and type of relatives affected by CRC, and age at diagnosis (refer to Table 9.2.1. Colorectal cancer: Identifying risk). The new guideline also changed the recommendations on CRC screening modality in people at moderate risk of CRC. Of note, iFOBT is now recommended for people in this group from 40 to 49 years of age and colonoscopy five-yearly from 50 to 74 years of age. Digital rectal examination (DRE) is not recommended as a screening tool (D), but is important in evaluating patients who present with symptoms (eg rectal bleeding).

Colonoscopy is not recommended as a screening test for people at average risk of CRC. No randomised controlled trial (RCT) has evaluated the effect of colonoscopy on CRC mortality, although trials are in progress in Spain, Sweden and the US. Colonoscopy has indirect and direct harms, including, rarely, death from the procedure (one in 10,000–14,000 colonoscopies).20, 21 Harm may be caused by the bowel cleanout prior to the procedure (eg dehydration, electrolyte imbalances), sedation used during the procedure (eg cardiovascular events), or the procedure itself (eg infection, colonic perforations, bleeding). There is insufficient evidence about the use of computed tomography (CT) colonography (also refer to Chapter 15. Screening tests of unproven benefit), faecal deoxyribonucleic acid (DNA) or plasma circulating DNA tests to recommend them as alternatives to iFOBT for CRC screening.22

The 2017 NHMRC-endorsed guideline also examined an updated systematic review of trial evidence on the effects of low-dose aspirin on CRC incidence and mortality. The guideline development group considered evidence relating to the additional benefits from reduction in cardiovascular disease risk and potential adverse effects (ie haemorrhagic stroke, gastrointestinal bleeding, peptic ulcer).109 Overall, it was found that the benefits of taking low-dose aspirin outweighed the harms, and the guideline recommends that aspirin should be actively considered in all people aged 50–74 years.

Table 9.2.1. Colorectal cancer: Identifying risk
Who is at risk?What should be done?How often?
Category 1 – Average or slightly increased risk (<1% 10-year risk of CRC; 95–98% of the population)
Asymptomatic people with:
  • no personal history of bowel cancer, colorectal adenomas, inflammatory bowel disease or family history of colorectal cancer (CRC)
OR
  • one first-degree or one first-degree and one second-degree relative with CRC diagnosed aged ≥55 years

Immunochemical faecal occult blood test (iFOBT; I, A)

Low-dose aspirin (100–300 mg daily) should be actively considered to prevent CRC*

Every two years from 50 to 74 years of age (Practice Point) 17, 19, 24

Aspirin for at least 2.5 years commencing at 50 until 70 years of age
Category 2 – Moderately increased risk (1–4% 10-year risk of CRC; 2–5% of the population)
Asymptomatic people with:
  • one first-degree relative with CRC diagnosed aged <55 years
OR
  • two first-degree relatives with colorectal cancer diagnosed at any age
  • one first-degree relative and at least two second-degree realtives diagnosed with colorectal cancer at any age
iFOBT

Colonoscopy

Low-dose aspirin (100–300 mg daily) should be actively considered
iFOBT every two years from 40 to 49 years of age 19, 25, 26

Colonoscopy every five years from 50 to 74 years of age

Aspirin for at least 2.5 years commencing at age 50 until 70 years of age
Category 3 – High risk (relative risk of ~4–20%; <1% of the population)
Asymptomatic people with 25,26:
  • at least three first-degree or second‑degree relatives with CRC, with at least one relative diagnosed aged <55 years
  • at least three first-degree relatives with CRC diagnosed at any age
People with high-risk familial syndromes, Lynch syndrome:
  • three or more first-degree or second-degree relatives on the same side of the family diagnosed with CRC or other Lynch syndrome–related cancers§ (suspected Lynch syndrome)
OR
  • two or more first-degree or second-degree relatives on the same side of the family diagnosed with CRC, including any of the following high-risk features
  • multiple CRC in the one person
  • CRC aged <50 years="" li="">
A family member who has or had Lynch syndrome-related cancer

People with familial polyposis syndromes:
  • at least one first-degree or second‑degree relative with CRC, with a large number of adenomas throughout the large bowel#
Refer to familial cancer clinic for genetic risk assessment


High-risk familial syndromes

Refer to familial cancer clinic for genetic risk assessment and genetic screening of affected relatives



Refer to bowel cancer specialist to plan appropriate surveillance (III, B) and dose of aspirin










Familial polyposis syndromes



Refer to familial cancer clinic for genetic risk assessment and genetic screening of affected relatives


Refer to bowel cancer specialist to plan appropriate surveillance (III, B) and chemoprevention

iFOBT every two years from 35 to 44 years of age

Colonoscopy every five years from 45 to 74 years of age


Frequency and starting age of colonoscopic surveillance will be determined by specialist team


Starting age and dose of aspirin will be determined by specialist team||


Frequency and starting age of colonic surveillance and chemoprevention will be determined by specialist team

*The choice to take aspirin should be personalised based on age, sex and potential reduction in cardiovascular events, cerebrovascular events and thrombotic stroke. The individual should take into account the potential risks of taking aspirin. Aspirin should be avoided in patients with current dyspepsia, any history of peptic ulcer, aspirin allergy, bleeding diathesis, an increased risk of gastrointestinal haemorrhage (eg associated with use of oral anticoagulants or antiplatelet agents), or renal impairment.

The benefit may extend to older ages with longer duration of use. The benefit for cancer prevention (though shorter for cardiovascular risk) is evident only after 10 years of initiation, so a life expectancy of at least 10 years should be taken into consideration in the advice to use aspirin.

Approximately 5% of all CRCs and 10–15% of CRCs diagnosed in people aged <50 years are caused by high-risk germline mutations. Genetic knowledge is rapidly expanding and new discoveries are likely to explain cases of heritable predisposition for which a mutation cannot currently be identified. Genetic testing for familial cancer syndromes is undergoing rapid change as technology improves and costs for more extensive testing strategies drop. Testing strategies are moving towards testing a panel of genes covering all polyposis conditions, or a non-polyposis Lynch panel, or both where the phenotype is unclear.

§Lynch syndrome–related cancers include endometrial, ovarian, gastric, pancreatic, urothelial, renal pelvic, small intestine, biliary tract, brain, sebaceous gland adenomas and keratoacanthomas.

||Aspirin at 600 mg/day reduced Lynch syndrome cancer incidence by 50–68% in the Colorectal Adenoma/Carcinoma Prevention Programme 2 (CAPP2) trial.27 Follow-up of the low-dose aspirin randomised controlled trials (RCTs)28,29 suggests low-dose aspirin (100 mg/day) also reduces cancer incidence by half. A dose–response RCT in Lynch syndrome is open for recruitment at www.capp3.org

#There are several rare polyposis syndromes, some of which are associated with other cancers (eg familial adenomatous polyposis is associated with duodenal, gastric, desmoid, brain, thyroid cancers and hepatoblastoma).

CAPP2, Colorectal Adenoma/Carcinoma Prevention Programme 2; CRC, colorectal cancer; iFOBT, immunochemical faecal occult blood test; RCT, randomised controlled trial

Patients who have adenomatous polyps removed at colonoscopy are then classified as having above-average risk for the development of metachronous adenomatous polyps and CRC. Table 9.2.2 provides advice about colonoscopic surveillance and recommended frequency based on the number and histology of polyps. It is important to try to obtain information about the histology, size and number of polyps removed, as this determines the future risk of adenomas and CRC and, therefore, frequency of recommended surveillance colonoscopy.30

Table 9.2.2. Follow up after polypectomy
Polyp type and numberRecommended colonoscopy screening interval
Small pale distal hyperplastic polyps only (not adenomas) No follow up required as no increased risk of metachronous colorectal neoplasia
One to two small tubular (<10 mm) adenomas Repeat colonoscopy at five years

If that colonoscopy is normal, repeat colonoscopy at 10 years or immunochemical faecal occult blood test (iFOBT) every two years
High-risk adenomas (three or more adenomas, ≥10 mm, or with tubulovillous or villous histology, or high-grade dysplasia) Three-year intervals
Large and sessile adenomas removed piecemeal Three to six months and again at 12 months to ensure complete removal
Multiple adenomas, which is a strong determinant of risk of metachronous advanced and non-advanced neoplasia:
  • ≥5 adenomas
12 months
Multiple adenomas, which is a strong determinant of risk of metachronous advanced and non-advanced neoplasia:
  • ≥10 adenomas
Sooner than 12 months (because of the likelihood of missed synchronous polyps)
Family history in addition to adenomas Intervals determined by adenoma characteristics, unless a syndromic risk mandates more frequent surveillance
If advanced adenomas are found during subsequent surveillance Three-yearly schedule is prudent, but the choice should be individualised. The interval can be lengthened if advanced adenomas are not found
People aged >75 years No surveillance as lead time for progression of an adenoma to cancer is around 10–20 years
iFOBT, immunochemical faecal occult blood test
Table 9.2.3. Test to detect colorectal cancer
TestTechnique
Faecal occult blood test (FOBT) screening Two main types of FOBT are available: guaiac test and immunochemical faecal immunochemical test (iFOBT) 31, 32

iFOBTs are preferred as they have greater sensitivity and higher uptake (A).31 Two or three serial stools should be tested, depending on the type and brand of test being used. Follow the manufacturer’s instructions

It is essential that any positive iFOBT (including just one of the samples) is appropriately investigated by colonoscopy (such people being at least 12 times more likely to have colorectal cancer [CRC] than those with a negative test). With guaiac tests, even if a subject fails to follow dietary restrictions, it is dangerous to assume that a positive result is a result of dietary non-compliance
CRC, colorectal cancer; FOBT, faecal occult blood test; iFOBT, immunochemical faecal occult blood test

Implementation

Strategy

Measures to increase screening in these groups include organised approaches such as employing recall and reminder systems;32,33 recommendations by the GP for the screening;33,34 addressing capacity issues, including convenience;33,35 and minimising barriers such as cost.33,35,36 Refer to the RACGP’s Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting (Green Book).

The National Bowel Cancer Screening Program, using iFOBT, is being expanded, and by 2020 will offer biennial screening for people aged 50–74 years. GPs are critical, not just in maximising participation but in managing participants with a positive iFOBT.34,37

Participation is under-represented by Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse (CALD) peoples.38

References

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