Guidance on large bowel surveillance for people with two first degree relatives with colorectal cancer or one first degree relative diagnosed with colorectal cancer under 45 years

SMAD4 juvenile polyposis syndrome and hereditary haemorrhagic telangiectasia presenting in a middle-aged man as a large fungating gastric mass, polyposis in both upper and lower GI tract and iron deficiency anaemia, with no known family history

Juvenile polyposis syndrome (JPS) and hereditary haemorrhagic telangiectasia (HHT) are rare autosomal dominant diseases, where symptoms manifest at childhood. A 32-year-old man with no family history of JPS or HHT with SMAD4 gene mutation who developed signs and symptoms only at the age of 32, when he was an adult. In this article, we highlight the steps taken to diagnose this rare pathology, explain its pathophysiology and management.

Ideal colonoscopic surveillance intervals to reduce incidence of advanced adenoma and colorectal cancer

BACKGROUND AND AIMS

There is limited information about the interplay between multiple risk factors contributing to the risk of advanced neoplasia. We determined the actual risk for advanced neoplasia in relation to lapsed time between colonoscopies in people enrolled in a structured surveillance program. This risk information can be used to guide the selection of optimal surveillance intervals.

METHODS

Patients were recruited into programs at two major tertiary hospitals, with a personal or family history of advanced neoplasia. Five thousand one hundred forty-one patients had an index and one or more surveillance colonoscopies. Fifty-one percent had a family history of colorectal neoplasia while the remainder had a personal history.

RESULTS

Patients with an immediately prior colonoscopy result (prior result) of advanced adenoma had a risk for advanced neoplasia 7.1 times greater than those with a normal prior result. Cancer as a prior result did not confer a greater risk than either a hyperplastic polyp or a nonadvanced adenoma. Being female reduced risk, age increased risk. Only a family history of a first-degree relative diagnosed under 55, or definite or suspected hereditary nonpolyposis colorectal cancer (HNPCC) conferred an increased risk over a personal history of advanced neoplasia.

CONCLUSIONS

Most family history categories did not confer excess risk above personal history of advanced neoplasia. A prior cancer poses less of a risk than a prior advanced adenoma. Based on our models, a person with an advanced adenoma should be scheduled for colonoscopy at 3 years, corresponding to a 15% risk of advanced neoplasia for a male aged under 56. Guidelines should be updated that uses a 15% risk as a benchmark for calculating surveillance intervals.

Individual having a parent with early-onset gastric cancer may need screening at younger age

AIM: To evaluate whether individuals with gastric cancer (GC) are diagnosed earlier if they have first-degree relatives with GC.

METHODS: A total of 4282 patients diagnosed with GC at National Cancer Center Hospital from 2002 to 2012 were enrolled in this retrospective study. We classified the patients according to presence or absence of first-degree family history of GC and compared age at diagnosis and clinicopathologic characteristics. In addition, we further classified patients according to specific family member with GC (father, mother, sibling, or offspring) and compared age at GC diagnosis among these patient groups. Baseline characteristics were obtained from a prospectively collected database. Information about the family member’s age at GC diagnosis was obtained by questionnaire.

RESULTS: A total of 924 patients (21.6%) had a first-degree family history of GC. The mean age at GC diagnosis in patients having paternal history of GC was 54.4 ± 10.4 years and was significantly younger than in those without a first-degree family history (58.1 ± 12.0 years, P < 0.001). However, this finding was not observed in patients who had an affected mother (57.2 ± 10.0 years) or sibling (62.2 ± 9.8 years). Among patients with family member having early-onset GC (< 50 years old), mean age at diagnosis was 47.7 ± 10.3 years for those with an affected father, 48.6 ± 10.4 years for those with an affected mother, and 57.4 ± 11.5 years for those with an affected sibling. Thus, patients with a parent diagnosed before 50 years of age developed GC 10.4 or 9.5 years earlier than individuals without a family history of GC (both P < 0.001).

CONCLUSION: Early-onset GC before age of 50 was associated with parental history of early-onset of GC. Individual having such family history need to start screening earlier.

Do people really know what makes a family history of cancer?

BACKGROUND

Family history is often referred to as a family tree in casual everyday conservations, but it carries a different connotation in medicine. This study is the first to investigate people's understanding of 'family medical history' and the concept of 'family' in the context of inherited cancer.

METHODS

Three hundred and nine staff at the Faculty of Medicine and Health, University of Leeds completed an online web survey.

RESULTS

Not all respondents understood or knew what makes a family history of cancer. Only 54% knew exactly the type of information required to make a family history. Apart from blood relatives, adopted and step-siblings, step parents, in-laws, spouses, friends and colleagues were also named as 'family' for family history taking. Personal experience of living with cancer and academic qualification were not significant in influencing knowledge of family history.

CONCLUSIONS

There is misunderstanding and poor knowledge of family history of cancer and the type of information required to make a family history even in a sample of people teaching and researching medicine and health issues. Public understanding of the value of family medical history in cancer prevention and management is important if informed clinical decisions and appropriate health care are to be delivered.

22-year longitudinal study of repetitive colonoscopy in patients with a family history of colorectal cancer

INTRODUCTION

We report the outcomes of a long-term surveillance programme for individuals with a family history of colorectal cancer.

METHODS

The details of patients undergoing a colonoscopy having been referred on the basis of family history of colorectal cancer were entered prospectively into a database. Further colonoscopy was arranged on the basis of the findings. The outcomes assessed included incidence of cancer and adenoma identification at initial and subsequent colonoscopy.

RESULTS

The records of 2,293 patients (917 men; median patient age: 51 years) were entered over 22 years, giving data on 3,982 colonoscopies. Eight adverse events (0.2%) were recorded. Twenty-seven cancers were found at first colonoscopy and thirteen developed during the follow-up period. There were significantly more cancers identified in those with more than one first-degree relative with cancer than in other groups (p=0.01). The number of adenomas identified at subsequent surveillance colonoscopies remained constant with between 9.3% and 12.0% of patients having adenomas that were removed. Two-thirds (68%) of patients with cancer and three-quarters (77%) with adenomas fell outside the British Society of Gastroenterology (BSG) 2006 guidelines.

CONCLUSIONS

Repeated colonoscopy continues to yield significant pathology including new cancers. These continue to occur despite removal of adenomas at prior colonoscopies. The majority of patients with cancers and adenomas fell outside the BSG 2006 guidelines; more would have fallen outside the 2010 guidelines.

22-year longitudinal study of repetitive colonoscopy in patients with a family history of colorectal cancer

Introduction

We report the outcomes of a long-term surveillance programme for individuals with a family history of colorectal cancer.

Methods

The details of patients undergoing a colonoscopy having been referred on the basis of family history of colorectal cancer were entered prospectively into a database. Further colonoscopy was arranged on the basis of the findings. The outcomes assessed included incidence of cancer and adenoma identification at initial and subsequent colonoscopy.

Results

The records of 2,293 patients (917 men; median patient age: 51 years) were entered over 22 years, giving data on 3,982 colonoscopies. Eight adverse events (0.2%) were recorded. Twenty-seven cancers were found at first colonoscopy and thirteen developed during the follow-up period. There were significantly more cancers identified in those with more than one first-degree relative with cancer than in other groups (p=0.01). The number of adenomas identified at subsequent surveillance colonoscopies remained constant with between 9.3% and 12.0% of patients having adenomas that were removed. Two-thirds (68%) of patients with cancer and three-quarters (77%) with adenomas fell outside the British Society of Gastroenterology (BSG) 2006 guidelines.

Conclusions

Repeated colonoscopy continues to yield significant pathology including new cancers. These continue to occur despite removal of adenomas at prior colonoscopies. The majority of patients with cancers and adenomas fell outside the BSG 2006 guidelines; more would have fallen outside the 2010 guidelines.

Cumulative impact of common genetic variants and other risk factors on colorectal cancer risk in 42,103 individuals

OBJECTIVE

Colorectal cancer (CRC) has a substantial heritable component. Common genetic variation has been shown to contribute to CRC risk. A study was conducted in a large multi-population study to assess the feasibility of CRC risk prediction using common genetic variant data combined with other risk factors. A risk prediction model was built and applied to the Scottish population using available data.

DESIGN

Nine populations of European descent were studied to develop and validate CRC risk prediction models. Binary logistic regression was used to assess the combined effect of age, gender, family history (FH) and genotypes at 10 susceptibility loci that individually only modestly influence CRC risk. Risk models were generated from case-control data incorporating genotypes alone (n=39,266) and in combination with gender, age and FH (n=11,324). Model discriminatory performance was assessed using 10-fold internal cross-validation and externally using 4187 independent samples. The 10-year absolute risk was estimated by modelling genotype and FH with age- and gender-specific population risks.

RESULTS

The median number of risk alleles was greater in cases than controls (10 vs 9, p<2.2 × 10(-16)), confirmed in external validation sets (Sweden p=1.2 × 10(-6), Finland p=2 × 10(-5)). The mean per-allele increase in risk was 9% (OR 1.09; 95% CI 1.05 to 1.13). Discriminative performance was poor across the risk spectrum (area under curve for genotypes alone 0.57; area under curve for genotype/age/gender/FH 0.59). However, modelling genotype data, FH, age and gender with Scottish population data shows the practicalities of identifying a subgroup with >5% predicted 10-year absolute risk.

CONCLUSION

Genotype data provide additional information that complements age, gender and FH as risk factors, but individualised genetic risk prediction is not currently feasible. Nonetheless, the modelling exercise suggests public health potential since it is possible to stratify the population into CRC risk categories, thereby informing targeted prevention and surveillance.

Colorectal cancer screening in patients at moderately increased risk due to family history

Patients with a positive family history have an increased risk of colorectal cancer (CRC) and, in many countries, more intensive screening regimens, sometimes involving the use of colonoscopy as opposed to sigmoidoscopy or fecal occult blood testing, are recommended. This review discusses current screening guidelines in the United States and other countries, data on the magnitude of CRC risk in the presence of a family history and the efficacy of recommended screening programs, as well as ancillary issues such as compliance, cost-effectiveness and accuracy of family history ascertainment. We focus on the relatively common “sporadic” family histories of CRC, which typically imparts a mild to moderate elevation in the risk for CRC development in the proband. Defined familial syndromes associated with extremely high risks of CRC, such as hereditary non-polyposis colorectal syndrome or familial adenomatous polyposis, require specialized management approaches and are beyond the scope of this article. We will also not discuss colonoscopic surveillance in patients with a personal history of adenomas or CRC.

Do guidelines improve clinical practice? - a national survey on surveillance colonoscopies

BACKGROUND

Colonoscopic services are increasingly being utilized in surveillance of conditions predisposing to colorectal cancers (CRC). The ACPGBI/BSG guidelines are the most commonly followed recommendations. Numerous retrospective studies have shown poor compliance with them. We conducted a national survey of colonoscopic practitioners investigating attitudes, awareness and implementation of surveillance guidelines.

METHOD

A postal questionnaire was sent to a random population of 250 ACPGBI and 200 BSG members. Questions assessed practice as regards colorectal polyp surveillance, family screening and surveillance for past history of CRC.

RESULTS

The ACPGBI/BSG guidelines were the most commonly followed recommendations. Only 17.2% of practitioners used the criteria that would ensure accurate implementation of guidelines for colorectal adenoma surveillance. With regards to familial surveillance for CRC, 53.5% respondents assessed familial risk accurately, while 69.3% recommended surveillance incorrectly. A total of 48.8% of ACPGBI members recommended five yearly colonoscopies following curative treatment for CRC.

CONCLUSION

This study has revealed the widespread ignorance of guidelines, which will potentially translate into the gross over utilization of colonoscopic resources. Strategies to improve and audit guideline implementation must be integral to guideline formation. Methods to improve accurate guideline implementation need to be explored.

An Overview of Colorectal Cancer Screening

Colorectal cancer ranks highly amongst all cancer sites in incidence and contributes to a substantial number of cancer related deaths in the United Kingdom. However, screening of average risk individuals has been shown to reduce both disease associated mortality and incidence. This paper provides an overview of both current and future screening methods for colorectal cancer, as well as current practice for screening in both average and high risk individuals.

The BSG/ACPGBI guidelines for colonoscopic screening: what are we missing?

INTRODUCTION

Before publication of the British Society of Gastroenterology and Association of Coloproctology of Great Britain and Ireland guidelines in 2002, screening for people with a family history of colorectal cancer was sporadic and largely dependant on unvalidated local guidelines. Since 1990 we have been screening patients with both high and moderate risk family histories of colorectal cancer using local protocols which were more liberal than the new guidelines. In this study, we have analysed the pathology that would have been missed if we had been using the new guidelines in the period 1990-2002.

METHOD

A total of 399 consecutive patients with a positive family history of colorectal malignancy underwent screening endoscopy according to local guidelines. Demographic, endoscopic and pathologic data were prospectively collected. Patients were retrospectively divided into those who would have been screened under the new guidelines (group 1) and those who would not (group 2). The recorded pathology was graded as significant or insignificant and the findings compared between the two groups.

RESULTS

A total of 399 patients underwent 557 endoscopies of which 278 (50%) were indicated under the new guidelines (group 1) and 279 (50%) were not indicated (group 2). A significant pathology or carcinoma was found in 15.8% of group 1 endoscopies and 10.0% of group 2 endoscopies. This difference was significant.

CONCLUSION

If we had been using the new guidelines in the period 1990-2002, we would not have performed 279 (50%) of the 557 procedures, but would not have discovered significant pathology in 10% of the moderate risk endoscopies representing 39% of the significant pathology, which was actually present in this population.

Acromegaly, growth hormone and cancer risk

Acromegaly is an endocrine disorder characterized by sustained hypersecretion of growth hormone (GH) with concomitant elevation of insulin-like growth factor I (IGF-I) associated with premature mortality from cardiopulmonary diseases and certain malignancies. In particular, there is a two-fold increased risk of developing colorectal cancer. Possible mechanisms underlying this association include elevated levels of circulating GH and IGF-I, but several other plausible processes may be relevant. In a parallel literature, there has been debate whether GH replacement therapy is associated with increased cancer risk in three scenarios: (1) tumour recurrence in children with previously treated cancer; (2) second neoplasms (SNs) in survivors of childhood cancer treated with GH; and (3) de-novo cancer in non-cancer patients treated with GH. The general evidence suggests no increased risk in scenario 1. Through a maze of complex study designs, there is inconclusive evidence of a very modest increase in cancer risk in treated GH-deficiency patients in scenarios 2 and 3, but it is likely that the cumulative risk equates to that of the general population. This emphasizes the need for patient selection balanced against the known morbidity of untreated GH deficiency.

Colonoscopy for screening and follow up of patients with a family history of colorectal cancer

OBJECTIVE

To determine the minimum family history of colorectal cancer (CRC), which justifies colonoscopy and to establish whether further colonic assessment is necessary after a negative screening colonoscopy.

METHOD

A retrospective review of every colonoscopy undertaken for family screening at the Royal Berkshire and Battle Hospitals, Reading between October 1996 and July 2004.

RESULTS

Four hundred and thirty-two patients (261 women) with an average age of 48 years (range 14-84) were screened. Three cancers in patients over the age of 60 years and 49 adenomas were found in 37 patients. Twenty three of 281 (8%) patients with a 'low-risk' family history (one in 12 or less lifetime risk of developing CRC) had either a cancer or an adenoma. Eighteen of 151 (12%) patients with a 'high-risk' family history (one in 10 or greater) had a similar positive colonoscopy. Thirteen of 15 patients who had an adenoma aged under 45 years had a high-risk family history. Seventy-three patients subsequently underwent two or more follow-up colonoscopies. There were 22 adenomatous polyps found in 12 patients (16%) at the first screening, nine adenomas in seven patients in the second colonoscopy and four adenomas found in four patients in all subsequent colonoscopies.

CONCLUSION

Patients with a low-risk family history have a similar adenoma pick-up to that of the general population. These patients need not be screened below the age of 50 unless symptomatic. Follow up of low-risk family history (FH) patients with a negative screening colonoscopy is unlikely to be beneficial.

Validation of the Lower Gastrointestinal Electronic Referral Protocol

Background

Recognition of people presenting to the general practitioner with symptoms suggestive of colorectal cancer varies considerably, as do the subsequent patterns of referral and treatment. The Lower Gastrointestinal Electronic Referral Protocol (e-RP) was developed to be used alongside the national Choose and Book programme. This paper addresses the validation of the e-RP.

Methods

The e-RP was validated using three datasets: 100 consecutive patients with colorectal cancer, 100 2-week wait (TWW) suspected cancer referrals and 100 routine referrals. The actual destination of referred patients, their clinical diagnosis and referral urgency were compared with destination and referral urgency assigned by the e-RP.

Results

Some 43·0 per cent of patients with colorectal cancer were actually referred through the TWW system and the e-RP successfully upgraded 85·0 per cent of these patients as TWW referrals (Pearson χ2 = 9·76, 1 d.f., P = 0·002). The e-RP also redirected three of four patients with colorectal cancer in routine referrals to TWW clinics. Right-sided cancers were appropriately directed to colonoscopy as the first contact in secondary care or to outpatients for investigation of a palpable mass. Most patients with left-sided cancers were directed to flexible sigmoidoscopy clinics.

Conclusion

A dedicated referral protocol addressing all colorectal symptoms would significantly improve the overall yield of colorectal cancers through the TWW route and reduce delays in patient pathways with ‘straight to test’ in secondary care.

Guidelines on the irritable bowel syndrome: mechanisms and practical management

BACKGROUND

IBS affects 5-11% of the population of most countries. Prevalence peaks in the third and fourth decades, with a female predominance.

AIM

To provide a guide for the assessment and management of adult patients with irritable bowel syndrome.

METHODS

Members of the Clinical Services Committee of The British Society of Gastroenterology were allocated particular areas to produce review documents. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases.

RESULTS

Patients can usefully be classified by predominant bowel habit. Few investigations are needed except when diarrhoea is a prominent feature. Alarm features may warrant further investigation. Adverse psychological features and somatisation are often present. Ascertaining the patients' concerns and explaining symptoms in simple terms improves outcome. IBS is a heterogeneous condition with a range of treatments, each of which benefits a small proportion of patients. Treatment of associated anxiety and depression often improves bowel and other symptoms. Randomised placebo controlled trials show benefit as follows: cognitive behavioural therapy and psychodynamic interpersonal therapy improve coping; hypnotherapy benefits global symptoms in otherwise refractory patients; antispasmodics and tricyclic antidepressants improve pain; ispaghula improves pain and bowel habit; 5-HT(3) antagonists improve global symptoms, diarrhoea, and pain but may rarely cause unexplained colitis; 5-HT(4) agonists improve global symptoms, constipation, and bloating; selective serotonin reuptake inhibitors improve global symptoms.

CONCLUSIONS

Better ways of identifying which patients will respond to specific treatments are urgently needed.

Guidelines on the irritable bowel syndrome: mechanisms and practical management

BACKGROUND

IBS affects 5-11% of the population of most countries. Prevalence peaks in the third and fourth decades, with a female predominance.

AIM

To provide a guide for the assessment and management of adult patients with irritable bowel syndrome.

METHODS

Members of the Clinical Services Committee of The British Society of Gastroenterology were allocated particular areas to produce review documents. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases.

RESULTS

Patients can usefully be classified by predominant bowel habit. Few investigations are needed except when diarrhoea is a prominent feature. Alarm features may warrant further investigation. Adverse psychological features and somatisation are often present. Ascertaining the patients' concerns and explaining symptoms in simple terms improves outcome. IBS is a heterogeneous condition with a range of treatments, each of which benefits a small proportion of patients. Treatment of associated anxiety and depression often improves bowel and other symptoms. Randomised placebo controlled trials show benefit as follows: cognitive behavioural therapy and psychodynamic interpersonal therapy improve coping; hypnotherapy benefits global symptoms in otherwise refractory patients; antispasmodics and tricyclic antidepressants improve pain; ispaghula improves pain and bowel habit; 5-HT(3) antagonists improve global symptoms, diarrhoea, and pain but may rarely cause unexplained colitis; 5-HT(4) agonists improve global symptoms, constipation, and bloating; selective serotonin reuptake inhibitors improve global symptoms.

CONCLUSIONS

Better ways of identifying which patients will respond to specific treatments are urgently needed.

The impact of new screening protocol on individuals at increased risk of colorectal cancer

OBJECTIVE

Screening colonoscopy has been shown to reduce mortality and cancer stage in hereditary nonpolyposis colorectal cancer (HNPCC) individuals. However, the benefit of screening in intermediate risk groups is unknown. The most recent national guidelines have recommended a reduction of screening frequency for the intermediate risk group. Therefore, this study aims to compare the results of colonoscopic screening in HNPCC and intermediate risk groups and assess the effect of the most recent screening protocol recommendations.

METHOD

A total of 244 individuals; 108 from HNPCC families (28 mismatch repair gene carriers) and 136 from intermediate risk families were referred for regular colonoscopic screening by the Regional Genetics Service. Findings from 417 colonoscopies performed between 1992 and 2003 were evaluated.

RESULTS

A total of three cancers, 39 adenomas and 41 hyperplastic polyps were found in the HNPCC group compared with one cancer, 22 adenomas and 19 hyperplasic polyps in the intermediate risk group. If the recent screening guidelines for the intermediate group were applied, then 89 (44%) fewer colonoscopies would have been performed. Although no cancers would have been missed, six adenomas (mean size = 5.7 mm, range 2-10 mm) with two graded as severely dysplasic and six hyperplastic polyps would not have been detected.

CONCLUSION

The detection rate and distribution of adenomas were similar in both groups. If the new colonoscopic screening recommendations for the intermediate risk group had been applied, a small number of significant lesions would have been missed.

Mobile colonoscopic surveillance provides quality care for hereditary nonpolyposis colorectal carcinoma families in South Africa

BACKGROUND

It is difficult to provide a colonoscopic surveillance service for at-risk family members with hereditary nonpolyposis colorectal carcinoma when many of those family members live in a remote area of South African far from endoscopic services. A mobile surveillance programme was established to service these individuals.

OBJECTIVE

The aim of this study was to compare the quality of the mobile service to that provided in established endoscopy units.

METHOD

Ninety-one asymptomatic subjects with known disease-causing mutations underwent 259 colonoscopies. Of these, 171 colonoscopies were performed by a mobile colonoscopy service in small rural hospitals and 88 in established endoscopy units. The quality of the colonoscopic services was measured by completion rate, the rate of detection of colonoscopic abnormalities, histopathological analyses of biopsies, surgical intervention and colorectal cancer deaths.

RESULTS

The caecum was reached in 96% of all colonoscopies. A significant lesion was detected in 8.8% of colonoscopies. There was no difference in the rate of complete colonoscopy and detection rate of lesions in the established units and the mobile service (both P = 0.6). The rate of detection of early adenocarcinomas was similar (P = 0.17). The colonoscopic screening/surveillance programme meets international standards with a high accuracy (95.75%) and negative predictive value (100%).

CONCLUSION

The mobile service provides access to colonoscopy in remote areas without compromising the quality of service.

Providing a community-based cancer risk assessment service for a socially and ethnically diverse population

BACKGROUND

Patients from ethnic minorities are under-represented in referrals to cancer genetics services. In a regional genetics centre that serves two London boroughs, the existing service attracts 3% of its referrals from Black and Minority Ethnic (BME) and other ethnic groups, despite the fact that these groups make up 34% of the population.

OBJECTIVES

To improve access to familial cancer risk assessment in a socially and ethnically diverse population.

SETTING

The London boroughs of Lambeth and Southwark.

DESIGN

Community-based, nurse-led clinics were established for people who were concerned about their familial cancer risk. Patients were asked to triage themselves by answering three questions. Self-referral was encouraged.

MAIN OUTCOME MEASURES

Data were gathered on ethnicity of clients, cancer risk, source of referral and patient and health professional satisfaction with the service.

RESULTS

Of the 415 people who have accessed the service, 46% were from not White British groups and 67% referred themselves to the service, demonstrating the success of this model in reaching 'hard to reach' groups. Thirty-seven percent of patients were assessed as being at population risk and 63% were assessed as being at moderate risk or higher, showing that the clinics were meeting an unmet need in the community.

Cancer genetics clinics and the surgeon: a valuable role for family history screening

INTRODUCTION

This study examines how a colorectal surgeon can use a regional cancer genetics service to deal safely and efficiently, with community referrals for colorectal cancer screening on the basis of family history.

PATIENTS AND METHODS

A retrospective review of consecutive asymptomatic people with a strong family of colorectal cancer referred by the surgeon to the genetics service over a 30-month period.

RESULTS

A total of 45 people were referred by the surgeon to the cancer genetics service. Following official verification of family histories, 15 were thought to be in a low-risk category for developing colorectal cancer, 18 were moderate risk, 4 had a high-to-moderate risk and 2 satisfied the criteria for HNPCC. After official authentication, it was discovered that 20% of people had mistakenly informed the surgeon of important inaccuracies in their family history.

CONCLUSIONS

The cancer genetics service seeks to identify accurately those at increased risk of developing colorectal cancer due to their family history. It has the time, resources and expertise to verify officially a family history that cannot be properly done in a busy surgical clinic. This study shows that it can provide a valuable role for correctly identifying and counselling people who truly require screening due to their familial predisposition for colorectal cancer.

Anxieties should not be forgotten when screening relatives of colorectal cancer patients by colonoscopy

OBJECTIVE

Individuals with a strong family history have a high risk of developing colorectal cancer. They could well benefit from targeted screening and their increased risk warrants an invasive procedure such as colonoscopy. This study aims to assess the anxieties of symptom-free relatives offered screening by colonoscopy.

METHOD

A simple questionnaire was sent to 50 consecutive people who had colorectal cancer screening by colonoscopy because of a strong family history.

RESULTS

Forty-five questionnaires were answered. On assessing their anxiety levels before and after colonoscopy, 56% noticed an improvement after the test, 33% were still as anxious and 11% had raised anxiety levels despite screening. Although most of the screening colonoscopies were normal, 44% of asymptomatic relatives undergoing invasive screening had no improvement of their cancer anxieties.

CONCLUSION

Screening people with a strong family history of colorectal cancer may be an efficient, cost-effective and focussed way of detecting early neoplasms rather than screening the general population. Using colonoscopy alone however, a large proportion of people still have cancer anxieties after being screened. This small study suggests that in order to attempt to alleviate anxieties, a colonoscopy alone is insufficient for some in this high-risk group.

Prevalence of family history of colorectal cancer in the general population

BACKGROUND

Robust estimates of the prevalence of a family history of colorectal cancer in the general population are essential to inform planning of provision for colonoscopic surveillance and for clinical genetics services. However, there is a paucity of high-quality data.

METHODS

Computerized record linkage was used to assess systematically the family history of 160 cancer-free community subjects and thereby provide prevalence data that are independent of participant recall. The data set comprised 2664 first- and second-degree relatives of study subjects, with 148 068 years at risk.

RESULTS

Of people in the 30-70 years age range, 9.4 (95 per cent confidence interval (c.i.) 5.8 to 14.9) per cent had a first-degree relative affected by colorectal cancer, and 28.8 (95 per cent c.i. 22.3 to 36.2) per cent had an affected first- or second-degree relative. Between 0 and 3.1 per cent of study subjects merited colonic surveillance, depending on the stringency of the guidelines used.

CONCLUSION

An appreciable proportion of the general population has a relative affected by colorectal cancer, sufficient to merit screening under certain criteria. In the absence of good-quality evidence supporting colonoscopic surveillance in groups at moderate risk, these data directly inform the planning of services for people with a family history of colorectal cancer. However, the clinical risk and financial implications of screening should be taken into account.

Colonoscopic surveillance and clinical genetics services

Coordinating activities should produce benefit

Screening behavior of individuals at high risk for colorectal cancer

BACKGROUND AND AIMS

Periodic colonoscopy is an effective means of reducing the incidence and mortality of colorectal cancer in individuals with a family history of the disease. The aims of this study were to determine the degree of compliance and to identify the factors related significantly to noncompliance with periodic screening in this high-risk population.

METHODS

A total of 178 individuals who had undergone genetic counseling for colorectal cancer between 1986 and 1998 and who had been advised to undergo periodic screening because of familial colorectal cancer (FCRC) or hereditary nonpolyposis colorectal cancer (HNPCC) were invited to complete a self-report questionnaire on psychosocial issues and screening experiences. Compliance data were derived from medical records and via self-report.

RESULTS

A total of 149 individuals (84%) participated in the study. Noncompliance with screening advice was rare (in 3% of cases), but significant delays (more than 1 year) in undergoing screening were observed in approximately 25% of the cases. The number of perceived barriers to screening (eg, discomfort, embarrassment) was the only variable related significantly to noncompliance/screening delay (odds ratio, 1.2; 95% confidence interval, 1.1-1.3). Use of sedatives during the procedure and receipt of a reminder letter seemed to facilitate better compliance.

CONCLUSIONS

Although few high-risk individuals abstain from screening entirely, approximately one in 4 deviates significantly from the recommended frequency of screening. Increased compliance may be achieved by reducing the discomfort and embarrassment associated with the procedure and by the use of reminder letters.

Accuracy of reporting of family history of colorectal cancer

BACKGROUND AND AIMS

Family history is used extensively to estimate the risk of colorectal cancer but there is considerable potential for recall bias and inaccuracy. Hence we systematically assessed the accuracy of family history reported at interview compared with actual cancer experience in relatives.

METHODS

Using face to face interviews, we recorded family history from 199 colorectal cancer cases and 133 community controls, totalling 5637 first and second degree relatives (FDRs/SDRs). We linked computerised cancer registry data to interview information to determine the accuracy of family history reporting.

RESULTS

Cases substantially underreported colorectal cancer arising both in FDRs (sensitivity 0.566 (95% confidence interval (CI) 0.433, 0.690); specificity 0.990 (95% CI 0.983, 0.994)) and SDRs (sensitivity 0.271 (95% CI 0.166, 0.410); specificity 0.996 (95% CI 0.992, 0.998)). There was no observable difference in accuracy of reporting family history between case and control interviewees. Control subjects similarly underreported colorectal cancer in FDRs (sensitivity 0.529 (95% CI 0.310, 0.738); specificity 0.995 (95% CI 0.989, 0.998)) and SDRs (sensitivity 0.333 (95% CI 0.192, 0.512); specificity 0.995 (95% CI 0.991, 0.995)). To determine practical implications of inaccurate family history, we applied family history criteria before and after record linkage. Only two of five families reported at interview to meet surveillance criteria did so after validation, whereas only two of six families that actually merited surveillance were identified by interview.

CONCLUSIONS

This study has quantified the inaccuracy of interview in identifying people at risk of colorectal cancer due to a family history. Colorectal cancer was substantially underreported and so family history information should be interpreted with caution. These findings have considerable relevance to identifying patients who merit surveillance colonoscopy and to epidemiological studies.

Colonoscopy surveillance of individuals at risk of familial colorectal cancer

BACKGROUND

Individuals with first degree relatives affected with colorectal cancer (CRC) at a young age, or more than one relative affected but who do not fulfil the Amsterdam criteria for a diagnosis of hereditary non-polyposis colon cancer (HNPCC), are believed to be at an increased risk of CRC. However, there is a paucity of prospective data on the potential benefit of colonoscopic surveillance in such groups categorised by empiric family history criteria. We report a prospective study of 448 individuals seeking counselling about their perceived family history of CRC.

PATIENTS AND METHODS

Following pedigree tracing, verification, and risk assignment by genetic counsellors, colonoscopy was undertaken for those at a moderate or high risk (HNPCC). Those classified as low risk were reassured and discharged without surveillance. Here we report our findings at the prevalence screen in the 176 patients of the 448 assessed who underwent colonoscopy.

RESULTS

Fifty three individuals had a family history that met Amsterdam criteria (median age 43 years) and 123 individuals were classed as moderate risk (median age 43 years). No cancers were detected at colonoscopy in any group. Four individuals (8% (95% confidence limits (CL) 0.4-15%)) in the high risk group had an adenoma detected at a median age of 46 years and all four were less than 50 years of age. Five (4% (95% CL 0.6- 8%)) of the moderate risk individuals had an adenoma at a median age of 54 years, two of whom were less than 50 years of age.

CONCLUSIONS

These findings indicate that the prevalence of significant neoplasia in groups defined by family history is low, particularly in younger age groups. These prospective data call into question the value of colonoscopy before the age of 50 years in moderate risk individuals.

Surveillance of individuals at intermediate risk of colorectal cancer--the impact of new guidelines

OBJECTIVE

Individuals with two first degree relatives, or one diagnosed at age < 45 years, with colorectal cancer are at sufficient risk to merit surveillance. Most undergo colonoscopy four to five yearly, starting 10 years before the youngest case. The aim of this study was to assess the impact of a proposed new surveillance protocol.

SUBJECTS AND METHODS

We identified individuals with these risk criteria seen in our clinic from 1989 to 2001 and reviewed their notes with respect to colonoscopy.

RESULTS

Colonoscopy (n = 295) was performed on 186 patients in accordance with current recommendations. Cancer was detected in three and adenoma in 21 individuals. Applying the proposed protocol, 123 (42%) fewer colonoscopies would have been performed. No cancers would have been missed, but in five cases a small adenoma would not have been detected.

CONCLUSIONS

Proposed new guidelines for surveillance of those at intermediate risk reduce the burden of colonoscopy without compromising identification of significant neoplasia.