Do gastroenterologists notify polyp patients that family members should have screening?

Objective: The objective of this study was to determine whether patients found to have adenomatous polyps or cancer were notified that their relatives should have screening, due to an increased risk of developing colorectal cancer.

Methods: Consecutive (n = 121) colonoscopy patients from December of 1999 to October of 2001 found to have adenomatous colon polyps or colon cancer formed the study group. Charts were reviewed for documentation of relative notification, and when documentation was not present, study subjects were contacted by telephone.

Results: Overall, 71% had data that were able to be evaluated; the remaining 29% were unable to be contacted because of changes of address or phone numbers. Adenomatous polyps were seen in 95%, and cancer seen in 5%. Overall, 30% of the patients were notified: 23 of 82 (28%) in the polyp group and 3 of 4 (75%) in the cancer group. Advanced adenomas or multiple adenomas were noted in 28 of the 82 (34%). Of those, 8 of 28 (29%) were notified.

Conclusions: Gastroenterologists should be aware of the need for increased attention to family notification, especially in those with advanced adenomas or multiple adenomas. Template notification letters may complement the polyp surveillance programs that many colonoscopists use.

Key Words: adenomatous polyps, colorectal cancer, first-degree relatives, screening

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Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. (1) The average lifetime risk for the development of colorectal cancer is approximately 6%. (2) However, this risk is increased two- to three-fold in first-degree relatives of patients with CRC. (3-5) More than 95% of CRC develops from adenomatous polyps. Due to the adenoma-carcinoma sequence, there is an increased risk of development of CRC in first-degree relatives of patients who were found to have adenomatous polyps. The age-adjusted relative risk of developing CRC in these individuals is 1.72 and is increased to 2.75 if two first-degree relatives are found to have adenomatous polyps. (3) Colonoscopy with polypectomy has been shown in several studies to reduce the incidence and mortality rates of CRC. (6) Physicians should therefore inform their patients of the risk of colorectal neoplasia in their first-degree relatives when adenomatous polyps are discovered. The objective of this study was to determine whether patients found to have adenomatous polyps or CRC were notified that their relatives should have appropriate colon cancer screening.

Materials and Methods

This investigation was prospectively approved by the University of South Alabama Institutional Review Board. Consecutive colonoscopy patients at the University of South Alabama from December of 1999 to October of 2001 who were found to have adenomatous colon polyps or colon cancer formed the study group. Advanced adenomas were classified as those containing villous architecture on histology, those that were greater than 1 cm in diameter, or those containing high-grade dysplasia.

Those performing the endoscopies included six gastroenterology fellows and two attending physicians. Attending physicians were present during all fellows' procedures. Medical records were reviewed for documentation that the patient was notified of the potential increased risk to first-degree family members. When documentation was not present, study subjects were contacted by phone. The patients were asked whether they were verbally notified after the procedure of the potential increased risk to first-degree family members.

Results

A total of 121 patients formed the study group. The median age of the patients was 58.9 years, with a range of 37 to 84 years. The study group consisted of 51% females and 49% males. For 58 (67%) of the patients, it was their first colonoscopy, whereas 28 (33%) had previous procedures. Overall, 86 of the 121 (71%) patients had data that were able to be evaluated. The remaining 35 patients (29%) were unable to be contacted because of changes in address or phone numbers. Adenomatous polyps were found in 95% and CRC in 5%. Overall, 30% of the patients were notified of the increased risk to relatives: 23 of 82 (28%) in the polyp group and 3 of 4 (75%) in the cancer group. Advanced adenomas (n = 3) or multiple adenomas (n = 25) were noted in 28 of the 82 patients (34%). Of those, 8 (29%) were notified of the increased risk to family members.

Discussion

There is significant evidence that the risk for developing CRC in relatives of those diagnosed with CRC is increased. In addition, there appears to be an increased risk to the first-degree relatives of those diagnosed with adenomatous polyps. A recent study has failed to show the magnitude of risk in familial CRC in individuals with any adenomas compared with previous series (1.7 to 3.4). (7) Lynch et al (7) found that parents or siblings of individuals found to have any adenoma at screening colonoscopy have a modestly higher rate of CRC (1.36-fold). In addition, they found that those with advanced adenomas or multiple adenomas had an odds ratio for a positive family history of CRC that was increased significantly (1.62 and 1.73, respectively). In our study, only one third of patients with adenomatous polyps, advanced adenomas, or multiple polyps were notified of the increased risk to their relatives. In contrast, two thirds of those with CRC were notified of the increased risk for their first-degree relatives.

Gastroenterologists should be aware of the need for increased attention to family notification. Template notification letters may complement the polyp surveillance programs that many colonoscopists use to optimize patient notification. Our template letters discuss the findings of colon cancer or adenomas, and the implications of the diagnosis for the patients and their families. By implementing this procedure, the morbidity and mortality rates of CRC may be reduced.

Too many pieces of music finish too long after the end.
--Igor Stravinsky

Accepted June 11, 2004.

References

1. Lieberman D, Prindiville S. Weiss D, et al. Risk factors for advanced colonic neoplasia and hyperplastic polyps in asymptomatic individuals. JAMA 2003;290:2959-2967.

2. Winawer S, Hill-Harmon M, Murray T, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594-642.

3. Fuchs C, Giovannucci E, Colditz G, et al. A prospective study of family history and risk of colorectal cancer. N Engl J Med 1994;331:1669-1674.

4. Burt R. Screening of patients with a positive family history of colorectal cancer. Gastrointest Endosc Clin NA 1997;7:65-79.

5. Trowdridge B, Randall B. Colorectal cancer screening. Surg Clin North Am 2002;82:943-957.

6. Peterson K, DiSario J. Secondary prevention: screening and surveillance of persons at average and high risk for colorectal cancer. Hematol Oncol Clin North Am 2002;16:841-865.

7. Lynch K, Ahnen D, Byers T, et al. First-degree relatives of patients with advanced colorectal adenomas have an increased prevalence of colorectal cancer. Clin Gastroenterol Hepatol 2003;1:96-102.

RELATED ARTICLE: Key Points

* Family members of patients found to have colonic adenomas may be at an increased risk for developing colon cancer, particularly if the adenomas are advanced or multiple.

* Only thirty percent of our patients noted to have colonic adenomas or colon cancer were notified of their family's increased risk for colon cancer and the need for potential appropriate screening.

* Template notification letters may complement the polyp surveillance programs that many colonoscopists use.

Michael R. Valantas, DO, William M. Farmer, DO, and Jack A. DiPalma, MD

From the Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, AL.

This study was approved by The University of South Alabama Institutional Review Board.

Reprint requests to Dr. Jack A. Di Palma. Division of Gastroenterology, USA Knollwood Pavilion, 5600 Girby Road, Mobile, AL 36693. E-mail: [e-mail]