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Involve patients in colorectal ca screening choice. (Fobt, Colonoscopy, Sigmoidoscopy).

ATLANTA -- Screening patients over age 50 for colorectal cancer is becoming the standard of care, but the decision about which screening method to use depends on what works in your practice and what your patients prefer, Dr. Paul S. Frame said at the annual meeting of the American Academy of Family Physicians.

Sit down and discuss with patients the pros and cons of the different screening methods and help them decide which is the best modality, he advised.

"This is not as unfeasible as it sounds," said Dr. Frame, who is clinical professor of family medicine at the University of Rochester (N.Y) and a member of the U.S. Preventive Services Task Force. The AAFP is developing brochures to help patients understand their options, he added.

Some experts believe that colonoscopy should be the screening test of choice, but expense, access problems, and potential morbidity can make it an unrealistic choice in some circumstances.

Limited availability also can limit access to flexible sigmoidoscopy, which is considered an acceptable screen for colorectal cancer when performed every 5-10 years.

For example, in Dr. Frame's hometown, the only gastroenterologist who performs colonoscopy is overwhelmed with acute patients. In Dr. Frame's group practice, only 2 of 12 physicians perform flexible sigmoidoscopy, so if the screening protocol relied on that method, many patients would not get appropriate screening, he said.

The basic protocol for screening in his practice is based on fecal occult blood testing (FOBT). The available evidence on colorectal cancer screening suggests that annual FOBT screening is more effective than biannual screening. A positive test should be followed up with colonoscopy.

There are no data to suggest that FOBT plus sigmoidoscopy is better than either of these screening methods alone, but it seems reasonable to believe that the combined approach would be superior, Dr. Frame said.

A less desirable approach is use of double-contrast barium enema. Digital rectal examination has not been shown to be useful and should be abandoned altogether, he added.

Dr. Frame also addressed these topics in colorectal cancer screening:

* Nonsteriodal anti-inflammatory drugs in patients with polyps. A significant amount of research suggests that the use of NSAIDs, as well as the use of aspirin, reduces polyp recurrence. There are no data that suggest that this will reduce the risk of colon cancer, but it does make some intuitive sense to use NSAIDs in these patients, he said--provided that patients are not at risk for gastrointestinal bleeding or other disorders that preclude their use.

* Rehydration of FOBT slides. Rehydration of slides dramatically increases the sensitivity of the FOBT; without rehydration the rate of positive tests is about 3%-4%, and with rehydration it is 10%-15%. Yet most of the additional positive tests among those that are rehydrated will be false positive, and most physicians feel that the effort is not worthwhile, Dr. Frame said.

* FOBT in patients who underwent previous screening colonoscopy. If you're comfortable doing colonoscopy every 10 years, then there really is no reason--other than suspicious symptoms--to do FOBT in the interim.

But if you are going to do FOBT in the interim, choose a cutoff time following colonoscopy after which you will consider a positive FOBT to be worth working up. If you're not going to pay attention to a positive test performed 1 year after a colonoscopy, then don't bother doing the FOBT until then, he advised.
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Comment:Involve patients in colorectal ca screening choice. (Fobt, Colonoscopy, Sigmoidoscopy).
Author:Worcester, Sharon
Publication:Family Practice News
Article Type:Brief Article
Geographic Code:1USA
Date:Feb 15, 2002
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