Does a 50-year-old male with a family history of colon cancer require a colonoscopy for screening, having never undergone one before, with an initial step of ordering a Hemoccult (fecal occult blood test)?

From the Guidelines

I strongly recommend scheduling a colonoscopy for this 50-year-old male patient with a family history of colon cancer, as it is the most effective screening method for detecting and preventing colorectal cancer in high-risk individuals. While a hemoccult test (fecal occult blood test) is a reasonable initial screening tool, this patient's age and family history warrant a more thorough examination. According to the American College of Gastroenterology 1, the recommended screening approach for individuals with a family history of colorectal cancer is to begin colonoscopy at age 40 or 10 years before the youngest diagnosed family member, whichever comes first. Given the patient's age and family history, proceeding directly to colonoscopy is the most appropriate course of action. The patient should be referred to a gastroenterologist for the procedure, which involves bowel preparation typically using medications like GoLYTELY, MoviPrep, or Suprep the day before. The colonoscopy will allow direct visualization of the colon to detect and remove polyps or identify cancerous lesions. Following the initial colonoscopy, the gastroenterologist will recommend an appropriate surveillance interval based on findings, typically ranging from 1-10 years 1.

Some key points to consider in this patient's case include:

• The patient's family history of colon cancer, which increases his risk of developing the disease
• The patient's age, which is within the recommended screening range for average-risk individuals, but given his family history, he is considered high-risk
• The importance of colonoscopy as a screening tool, as it can both detect and prevent cancer through polyp removal 1
• The need for prompt referral to a gastroenterologist to facilitate the colonoscopy procedure
• The importance of following the recommended surveillance interval after the initial colonoscopy to ensure ongoing monitoring and prevention of colorectal cancer.

The prison healthcare system should facilitate this referral promptly, as timely screening and prevention are crucial in reducing the risk of colorectal cancer in high-risk individuals 1.

From the Research

Patient Request for Colonoscopy

The patient, a 50-year-old male, is requesting to schedule a colonoscopy due to a family history of colon cancer and never having had one before.

Initial Screening Step

The first step ordered is a Hemoccult test, which is a type of fecal occult blood test (FOBT) used to detect hidden blood in the stool, a possible indicator of colorectal cancer 2, 3, 4.

Recommendations for Colorectal Cancer Screening

According to the U.S. Multi-Society Task Force on Colorectal Cancer, screening should begin at age 50 in average-risk persons, but those with a family history of colorectal cancer may need to start screening earlier 5.

• For individuals with a family history of CRC or a documented advanced adenoma in a first-degree relative, screening by colonoscopy every 5 years is recommended, starting 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier.
• The task force recommends colonoscopy and annual fecal immunochemical test (FIT) as the cornerstones of screening, with colonoscopy being one of the first-tier tests.

Effectiveness of Fecal Occult Blood Tests

Studies have shown that fecal occult blood tests, including the Hemoccult test, can reduce colorectal cancer mortality when used for screening 3, 4.

• A meta-analysis of randomized controlled trials found that screening with FOBT reduced colorectal cancer mortality by 16% 4.
• However, the sensitivity and specificity of FOBT can vary, and immunochemical tests may have better validity for detecting colorectal cancer compared to Guaiac-based tests like Hemoccult 2.

Next Steps

Given the patient's family history and age, a colonoscopy may be an appropriate screening option, especially if the Hemoccult test is positive or if the patient has other risk factors for colorectal cancer 5.

• The patient's medical history and risk factors should be taken into account when determining the best screening strategy.
• Further evaluation and discussion with the patient about the benefits and harms of screening, as well as the potential consequences of false-positive or false-negative results, are necessary 3, 4.