A 60-year-old man comes to the office for an annual preventive visit. The patient feels healthy and has no symptoms. He has a history of hypertension that is well controlled with lisinopril. The patient does not use tobacco or alcohol; he has a balanced diet and exercises regularly. He had a normal screening colonoscopy 10 years ago but says, "I had an awful experience during the bowel preparation, and I would rather not go through that again." He has no family history of colorectal cancer. Vital signs are normal, and physical examination shows no abnormalities. The patient agrees to undergo flexible sigmoidoscopy, which reveals 2 pedunculated polyps of 1-1.5 cm in the descending colon; the polyps are removed, and histopathology findings are consistent with villous adenoma in both polyps. Which of the following is the best recommendation for this patient regarding colorectal cancer screening?

Question

A 60-year-old man comes to the office for an annual preventive visit.  The patient feels healthy and has no symptoms.  He has a history of hypertension that is well controlled with lisinopril.  The patient does not use tobacco or alcohol; he has a balanced diet and exercises regularly.  He had a normal screening colonoscopy 10 years ago but says, "I had an awful experience during the bowel preparation, and I would rather not go through that again."  He has no family history of colorectal cancer.  Vital signs are normal, and physical examination shows no abnormalities.  The patient agrees to undergo flexible sigmoidoscopy, which reveals 2 pedunculated polyps of 1-1.5 cm in the descending colon; the polyps are removed, and histopathology findings are consistent with villous adenoma in both polyps.  Which of the following is the best recommendation for this patient regarding colorectal cancer screening?

Quizplus · Accepted Answer

Explanation: Colon cancer screening should be offered to patients at average risk beginning at age 45. Colonoscopy is the most sensitive test, but patients often find the necessary bowel preparation unpleasant. Flexible sigmoidoscopy requires less preparation and is an acceptable alternative for average-risk individuals. If findings are normal, it should be repeated at 5-year intervals (or 10-year intervals if combined with annual fecal immunochemical testing). However, sigmoidoscopy does not visualize the proximal colon and is less sensitive than colonoscopy. Any patient with an abnormal finding (eg, adenomatous polyp) on flexible sigmoidoscopy should undergo colonoscopy for visualization of the entire colon to rule out synchronous (ie, developing concurrently in another colon segment) polyps in the proximal colon. (Choices A, B, and E) Based on the sigmoidoscopy findings, this patient should not go without additional testing for a year or more. He needs a colonoscopy now to rule out synchronous adenomas and advanced neoplasia in the proximal colon. (Choice D) CT colonography is an appropriate initial screening test for individuals at average risk. However, it has lower sensitivity than colonoscopy, especially for small or sessile polyps, and does not allow for biopsy of suspicious lesions. Educational objective: Patients with adenomatous polyps found on screening sigmoidoscopy should undergo colonoscopy for visualization of the entire colon and detection of synchronous adenomas and advanced neoplasia. References: Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/34003218)

A 60-Year-Old Man Comes to the Office for an Annual