Case 9: Introduction


History of Present Illness (HPI)

A 40-year-old Caucasian woman with a past medical history of diabetes and hypertension presents to clinic for a wellness visit. She reports a history of colon cancer in her father at age 70. She asks at what age she should start colorectal cancer (CRC) screening and would like to know more about her options.

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At what age should our patient start CRC screening?
Age 40
Try Again! Screening from age 40 is recommended for patients with either: A first degree relative younger than age 60 with a history of CRC or advanced adenomatous polyps. OR At least two first degree relatives with CRC or adenomatous polyps at any age If either criteria is met, screening should be started at the earlier of the following: age 40 or 10 years before the age at which CRC was diagnosed in their relative. Our patient’s father was diagnosed with CRC beyond 60 years of age, hence early screening is not warranted for her. Of note advanced adenoma is defined as any adenoma with significant villous features (>25%), size of 1.0 cm or more, high-grade dysplasia, or early invasive cancer.
Age 45
Good choice. The 2021 ACG guidelines and USPSTF recommendations have been updated to include a conditional recommendation for CRC screening in average risk patients to start between age 45-49. This is because incidence rates among 40-49-year-olds have increased by almost 15% in the last 15 years.
Age 50
Reasonable choice, but make sure you know the update. The 2021 ACG guidelines and the USPSTF statement provide a strong recommendation (Grade A) to start CRC at age 50. However, this has now been updated with a conditional guideline (Grade B) to start at age 45 in order to reduce incidence of advanced adenoma, CRC and mortality in younger patients.

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