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Review ArticlePractice

Colorectal cancer screening for patients with a family history of colorectal cancer or adenomas

Anna N. Wilkinson, David Lieberman, Grigorios I. Leontiadis, Frances Tse, Alan N. Barkun, Ahmed Abou-Setta, John K. Marshall, Jewel Samadder, Harminder Singh, Jennifer J. Telford, Jill Tinmouth and Desmond Leddin
Canadian Family Physician November 2019, 65 (11) 784-789;
Anna N. Wilkinson
Assistant Professor in the Department of Family Medicine and the Department of Oncology and Program Director of the third-year family physician oncology program at the University of Ottawa in Ontario.
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  • For correspondence: anwilkinson@toh.ca
David Lieberman
Professor of Medicine and Chief of the Division of Gastroenterology and Hepatology at Oregon Health and Science University in Portland.
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Grigorios I. Leontiadis
Associate Professor in the Division of Gastroenterology at McMaster University Health Sciences Centre in Hamilton, Ont.
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Frances Tse
Associate Professor and Chief of Service, Gastroenterology, in the Division of Gastroenterology at McMaster University.
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Alan N. Barkun
Chairholder of the Douglas G. Kinnear Chair in Gastroenterology and Professor of Medicine, Director of the Endoscopy and Therapeutic Endoscopy Training Program, and Chief Quality Officer in the Division of Gastroenterology at McGill University and the McGill University Health Centre in Montreal, Que.
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Ahmed Abou-Setta
Director of the Knowledge Synthesis platform at the George and Fay Yee Centre for Healthcare Innovation at the University of Manitoba in Winnipeg.
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John K. Marshall
Professor of Medicine and Director of the Division of Gastroenterology at McMaster University.
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Jewel Samadder
Associate Professor and Director of the High Risk Cancer Clinic in the Division of Gastroenterology and Hepatology at the Mayo Clinic in Phoenix, Ariz.
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Harminder Singh
Associate Professor in the Department of Internal Medicine and the Department of Community Health Sciences at the University of Manitoba and in the Department of Hematology and Oncology of CancerCare Manitoba.
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Jennifer J. Telford
Clinical Professor of Medicine at the University of British Columbia in Vancouver and Medical Director of the BC Colon Screening Program at Pacific Gastroenterology Associates.
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Jill Tinmouth
Assistant Professor in the Department of Medicine at the University of Toronto in Ontario, Scientist in Evaluative Clinical Sciences in the Odette Cancer Research Program at the Sunnybrook Research Institute, a staff physician at Sunnybrook Health Sciences Centre, Adjunct Scientist at ICES, a faculty member of the Institute of Health Policy, Management and Evaluation at the University of Toronto, and Lead Scientist of the ColonCancerCheck program at Cancer Care Ontario.
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Desmond Leddin
Adjunct Professor of Medicine at the University of Limerick in Ireland and at Dalhousie University in Halifax, NS, and Head of Graduate Entry Medical School at the University of Limerick.
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  • RE: Wilkinson et al
    Eoin Lalor
    Published on: 19 November 2019
  • Published on: (19 November 2019)
    RE: Wilkinson et al
    • Eoin Lalor, Gastroenterologist, Royal Victoria Regional Health Centre, Barrie, ON

    Wilkinson et al. (CFP, November 2019) are to be commended for presenting the recent Canadian/American guidelines for colorectal cancer (CRC) screening for patients with a family history of colorectal neoplasia (Leddin et al, Gastroenterology, 2018).

    Unfortunately, they do not present evidence, or at least references, supporting their “conclusion” that “lifestyle advice already given to patients for weight, blood pressure and heart disease management will reduce the risk of CRC if implemented”. There is little if any evidence that treatment of blood pressure or heart disease will influence the risks for developing colorectal cancer (the authors appropriately omit discussing the complex effect of aspirin on CRC incidence and mortality). While obesity is associated with increased colorectal cancer risk, there is little if any published evidence that weight reduction will reduce that risk, (and copious evidence supporting the ineffectiveness of the medical profession in achieving longterm weight-loss).

    The main concern is the recommendation for screening starting “at age 40-50 or 10 years younger than the age of the first-degree relative at diagnosis”. Previous guidelines used to say “whichever comes first” - this clause has obviously been deliberately omitted. Providing the option for the primary care practitioner to decide between ages 40 and 50, or 10 years younger than the age of the relative, makes this guideline potentially difficult to implement. The in...

    Show More

    Wilkinson et al. (CFP, November 2019) are to be commended for presenting the recent Canadian/American guidelines for colorectal cancer (CRC) screening for patients with a family history of colorectal neoplasia (Leddin et al, Gastroenterology, 2018).

    Unfortunately, they do not present evidence, or at least references, supporting their “conclusion” that “lifestyle advice already given to patients for weight, blood pressure and heart disease management will reduce the risk of CRC if implemented”. There is little if any evidence that treatment of blood pressure or heart disease will influence the risks for developing colorectal cancer (the authors appropriately omit discussing the complex effect of aspirin on CRC incidence and mortality). While obesity is associated with increased colorectal cancer risk, there is little if any published evidence that weight reduction will reduce that risk, (and copious evidence supporting the ineffectiveness of the medical profession in achieving longterm weight-loss).

    The main concern is the recommendation for screening starting “at age 40-50 or 10 years younger than the age of the first-degree relative at diagnosis”. Previous guidelines used to say “whichever comes first” - this clause has obviously been deliberately omitted. Providing the option for the primary care practitioner to decide between ages 40 and 50, or 10 years younger than the age of the relative, makes this guideline potentially difficult to implement. The interval (5-10 years) is similarly vague.

    A second concern is the recommendation to utilize FIT (fecal immunochemical testing) as an alternative. While the authors explain some of the rationale for FIT, I am concerned that they suggest that the fecal immunochemical test is generally better accepted by patients (which is true), but a positive FIT requires colonoscopy. They suggest that it may be more available in rural areas, but I am not sure that rural Canadians deserve potentially inferior CRC screening. The authors recommend that the FIT might be more feasible for patients with multiple medical comorbidities, but (because a positive FIT requires colonoscopy), I would caution primary care practitioners against organizing FIT in patients with multiple medical comorbidities and a family history of colorectal cancer, (which is the topic of this paper), especially since the authors correctly admit that FIT has not been tested in higher risk patients with a family history of CRC.

    Disclosure: I am a gastroenterologist, who does colonoscopy, in a hospital setting, but not in an ambulatory clinic. I am strongly supportive of the FIT program for average risk screening.

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    Competing Interests: None declared.
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Canadian Family Physician: 65 (11)
Canadian Family Physician
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1 Nov 2019
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Colorectal cancer screening for patients with a family history of colorectal cancer or adenomas
Anna N. Wilkinson, David Lieberman, Grigorios I. Leontiadis, Frances Tse, Alan N. Barkun, Ahmed Abou-Setta, John K. Marshall, Jewel Samadder, Harminder Singh, Jennifer J. Telford, Jill Tinmouth, Desmond Leddin
Canadian Family Physician Nov 2019, 65 (11) 784-789;

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Colorectal cancer screening for patients with a family history of colorectal cancer or adenomas
Anna N. Wilkinson, David Lieberman, Grigorios I. Leontiadis, Frances Tse, Alan N. Barkun, Ahmed Abou-Setta, John K. Marshall, Jewel Samadder, Harminder Singh, Jennifer J. Telford, Jill Tinmouth, Desmond Leddin
Canadian Family Physician Nov 2019, 65 (11) 784-789;
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