Screening for colorectal cancer
Colorectal cancer. Screening for colorectal cancer is recommended for everyone over the age of 50. Fecal occult blood testing is the major test. It should be done on an annual basis. The best way to do this is not by doing a digital rectal examination and then smearing the stool on a card. It is best done by sending the patient home with three stool hem occult cards and having them mailed back to your office. That’s so there are three different specimens done where the patient is on a special diet prior to doing the test. This is one of the places where the American Cancer Society beat out the Preventative Health Services task force. The ACS has been saying for years and years and years, that all patients should have flexible sigmoidoscopies starting at the age of 50, every two to three years. U.S. Preventive Health Services task force said, no, there’s no data to support that, until their most recent edition where, based on a very good case controlled study which showed a decreased risk of dying from colorectal cancer if a patient had undergone flexible sigmoidoscopy. The recommendation is now to do so. It is unclear what the interval should be. There are some who say between every three to five years. Some, Preventative Health Services task force leaves this unclear, but says perhaps once every ten years would be useful. And, by the way, the different … I don’t do flexible sigmoidoscopy, so I refer to gastroenterologists to do it and each one gives me back a slightly different recommendation on a normal exam, about when the next one should be done. Canadian viagra at Canadian health care.
Of course, if a person has fecal occult blood positive stool, colonoscopy is, I think, considered the community standard for the best follow-up test. Most of us would consider barium enema evaluation or flexible sigmoidoscopy after a known positive occult blood test, to be inadequate. There are some high risk groups. A first degree relative with colorectal cancer; it is unclear, still, if the increased risk of having a first degree relative justifies the use of colonoscopy over other screening methods. That increased risk, though, may justify beginning screening before the age of 50; and many of the members of my group, without data to support this, actually start recommending screening colonoscopy to patients after the age of 40 if there is a first degree relative. There is no data to support that, but at the moment, that is where we are as a community standard. We also believe that you need increased surveillance for patients with familial polyposis, ulcerative colitis, a previous history of known adenomatous polyps, or previous history of colon cancer. If you are watching the literature, it’s also unclear that once you do a … if you do a screening colonoscopy, when should the next one occur. And that is changing from every three to every five, to perhaps every ten years.
Cervical cancer. Regular pap tests are recommended for all women who are sexually active. There is little evidence that annual screening is better than every three year testing. But this is assuming that you are sitting with a patient who is at standard risk, and these are risk factors that do not make you standard risk. So early onset of sexual intercourse, multiple sex partners. One question is to get an agreement as to what does multiple mean. Cialis professional – erectile dysfunction treatment. Is that two, is that three, is that four, is that five partners? Or is it more likely to be the case where you have one partner who has multiple partners, which might be a more significant risk problem. Low socioeconomic status. HIV infection; the recommendation is still every six month pap smears in patients with HIV disease. This is because it is known that human papilloma virus, which is the virus that is known to probably induce cervical cancer, seems to grow faster in patients who are HIV positive. Of course, if there is a previous history of abnormal pap smear, that patient should have ongoing annual exams. The thing we like to argue about is what about patients above the age of 65? Should they be undergoing pap smear screening and how often? By the way, the American College of Obstetrics and Gynecology says, “Yes they should be getting them on an annual basis.” There is no data to support that.
The other question is, what about the indication for pap testing in women who have undergone hysterectomy? There is a recent article in the Journal of American Medical Association looking at a large number of women who had undergone total hysterectomy, meaning that their cervix had been removed along with the uterus, which is the standard procedure now. And it’s been shown that basically if you are doing it, what you are really screening for is vaginal cancer. You are no longer screening for cervical cancer. Vaginal cancer is extraordinarily rare. Random pap smear scrapings of the vaginal mucosa are probably useless for making that diagnosis. So based on data, there’s no reason to do it. By the way, in my group, there’s no data but what we do is if a woman has had all normal pap smears consistently before the age of 65, we would sort of drop down to once every 3-5 years screening women past the age of 65. But if you happen to see, which I still do, every now and then you see a patient who is not … I see her at 67 for her hypertension and then find out that she hasn’t had a pap smear for about 20 years or since the birth of her last child, that patient, I believe in more intensive screening for a few years.