Screen for colorectal cancer earlier, more often in people with cystic fibrosis

Last Updated: 2018-01-11

By Reuters Staff

NEW YORK (Reuters Health) - Adults with cystic fibrosis (CF) should undergo colorectal cancer (CRC) screening with colonoscopy beginning at age 40 and be rescreened every five years, advise consensus recommendations from the Cystic Fibrosis Foundation.

Continued therapeutic advances have "impressively" increased survival among patients with CF, Dr. Denis Hadjiliadis from University of Pennsylvania in Philadelphia and colleagues note in their report. Median predicted survival is now 41 years, and individuals born in 2015 have an estimated average life expectancy of 45 years.

"The increasing longevity of adults with CF puts them at risk for other diseases, such as gastrointestinal cancer," write the authors.

Of note, the risk of CRC is five to 10 times higher in the CF population compared to the general population, and up to 30 times higher in CF patients after an organ transplantation. Adults with CF also develop CRC at a younger age - around age 40, or about 20 to 30 years younger than in the non-CF population.

To address this risk, the CF Foundation convened a multidisciplinary task force to develop CRC screening recommendations specifically for the CF population. The 18-member group reviewed 198 relevant articles and analyzed 123 articles to develop recommendation statements. The task force included recommendation statements in the final guideline only if they reached an 80% acceptance threshold. They make the following 10 CRC screening recommendations:

1. All decisions on CRC screening and surveillance in individuals with CF should be based on shared decisions between the provider and individual with CF about treatment, comorbidities, safety, and quality of life.

2. All CRC screening and surveillance for individuals with CF should be jointly managed by CF healthcare professionals and an endoscopist.

3. Colonoscopy is the recommended screening test for CRC in individuals with CF.

4. The evidence is insufficient to recommend the use of computed tomography, colonography, stool-based tests, or flexible sigmoidoscopy in individuals with CF for the purpose of CRC screening.

5. CRC screening should start at age 40 in individuals with CF and should be repeated every five years.

6. People with CF who have undergone a colonoscopy that revealed any adenomatous polyps should have surveillance colonoscopy in three years, unless a shorter interval is indicated by individual findings, with subsequent intervals based on the most recent endoscopic examination.

7. People with CF who are age 30 or older and have adequately recovered after receiving a solid organ transplantation should begin CRC screening within two years of transplantation, except when they have had a negative colonoscopy within the past five years.

8. Repeat CRC screening is advised every five years in individuals with CF who have received a solid organ transplant.

9. People with CF who have undergone a solid organ transplantation and had colonoscopy that had any adenomatous polyps should have surveillance colonoscopy in three years, unless a shorter interval is indicated by individual findings, with subsequent intervals based on the most recent endoscopic examination.

10. Adults with CF undergoing a colonoscopy should receive intensive regimens for bowel preparation to allow for optimal examination. This includes: three to four washes (minimum of 1-liter purgative per wash), with the last wash occurring within four to six hours before the examination.

"These recommendations will need to be updated when additional information becomes available about the potential benefit of alternative screening procedures, and the role of other risk factors, such as sex, mutational status, and family history," the task force notes.

The recommendations were published online December 29 in Gastroenterology.

A related article in the journal shows that CRC screening is cost-effective in patients with CF. In support of the task force recommendations, screening should start at an earlier age with a shorter screening interval, "due to the higher risk in these patients for CRC," report Dr. Andrea Gini from Erasmus Medical Center, Rotterdam, the Netherlands, and colleagues.

Their analysis suggests that colonoscopy every five years, beginning at age 40, is the optimal colonoscopy strategy for patients with CF who never received an organ transplant; this strategy prevented 79% of deaths from CRC.

For CF patients with an organ transplant, optimal colonoscopy screening should start at age 30 or 35 years, depending on the patient's age at time of transplantation, the authors report.

Annual fecal immunochemical test (FIT) screening was "predicted to be cost-effective for patients with CF," but they note that the level of accuracy of the FIT in this population is not clear.

This research had no commercial funding, and the authors have disclosed no conflicts of interest.

SOURCES: http://bit.ly/2Dh6eok and http://bit.ly/2AO8Nvo

Gastroenterology 2017.