Note: These decision points can be printed in a one page format by opening the attached PDF.
PATIENT-DETECTED RECTAL BLEEDING
The cause of rectal bleeding should be investigated to resolution, regardless of the patient’s age, or personal or family medical history. A single, in-office fecal occult blood test via digital exam is not an adequate assessment.
Prevention and Early Detection of Colorectal Cancer
Periodic screening and aggressive follow up of key symptoms can reduce a patient’s likelihood of developing later stage colorectal cancer. Discuss the benefits and limitations of screening and the importance of reporting to you any symptoms (e.g., rectal bleeding, anemia, change in bowel habits). Patients should understand that, while early detection of colorectal cancer can significantly reduce the risk of mortality, health care providers cannot guarantee a cure based on the timing of the diagnosis. Patients may need to be educated as to the subtleties of research data and discrepancies in findings among various studies.
Risk of Colorectal Cancer for Patients Younger than Age 50
Ten percent of colorectal cancers occur in patients less than age 50: approximately eight percent between ages 40–50; two percent occur in patients younger than 40. Other than an age of greater than 50 years, definite risk factors for an increased risk for colon cancer include being African-American, having a strong family history of colorectal cancer (see more), obesity, heavy alcohol use, and smoking. Patients treated with chemotherapy or abdominal radiation for non-gastrointestinal malignancies (e.g., childhood cancer survivors) are at a significantly increased risk for the development of colorectal cancer.
Regardless of age, patients with a complex personal history of colorectal cancer should be referred—along with family members—to a high-risk clinic (if available) for genetic counseling and development of their ongoing screening plans.
Risk of Interval Colorectal Cancer for Patients with a Screening History
For patients > age 50 who present with rectal bleeding or anemia in the months or years following a negative colonoscopy, explain that:
- if the colonoscopy was more than two years prior, a repeat colonoscopy is recommended;
- if the colonoscopy was less than two years prior, was completed successfully, and was negative, then a repeat colonoscopy—or sigmoidoscopy—should be considered
COLORECTAL CANCER Screening FOR ASYMPTOMATIC PATIENTS > AGE 75
Before ordering a screening colonoscopy or flexible sigmoidoscopy for a patient age 75–84, discuss the risks and benefits, taking into account the patient’s general quality of life and prior screening history. Screening is not recommended for patients over age 85, as the risks generally outweigh the benefits.
Patients respond best to a definitive recommendation from their primary care providers regarding the need for colorectal cancer screening and the most appropriate modality. As necessary, discuss and document the advantages and disadvantages of the relevant screening modes. Confirm with patients that they fully understand what’s involved for each relevant modality. When you and the patient agree to a screening plan, confirm that the appointment has been made.
Emphasize with the patient the importance of a good bowel preparation—including the fact that a poor prep reduces the ability to detect cancerous polyps and increases the likelihood that a repeat procedure will be necessary sooner than usually recommended. Be prepared for patient questions about bowel preparation (e.g., nurse navigators, on- and off-hour call-in systems).
- Explain to the patient how test results will be communicated to him or her and (if appropriate) other clinicians.
- To ensure notification of test results, employ a system to track ordered tests through the receipt by and communication to the patient.
- Document any conversations with patients regarding the reported results.
- Make follow-up or test appointments before the patient leaves your office.
- Physicians and patients share responsibility for follow up; explain to your patients your tracking and adherence system (contacting patients a day or two before their follow-up appointments can reduce non-adherence).
- Track all referrals to ensure that you are receiving a timely report from the specialist.
- Ask the Gastroenterology Department or other specialist to notify your office of patients who do not keep scheduled appointments. Document all patient no-shows or cancellations.
- If a patient refuses follow up, explain the risks of not having a recommended diagnostic test or procedure. Note the patient’s refusal for follow up in the record; consider using an informed refusal form signed by the patient
- Update and document the patient’s personal and family history, and any physical examination; enter, in quotes, the patient’s complaints (if any).
- During each visit, update the patient’s risk factor assessment and your recommendations for screening based on that patient’s current risk for developing colorectal cancer.
- Consider using the patient's problem list to highlight patients with a positive family history of colorectal cancer.