Cancer Screening

Cancer screening in my primary care clinic often feels mundane. “You’re 50, you know what that means,” I’ll often say. The patient will often sigh knowingly, and I will put in the ambulatory referral for screening colonoscopy. Our conversation is brief, and the health maintenance reminder will clear. Now on to the next problem on the list. Usually the scope comes back normal, sometimes with a few polyps; the patient will have concerns about the preparation at our next visit, but then say it wasn’t THAT bad.

In their Annals editorial, Bretthauer and colleagues (1) question the American Cancer Society recommendation to begin colorectal cancer screening at 45 years instead of 50 years. Although they acknowledge the increased incidence of colorectal cancer in American’s younger than 50 years, they note the lack of empirical evidence and low absolute risk for colorectal cancer in these patients, along with the risks and costs associated with expanded screening. In addition, they cite evidence published in Annals that carcinoid tumors, not colonic adenocarcinomas, drive some of the increased cancer incidence in this group.

As I finish my internal medicine residency and enter oncology fellowship, I doubt I will remember the patient who had 3 adenomas removed. I’ll also forget the patient who let the referral coordinator’s calls go unanswered and missed his screening. However, stories of patients with cancer feel etched into my brain. I still remember a patient I saw while on an oncology rotation in medical school. She was 49 years old and saw her primary because she was noticing some changes in her stools. She was having some more abdominal bloating and some constipation that was new for her. “You are due for your screening colonoscopy in a few months anyways, let’s just order it now to be safe,” her primary said. She was diagnosed with colon cancer metastatic to the liver. A year later, the American Cancer Society updated their recommendations. Reading the practice alert, her story immediately came to mind.

It’s hard to hold in one's mind simultaneously the image of a young woman with metastatic colon cancer, who screening might have helped, with models of screening cost per averted colorectal cancer death. I appreciate the need for more research and more answers for our patients. In the next stage of my training, I will shift from diagnosing cancer to treating it, and my perspective on screening will evolve further. I am reminded that although ordering screening may feel rote—a box to check, a button to click—the rationale behind screening is full of complexity.

References

1. Bretthauer M, Kalager M, Weinberg DS. Colorectal cancer screening in young adults: about carcinoid tumors and cancer. Ann Intern Med. 2021;174:263-264. [PMID: 33315472] doi:10.7326/M20-7244