Should family history affect surveillance intervals?

From Cancer Guidelines Wiki


Background

A family history of colorectal cancer (CRCColorectal cancer) occurs in 3–12% of the population.[1][2] Increased risk of CRCColorectal cancer is graded and proportional to the number of relatives affected, age at onset and relatedness.[1] Detecting those at increased risk is important, although Australian work has demonstrated family history recording is inconsistent.[3] Higher risk individuals undergoing screening have an increased prevalence of adenomas found compared to those without a family history.[1]

At the time of the previous edition of these guidelines (Australian clinical practice guidelines for surveillance colonoscopy, 2011)[4] there was no consistent evidence that surveillance recommendations for patients with adenomas should differ for those with a family history unless a syndrome is suspected.

For guidance on family history screening recommendations from the Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (2017), refer to Recommendations for risk and screening based on family history of colorectal cancer.

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Evidence

Systematic review evidence

Two level II studies at high risk of bias[5][6] and one level III-3 study[7] at moderate risk of bias were included in the systematic review. The three studies compared outcomes of metachronous adenoma (MAMetachronous adenoma), metachronous advanced adenoma (MAAMetachronous advanced adenoma) and metachronous advanced neoplasia (MANMetachronous advanced neoplasia) in those with and without a family history of CRCColorectal cancer. The studies were consistent and although the population was not directly generalisable, the evidence can be sensibly applied and is relevant in the Australian healthcare context. Overall, the studies demonstrated no significant difference in the risk of metachronous adenoma, advanced adenoma or advanced neoplasm in those with a family history of CRCColorectal cancer compared to those without.

Overview of additional evidence (non-systematic literature review)

The literature distinguishing between different risks of family history is sparse outside of known or likely syndromes. One group[8] randomised those with a family history of CRCColorectal cancer (one first-degree relative [FDR] aged <50 years or two FDRs at any age) to surveillance at 3 or 6 years following baseline colonoscopy at which ≤2 adenomas were found. Advanced adenoma at the baseline colonoscopy was associated with MAAMetachronous advanced adenoma, but type of family history (reference 1 FDR age <50 years), age and sex were not. In Australian work by Good et al,[9] the non-adjusted odds ratio for MANMetachronous advanced neoplasia in those with 1 FDR and age <55 years was significant at 1.75 (1.18–2.61) when compared to those with a personal history of adenoma and no family history. This level of increased risk is considered insufficient to modify surveillance intervals based on the personal history of adenomas. A Swedish study[10] also demonstrated an increased risk of MAAMetachronous advanced adenoma in those with two close relatives with relative risk of 2.19 (1.68–2.87) but not one close relative age <50 years, with RRRelative risk 1.46 (0.89–2.31), both age-adjusted.

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Evidence summary and recommendations

Evidence summary Level References
The presence of a family history of colorectal cancer did not alter the risk of any metachronous adenoma within 5 years of polypectomy, following surveillance colonoscopy. II, III-3 [6], [7]
The presence of a family history of colorectal cancer did not alter the risk of metachronous advanced adenoma within 5 years of polypectomy, following surveillance colonoscopy. II, III-3 [6], [7], [11]
No studies reported colorectal cancer risk or incidence in those with a family history of colorectal cancer and previous adenoma(s).
Evidence-based recommendationA recommendation formulated after a systematic review of the evidence, indicating supporting references.Question mark transparent.png Grade
Family history of CRCColorectal cancer

First surveillance intervals following adenoma removal in those with a family history of colorectal cancer should be based on patient factors and the adenoma history, unless a genetic syndrome is known or suspected.

D
Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

To identify those who may have an increased familial risk of colorectal cancer, a family history of colorectal cancer and associated malignancies including number of affected relatives, relatedness and age of onset should be taken and updated every 5 to 10 years.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

In individuals who are undergoing screening colonoscopy for colorectal cancer based on family history, adenoma surveillance and screening recommendations should be compared and the shorter interval used. Refer to Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (2017) (see Recommendations for risk and screening based on family history of colorectal cancer).

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

To address individual’s concerns, clinicians should take adequate time to explain the relationship of family history to recommended surveillance intervals and refer for counselling where appropriate.

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References

  1. 1.01.11.2 Henrikson NB, Webber EM, Goddard KA, Scrol A, Piper M, Williams MS, et al. Family history and the natural history of colorectal cancer: systematic review. Genet Med 2015 Sep;17(9):702-12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25590981.
  2. Lowery JT, Ahnen DJ, Schroy PC 3rd, Hampel H, Baxter N, Boland CR, et al. Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review. Cancer 2016 Sep 1;122(17):2633-45 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27258162.
  3. Cameron E, Rose S, Carey M. Assessment of family history of colorectal cancer in primary care: perceptions of first degree relatives of people with colorectal cancer. Patient Educ Couns 2014 Mar;94(3):427-31 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24380670.
  4. Cancer Council Australia ColonoscopyAn examination of the large bowel using a camera on a flexible tube, which is passed through the anus. Surveillance Working Party. Clinical Practice Guidelines for Surveillance Colonoscopy – in adenoma follow-up; following curative resection of colorectal cancer; and for cancer surveillance in inflammatory bowel disease. Sydney: Cancer Council Australia; 2011 Dec.
  5. Anderson JC, Baron JA, Ahnen DJ, Barry EL, Bostick RM, Burke CAConventional adenoma,Bresalier RS, Church TR, Cole BF, Cruz-Correa M, Kim AS, Mott LA, Sandler RS, Robertson DJ. Factors Associated With Shorter Colonoscopy Surveillance Intervals for Patients With Low-risk Colorectal Adenomas and Effects on Outcome. Gastroenterology 2017.
  6. 6.06.16.2 Chung SJ, Kim YS, Yang SY, Song JH, Kim D, Park MJ, et al. Five-year risk for advanced colorectal neoplasia after initial colonoscopy according to the baseline risk stratification: a prospective study in 2452 asymptomatic Koreans. Gut 2011 Nov;60(11):1537-43 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21427200.
  7. 7.07.17.2 Park SK, Hwang SW, Kim KO, Cha JM, Boo SJ, Shin JE, et al. Risk of advanced colorectal neoplasm in patients with more than 10 adenomas on index colonoscopy: A Korean Association for the Study of Intestinal Diseases (KASID) study. J Gastroenterol Hepatol 2017 Apr;32(4):803-808 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27785837.
  8. Hennink SD, van der Meulen-de Jong AE, Wolterbeek R, Crobach AS, Becx MC, Crobach WF, et al. Randomized Comparison of Surveillance Intervals in Familial Colorectal Cancer. J Clin Oncol 2015 Dec 10;33(35):4188-93 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26527788.
  9. Good NM, Macrae FA, Young GP, O'Dywer J, Slattery M, Venables W, et al. Ideal colonoscopic surveillance intervals to reduce incidence of advanced adenoma and colorectal cancer. J Gastroenterol Hepatol 2015 Jul;30(7):1147-54 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25611802.
  10. Forsberg A, Kjellström L, Andreasson A, Jaramillo E, Rubio CAConventional adenoma, Björck E, et al. Colonoscopy findings in high-risk individuals compared to an average-risk control population. Scand J Gastroenterol 2015 Jul;50(7):866-74 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25762374.
  11. Anderson JC, Baron JA, Ahnen DJ, Barry EL, Bostick RM, Burke CAConventional adenoma, Bresalier RS, Church TR, Cole BF, Cruz-Correa M, Kim AS, Mott LA, Sandler RS, Robertson DJ,. Factors Associated With Shorter Colonoscopy Surveillance Intervals for Patients With Low-risk Colorectal Adenomas and Effects on Outcome. Gastroenterology 2017.

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Appendices

Jutta's magnifying glass icon.pngPICO question SFH1 View Evidence statement form SFH1Evidence statement form SFH1 View Systematic review report SAFH1Systematic review report SFH1
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