Shared Decision-Making for Colorectal Cancer Screening in a Patient with Multiple Comorbidities
A 72-year-old man with a history of well-controlled hypertension, type 2 diabetes, and mild chronic kidney disease (eGFR 55) presents for a routine visit. He is asymptomatic and has no family history of colorectal cancer. He has never been screened for colorectal cancer. He is active, independent, and manages his own affairs. His life expectancy is estimated to be at least 10 years. He is unsure about screening and asks for your advice.
1. What are the screening options for colorectal cancer, and how would you counsel this patient?
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Screening options include colonoscopy every 10 years, annual fecal immunochemical test (FIT), multitarget stool DNA test every 3 years, flexible sigmoidoscopy every 5 years, or CT colonography every 5 years. In a 72-year-old with a life expectancy >10 years and no significant comorbidities, screening is recommended. Colonoscopy is the gold standard but requires bowel prep and is invasive; FIT is non-invasive but requires annual adherence. Given his age and mild CKD, colonoscopy is generally safe but should be discussed in terms of risks (bleeding, perforation) and benefits (detection and removal of polyps). The patient's preferences and values should guide the decision. Use shared decision-making, explaining that screening can reduce mortality from colorectal cancer. Also consider his diabetes and hypertension management during prep if colonoscopy is chosen.
2. If the patient chooses FIT and the result is positive, what is the next step?
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A positive FIT requires follow-up colonoscopy for further evaluation. It is not a diagnosis of cancer but indicates the need for direct visualization. Ensure timely referral and follow-up. If colonoscopy is normal, he can return to routine screening intervals. If polyps or cancer are found, appropriate management ensues. Emphasize the importance of adherence to annual FIT if he chooses that strategy.