Menopause Live - IMS Updates

Date of release: 06 July, 2009

Colorectal Cancer Screening – 2009

Colorectal cancer is one of the most prevalent malignancies in women. Similar to breast cancer, there are efficient strategies for its early detection that are associated with significantly improved prognosis. When I was a student, the combination of barium enema and fecal occult blood test (FOBT) was the mainstay of colorectal screening. Years later, colonoscopy replaced colorectal radiography, but nowadays many patients are inquiring about virtual colonoscopy as the preferred method for screening. In parallel, official guidelines have followed the development of new techniques and, recently, the American College of Gastroenterology published its updated recommendations for colorectal screening [1].


These are the main points: 


1. In an average risk situation, the preferred test is colonoscopy every 10 years, beginning at age 50. Screening should begin in African-Americans at age 45. 

2. In the case where colonoscopy is not available, or if a person is not willing to undergo colonoscopy, the alternative tests are flexible sigmoidoscopy or virtual (CT) colonoscopy every 5 years. 

3. The same guidelines apply when a single first-degree relative is diagnosed with a small colorectal adenoma beyond age 60. However, if there are two first-degree relatives with adenoma, or one first-degree relative with advanced adenoma diagnosed before age 60, colonoscopy should be offered once in 5 years, starting at age 40 or 10 years younger than the age at diagnosis of the youngest affected relative. 

4. Barium enema was deleted from the list of optional tests. 

5. The old guaiac-based FOBT (Hemoccult II card) is replaced by an annual fecal immunochemical test for blood (FIT). The overall result with FIT is superior to Hemoccult II, with doubling in the detection of advanced lesions. Alternative methods are the higher-sensitivity Hemoccult Sensa and the fecal DNA testing, but these are more expensive and still lack extensive data to allow their recommendation as the preferred tests. 

6. High-risk groups (inflammatory bowel disease, personal or family history of polyposis coli, family history of colorectal cancer, etc.) should have a more frequent screening schedule.


I would suggest that every menopause specialist should mention the need for colorectal screening whenever his/her patient comes for an annual check-up. People do have some reservations about undergoing colonoscopy, which is perceived as a most unpleasant procedure. In fact, the unpleasant part is bowel preparation prior to colonoscopy, which includes drinking a large quantity of an osmotic solution and further cleansing by an enema. Colonoscopy itself is performed under sedation, and the specific pre-medication is associated with a short amnesia, leading to a situation where the patient does not remember the procedure. Virtual, CT colonoscopy, which involves substantial irradiation, is less invasive, but preparation of the bowel is necessary to the same extent as with regular colonoscopy. Also, air is pumped through the anus to increase contrast, which may cause a lot of pain and discomfort. Obviously, taking biopsies is not possible during CT colonoscopy and therefore patients would still need a traditional colonoscopy when CT colonoscopy raises a suspicion for a lesion. Tests for detection of fecal blood are important as well, despite being much less sensitive and having a high false-negative rate. Nevertheless, these tests are very simple to handle by the patient and newer techniques are becoming even easier and more sensitive.


Amos Pines
Department of Medicine T, Ichilov Hospital, Tel-Aviv, Israel


  1. Rex D, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009. Am J Gastroenterol 2009;104:73950. Published March, 2009.