Colorectal Cancer Prevention

Strategies to prevent colorectal cancer can be done with pharmacologic or surgical interventions and involve either preventing the initial development of colorectal cancer (primary prevention) or preventing cancer in patients that demonstrate early signs of colorectal cancer (secondary prevention).

The most widely studied agents for the chemoprevention of colorectal cancer are agents that inhibit COX-2 (aspirin, NSAIDs, and selective COX-2 inhibitors) and calcium supplementation.19 COX-2 appears to play a role in polyp formation and COX-2 inhibition suppresses polyp growth. In 1999, the FDA approved the use of celecoxib to reduce the number of colorectal polyps in patients with FAP, as an adjunct to usual care. This may delay the need for surgical intervention in these patients but the results cannot be extrapolated to the general population. The dose of celecoxib for this indication is 400 mg orally twice daily and the risk of cardiovascular damage from COX-2 inhibition needs to be assessed carefully in these patients. The use of aspirin as both a primary and secondary chemoprevention agent has also been studied. In a prospective, randomized trial, low-dose (81 mg/day) aspirin was shown to decrease the incidence of additional polyps by 19% in patients with a previous history of at 20

least one polyp.

Table 91-3 Colon Cancer Screening Guidelines

Average risk

Annual DRC after age 50 and

Annual FQBT or FIT after age SO, at the time of

DRC. Stool DNA testing may be used as an

alternative and

One of the tallowing after age 50:

Sigmoidoscopy every 5 years

Colonoscopy every 10 years

Barium enema every 5 yeats

CTC every 5 years

Family history

Screening at ager 35-40

HNPCC

Screening at age 30

FAP

Screening ar ages 10-12

HIT, fecal immunochemical tests; K>BI, fecal occult blood tests; CTC computed tomographic colonography; DREr digital rectal examination.

Calcium supplementation appears to be associated with a moderate reduction in risk of recurrent colorectal adenomas with prospective studies demonstrating a nons-

tatistical decrease in adenoma recurrence and its role as a chemoprevention agent re-

mains under investigation.

Additional agents including selenium, folic acid, and HMG-CoA reductase inhibitors (statins) show promise as chemopreventive agents in colorectal cancer and preliminary and confirmatory studies evaluating their effectiveness have been completed or are ongoing.19

Surgical resection remains an option to prevent colorectal cancer in individuals at extremely high risk for its development such as patients diagnosed with FAP. Individuals with FAP who are found to have polyps on screening examinations require total abdominal colectomy. In addition, removal of noncancerous polyps detected during screening colonoscopy is considered standard of care to prevent the progression of premalignant polyps to cancer.

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