Bowel cancer is usually a slow growing cancer so that early cancers

and premalignant lesions can bleed microscopically for some time

before the patient presents with symptoms.

Early detection is associated with greater survival rates.

Current Australian guidelines recommend regular screening with faecal occult blood
tests (FOBT) in asymptomatic people over 50 years of age in order to reduce
mortality from bowel cancer
There are two broad categories of FOBTs:
guaiac tests identify the haem portion of haemoglobin (these tests
were used in the RCTs), and
newer immunochemical tests react with the globin portion of haemoglobin and do
not cross react with certain foods, ie. unlike the guaiac tests, there are no
requirements for dietary or medication restrictions before their use.
Category 1: Average or slightly increased risk
Asymptomatic people with:

no personal history of bowel cancer, colorectal adenomas or ulcerative colitis

and no confirmed family history of CRC,

or

one first- or second-degree relative with CRC diagnosed at age 55 years or

older

FOBT Every 2 years from age 50 years

Category 2: Moderately increased risk

(12% of the population)
Asymptomatic people with:

one first-degree relative with CRC diagnosed before age 55 years,

or

two first-degree or one first- and one second-degree relative/s on the same
side of the family with CRC diagnosed at any age (without potentially high-risk
features as in Category 3)

Colonoscopy
Sigmoidoscopy plus double-contrast barium enema or CT colonography (performed
by an experienced operator) acceptable if colonoscopy is contraindicated

Consider offering FOBT -Every 5 years from age 50 years, or at an age 10 years
younger than the age of first diagnosis of CRC in the family, whichever comes first

Category 3: High risk (relative risk of ~420)

(<1% of the population)*
Asymptomatic people with:

three or more first- or second-degree relatives on the same side of the family
diagnosed with CRC (suspected Lynch syndrome, also known as hereditary nonpolyposis CRC or HNPCC) or other Lynch syndrome-related cancers

or

two or more first- or second-degree relatives on the same side of the family
diagnosed with CRC, including any of the following high-risk features:

multiple CRC in the one person

CRC before age 50 years

a family member who has or had Lynch syndrome-related cancer

or

at least one first- or second-degree relative with CRC, with a large number of
adenomas throughout the large bowel (suspected familial adenomatous
polyposis: FAP)

Refer for genetic screening of affected relatives

Refer to bowel cancer specialist to plan appropriate surveillance (III,B)
FAP: flexible sigmoidoscopy
or
Colonoscopy in attenuated FAP

Those at risk for:529,530

FAP (no APC mutation defined): every 12 months from age 1215 years to
age 3035 years and every 3 years after age 35 yearsII

Lynch syndrome: 12 yearly from age 25 years or 5 years earlier than the
youngest affected member of the family (whichever is earliest). Aspirin 100
mg/day is effective prophylaxis

or

somebody in the family in whom the presence of a high-risk mutation in the

adenomatous polyposis coli (APC) or one of the mismatch repair genes has been
identified

HNPCC:
- colonoscopy

Members of proven FAP and Lynch syndrome families who are shown not to carry
the family mutation are no longer at high risk and revert to the average-risk group
and still require population-based screening.

Consider offering FOBT (III,B)

Two main types of FOBT are available: guaiac and faecal immunochemical tests.
Immunochemical tests are preferred as they have greater sensitivity and higher
uptake535(A). Two or three serial stools should be tested, depending on the type and
brand of test being used.