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I am sitting here in Cleveland, Ohio as a Kiwi expat, troubled to the depths of my soul by what I have been reading about the ravages of bowel cancer in my homeland. I have had a career as a colorectal surgeon at the Cleveland Clinic and during these 30 years have developed a deep hatred for bowel cancer, doing my best to prevent it and to eradicate it in as many of my patients as I can. I have followed the bowel cancer situation in New Zealand closely and have contributed to the discussion regarding screening,1 but I still see reports of people dying from what is essentially a preventable and curable disease. While I cannot personally screen the entire population of Aotearoa (I wish I could), I have some suggestions that might be helpful to you, the people who are most directly responsible for the health and wellbeing of the population. These suggestions are informed by a relatively recent phenomenon that is being reported worldwide…a significant increase in the incidence of bowel cancer in people under age 50.2–3

The relevance of the rising rate of bowel cancer in young people is that these are an unscreened population. In this respect they are like all New Zealanders under age 60, and New Zealanders of all ages in the areas where the National Bowel Cancer Screening Program has not started. Features of bowel cancer in an unscreened population include diagnosis of disease through its symptoms, an advanced stage at diagnosis and a high mortality because of the advanced stage. These clinical characteristics are seen in New Zealand patients.3,4 In young patients, diagnosis is sometimes further delayed when symptoms are mistakenly attributed to more common, benign causes.5 As more kiwis have access to the National Bowel Cancer Screening Program there will be an increased number of patients diagnosed at early, curable stages. For the unscreened however, there are still several things that can be done to minimise the number of patients being diagnosed late, and to lower the overall incidence of cancer.

These options are inexpensive and available to all, and I wanted to describe them to you.

  1. Family history. A family history of bowel cancer is an important risk factor for developing the disease. The closer the affected relative and the younger their age at diagnosis, the higher the risk of family members. Having a first-degree relative with bowel cancer increases the risk of your patient developing it by 2.5-fold. If the relative was diagnosed under age 50 the increase in risk is 4.0-fold.5 Even having a second-degree relative with bowel cancer is associated with a significant increase in risk. People with multiple affected relatives are at especially high risk and should be considered for referral to the New Zealand Familial GI Cancer Programme.6 Please take a family history (ideally three generations) and refer a patient who has a positive family history for screening and possible genetic evaluation.
  2. New families. Don’t forget that each patient with a bowel cancer has a family. The risk of every member of that family for developing bowel cancer has just increased. Unfortunately, compliance with screening in such families is low. Colonoscopy should be performed 10 years prior to the age at which the youngest member of the family was diagnosed, or at age 50, whichever is younger. Dealing with the family of a newly diagnosed patient is difficult during the stress and anguish of a new diagnosis, but the patient’s family has to be made aware of their risk.7
  3. Personal history of colorectal neoplasia. A personal history of colorectal neoplasia is a risk factor for metachronous lesions. If a patient has already had an adenoma, adenocarcinoma or sessile serrated lesion removed from their large bowel they are at higher than average risk of developing more. The risk is highest with advanced adenomas and multiple adenomas. Such patients need colonoscopic surveillance.8
  4. Other risk factors. There are other risk factors for bowel cancer that can be measured and that are part of a full cancer risk assessment. These include gender, ethnicity, age, body mass index, diet, alcohol and activity level. Algorithms are available to assess and assign risk on an individual basis, but in a busy practice it is probably easier to focus on personal and family history.9
  5. Symptoms. Pay attention to symptoms. Rectal bleeding is never normal and needs to be promptly investigated. Bleeding can be triaged according to its pattern (Table 1)10 and suspicious bleeding mandates colonoscopy. In patients with typical outlet rectal bleeding a flexible sigmoidoscopy is a reasonable way to check for rectal and sigmoid neoplasms.10 Only when cancer is excluded can the diagnosis of more common benign conditions be made. A transitory change in bowel habits is usually due to readily identifiable factors such as changes in diet or medications, stress and travel, and is insignificant for cancer. A more lasting, progressive, or quickly recurrent change is more significant and should be investigated. Abdominal pain is also a common symptom but pain due to a bowel cancer usually does not resolve. It hangs around and gradually gets worse. Therefore, any abdominal pain that bears some relation to gastrointestinal function and lasts for more than a few days should be investigated. Unintentional weight loss and anorexia are significant symptoms, especially when there is concomitant change in bowel habits.
  6. Examination. Do a digital rectal examination as part of your patients’ annual physical exam. Start in the 30-year old. I know that they don’t like it, and that you don’t like doing it, but with the predominance of rectal cancer in the young it is a useful exam to do.11 Your exam can be more effective and better tolerated if you follow the ‘Open Sesame’ technique.12 A careful abdominal exam to rule out colonic masses is also cheap and easy.

While these suggestions will not solve the problem of bowel cancer in New Zealand, we all owe it to our patients to enquire about risk factors, pay attention to them when they are present, to do a thoughtful and thorough physical exam, and to exclude a cancer when patients present with symptoms that could have cancer as their cause. As general practitioners you are on the front lines of the war against bowel cancer. These are weapons that you can easily use.

Table 1: Definitions of rectal bleeding.10

Type of bleeding

Definition

Outlet-type

Bright red blood seen during or after defecation, on the toilet paper or in the toilet bowl, with no family or personal history of colorectal neoplasia, and no change in bowel habit.

Suspicious

Dark red blood, and/or blood mixed with or streaked on stool. Any sort of bleeding with a personal or family history of colorectal neoplasia. Bleeding associated with a change in bowel habit or passage of mucus.

Haemorrhage

Large volume bleeding needing urgent admission to hospital and transfusion of one or more units of blood.

Occult

Positive fecal occult blood test without visible bleeding

Type of bleeding

Definition

Outlet-type

Bright red blood seen during or after defecation, on the toilet paper or in the toilet bowl, with no family or personal history of colorectal neoplasia, and no change in bowel habit.

Suspicious

Dark red blood, and/or blood mixed with or streaked on stool. Any sort of bleeding with a personal or family history of colorectal neoplasia. Bleeding associated with a change in bowel habit or passage of mucus.

Haemorrhage

Large volume bleeding needing urgent admission to hospital and transfusion of one or more units of blood.

Occult

Positive fecal occult blood test without visible bleeding

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

James Church, Colorectal Surgeon, Cleveland Clinic, Cleveland, Ohio, USA.

Acknowledgements

Correspondence

James Church, Department of Colorectal Surgery, Desk A 30, 9500 Euclid Ave, Cleveland, Ohio 44195, USA.

Correspondence Email

churchj@ccf.org

Competing Interests

Nil.

  1. Church JM. Dealing with colorectal cancer in New Zealand. N Z Med J. 2013; 126:7–10.
  2. Potter JD. Rising rates of colorectal cancer in younger adults. BMJ. 2019; 365:l4280.
  3. Gandhi J, Davidson C, Hall C, Pearson J, Eglinton T, Wakeman C, Frizelle F. Population-based study demonstrating an increase in colorectal cancer in young patients. Br J Surg. 2017; 104:1063–1068.
  4. Windner Z, Crengle S, de Graaf B, Samaranayaka A, Derrett S. New Zealanders’ experiences and pathways to a diagnosis of bowel cancer: a cross-sectional descriptive study of a younger cohort. N Z Med J. 2018; 131:30–39.
  5. Johns LE, Houlston RS. A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol 2001; 96:2992–3003.
  6. Parry S, Ow M, Bergman R, Griffiths B, Keating J, Chalmers-Watson T, Wakeman C. Update from the New Zealand Familial GI Cancer Service 2018. N Z Med J. 2018; 131:54–57.
  7. Courtney RJ, Paul CL, Carey ML, Sanson-Fisher RW, Macrae FA, D’Este C, et al. A population-based cross-sectional study of colorectal cancer screening practices of first-degree relatives of colorectal cancer patients. BMC Cancer 2013 Jan 10; 13:13. doi: 10.1186/1471-2407-13-13.
  8. Cottet V, Jooste V, Fournel I, Bouvier AM, Faivre J, Bonithon-Kopp C. Long-term risk of colorectal cancer after adenoma removal: a population-based cohort study. Gut 2012; 61:1180–6.
  9. Walker JG, Macrae F, Winship I, Oberoi J, Saya S, Milton S, et al. The use of a risk assessment and decision support tool (CRISP) compared with usual care in general practice to increase risk-stratified colorectal cancer screening: study protocol for a randomised controlled trial. Trials. 2018; 19:397
  10. Marderstein EL, Church JM. Classic “outlet” rectal bleeding does not require full colonoscopy to exclude significant pathology. Dis Colon Rectum. 2008; 51:202–6.
  11. Segev L, Kalady MF, Church JM. Left-Sided Dominance of Early-Onset Colorectal Cancers: A Rationale for Screening Flexible Sigmoidoscopy in the Young. Dis Colon Rectum. 2018; 61:897–902.
  12. Farmer KC, Church JM. Open sesame: tips for traversing the anal canal. Dis Colon Rectum. 1992; 35:1092–3.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

I am sitting here in Cleveland, Ohio as a Kiwi expat, troubled to the depths of my soul by what I have been reading about the ravages of bowel cancer in my homeland. I have had a career as a colorectal surgeon at the Cleveland Clinic and during these 30 years have developed a deep hatred for bowel cancer, doing my best to prevent it and to eradicate it in as many of my patients as I can. I have followed the bowel cancer situation in New Zealand closely and have contributed to the discussion regarding screening,1 but I still see reports of people dying from what is essentially a preventable and curable disease. While I cannot personally screen the entire population of Aotearoa (I wish I could), I have some suggestions that might be helpful to you, the people who are most directly responsible for the health and wellbeing of the population. These suggestions are informed by a relatively recent phenomenon that is being reported worldwide…a significant increase in the incidence of bowel cancer in people under age 50.2–3

The relevance of the rising rate of bowel cancer in young people is that these are an unscreened population. In this respect they are like all New Zealanders under age 60, and New Zealanders of all ages in the areas where the National Bowel Cancer Screening Program has not started. Features of bowel cancer in an unscreened population include diagnosis of disease through its symptoms, an advanced stage at diagnosis and a high mortality because of the advanced stage. These clinical characteristics are seen in New Zealand patients.3,4 In young patients, diagnosis is sometimes further delayed when symptoms are mistakenly attributed to more common, benign causes.5 As more kiwis have access to the National Bowel Cancer Screening Program there will be an increased number of patients diagnosed at early, curable stages. For the unscreened however, there are still several things that can be done to minimise the number of patients being diagnosed late, and to lower the overall incidence of cancer.

These options are inexpensive and available to all, and I wanted to describe them to you.

  1. Family history. A family history of bowel cancer is an important risk factor for developing the disease. The closer the affected relative and the younger their age at diagnosis, the higher the risk of family members. Having a first-degree relative with bowel cancer increases the risk of your patient developing it by 2.5-fold. If the relative was diagnosed under age 50 the increase in risk is 4.0-fold.5 Even having a second-degree relative with bowel cancer is associated with a significant increase in risk. People with multiple affected relatives are at especially high risk and should be considered for referral to the New Zealand Familial GI Cancer Programme.6 Please take a family history (ideally three generations) and refer a patient who has a positive family history for screening and possible genetic evaluation.
  2. New families. Don’t forget that each patient with a bowel cancer has a family. The risk of every member of that family for developing bowel cancer has just increased. Unfortunately, compliance with screening in such families is low. Colonoscopy should be performed 10 years prior to the age at which the youngest member of the family was diagnosed, or at age 50, whichever is younger. Dealing with the family of a newly diagnosed patient is difficult during the stress and anguish of a new diagnosis, but the patient’s family has to be made aware of their risk.7
  3. Personal history of colorectal neoplasia. A personal history of colorectal neoplasia is a risk factor for metachronous lesions. If a patient has already had an adenoma, adenocarcinoma or sessile serrated lesion removed from their large bowel they are at higher than average risk of developing more. The risk is highest with advanced adenomas and multiple adenomas. Such patients need colonoscopic surveillance.8
  4. Other risk factors. There are other risk factors for bowel cancer that can be measured and that are part of a full cancer risk assessment. These include gender, ethnicity, age, body mass index, diet, alcohol and activity level. Algorithms are available to assess and assign risk on an individual basis, but in a busy practice it is probably easier to focus on personal and family history.9
  5. Symptoms. Pay attention to symptoms. Rectal bleeding is never normal and needs to be promptly investigated. Bleeding can be triaged according to its pattern (Table 1)10 and suspicious bleeding mandates colonoscopy. In patients with typical outlet rectal bleeding a flexible sigmoidoscopy is a reasonable way to check for rectal and sigmoid neoplasms.10 Only when cancer is excluded can the diagnosis of more common benign conditions be made. A transitory change in bowel habits is usually due to readily identifiable factors such as changes in diet or medications, stress and travel, and is insignificant for cancer. A more lasting, progressive, or quickly recurrent change is more significant and should be investigated. Abdominal pain is also a common symptom but pain due to a bowel cancer usually does not resolve. It hangs around and gradually gets worse. Therefore, any abdominal pain that bears some relation to gastrointestinal function and lasts for more than a few days should be investigated. Unintentional weight loss and anorexia are significant symptoms, especially when there is concomitant change in bowel habits.
  6. Examination. Do a digital rectal examination as part of your patients’ annual physical exam. Start in the 30-year old. I know that they don’t like it, and that you don’t like doing it, but with the predominance of rectal cancer in the young it is a useful exam to do.11 Your exam can be more effective and better tolerated if you follow the ‘Open Sesame’ technique.12 A careful abdominal exam to rule out colonic masses is also cheap and easy.

While these suggestions will not solve the problem of bowel cancer in New Zealand, we all owe it to our patients to enquire about risk factors, pay attention to them when they are present, to do a thoughtful and thorough physical exam, and to exclude a cancer when patients present with symptoms that could have cancer as their cause. As general practitioners you are on the front lines of the war against bowel cancer. These are weapons that you can easily use.

Table 1: Definitions of rectal bleeding.10

Type of bleeding

Definition

Outlet-type

Bright red blood seen during or after defecation, on the toilet paper or in the toilet bowl, with no family or personal history of colorectal neoplasia, and no change in bowel habit.

Suspicious

Dark red blood, and/or blood mixed with or streaked on stool. Any sort of bleeding with a personal or family history of colorectal neoplasia. Bleeding associated with a change in bowel habit or passage of mucus.

Haemorrhage

Large volume bleeding needing urgent admission to hospital and transfusion of one or more units of blood.

Occult

Positive fecal occult blood test without visible bleeding

Type of bleeding

Definition

Outlet-type

Bright red blood seen during or after defecation, on the toilet paper or in the toilet bowl, with no family or personal history of colorectal neoplasia, and no change in bowel habit.

Suspicious

Dark red blood, and/or blood mixed with or streaked on stool. Any sort of bleeding with a personal or family history of colorectal neoplasia. Bleeding associated with a change in bowel habit or passage of mucus.

Haemorrhage

Large volume bleeding needing urgent admission to hospital and transfusion of one or more units of blood.

Occult

Positive fecal occult blood test without visible bleeding

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

James Church, Colorectal Surgeon, Cleveland Clinic, Cleveland, Ohio, USA.

Acknowledgements

Correspondence

James Church, Department of Colorectal Surgery, Desk A 30, 9500 Euclid Ave, Cleveland, Ohio 44195, USA.

Correspondence Email

churchj@ccf.org

Competing Interests

Nil.

  1. Church JM. Dealing with colorectal cancer in New Zealand. N Z Med J. 2013; 126:7–10.
  2. Potter JD. Rising rates of colorectal cancer in younger adults. BMJ. 2019; 365:l4280.
  3. Gandhi J, Davidson C, Hall C, Pearson J, Eglinton T, Wakeman C, Frizelle F. Population-based study demonstrating an increase in colorectal cancer in young patients. Br J Surg. 2017; 104:1063–1068.
  4. Windner Z, Crengle S, de Graaf B, Samaranayaka A, Derrett S. New Zealanders’ experiences and pathways to a diagnosis of bowel cancer: a cross-sectional descriptive study of a younger cohort. N Z Med J. 2018; 131:30–39.
  5. Johns LE, Houlston RS. A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol 2001; 96:2992–3003.
  6. Parry S, Ow M, Bergman R, Griffiths B, Keating J, Chalmers-Watson T, Wakeman C. Update from the New Zealand Familial GI Cancer Service 2018. N Z Med J. 2018; 131:54–57.
  7. Courtney RJ, Paul CL, Carey ML, Sanson-Fisher RW, Macrae FA, D’Este C, et al. A population-based cross-sectional study of colorectal cancer screening practices of first-degree relatives of colorectal cancer patients. BMC Cancer 2013 Jan 10; 13:13. doi: 10.1186/1471-2407-13-13.
  8. Cottet V, Jooste V, Fournel I, Bouvier AM, Faivre J, Bonithon-Kopp C. Long-term risk of colorectal cancer after adenoma removal: a population-based cohort study. Gut 2012; 61:1180–6.
  9. Walker JG, Macrae F, Winship I, Oberoi J, Saya S, Milton S, et al. The use of a risk assessment and decision support tool (CRISP) compared with usual care in general practice to increase risk-stratified colorectal cancer screening: study protocol for a randomised controlled trial. Trials. 2018; 19:397
  10. Marderstein EL, Church JM. Classic “outlet” rectal bleeding does not require full colonoscopy to exclude significant pathology. Dis Colon Rectum. 2008; 51:202–6.
  11. Segev L, Kalady MF, Church JM. Left-Sided Dominance of Early-Onset Colorectal Cancers: A Rationale for Screening Flexible Sigmoidoscopy in the Young. Dis Colon Rectum. 2018; 61:897–902.
  12. Farmer KC, Church JM. Open sesame: tips for traversing the anal canal. Dis Colon Rectum. 1992; 35:1092–3.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

I am sitting here in Cleveland, Ohio as a Kiwi expat, troubled to the depths of my soul by what I have been reading about the ravages of bowel cancer in my homeland. I have had a career as a colorectal surgeon at the Cleveland Clinic and during these 30 years have developed a deep hatred for bowel cancer, doing my best to prevent it and to eradicate it in as many of my patients as I can. I have followed the bowel cancer situation in New Zealand closely and have contributed to the discussion regarding screening,1 but I still see reports of people dying from what is essentially a preventable and curable disease. While I cannot personally screen the entire population of Aotearoa (I wish I could), I have some suggestions that might be helpful to you, the people who are most directly responsible for the health and wellbeing of the population. These suggestions are informed by a relatively recent phenomenon that is being reported worldwide…a significant increase in the incidence of bowel cancer in people under age 50.2–3

The relevance of the rising rate of bowel cancer in young people is that these are an unscreened population. In this respect they are like all New Zealanders under age 60, and New Zealanders of all ages in the areas where the National Bowel Cancer Screening Program has not started. Features of bowel cancer in an unscreened population include diagnosis of disease through its symptoms, an advanced stage at diagnosis and a high mortality because of the advanced stage. These clinical characteristics are seen in New Zealand patients.3,4 In young patients, diagnosis is sometimes further delayed when symptoms are mistakenly attributed to more common, benign causes.5 As more kiwis have access to the National Bowel Cancer Screening Program there will be an increased number of patients diagnosed at early, curable stages. For the unscreened however, there are still several things that can be done to minimise the number of patients being diagnosed late, and to lower the overall incidence of cancer.

These options are inexpensive and available to all, and I wanted to describe them to you.

  1. Family history. A family history of bowel cancer is an important risk factor for developing the disease. The closer the affected relative and the younger their age at diagnosis, the higher the risk of family members. Having a first-degree relative with bowel cancer increases the risk of your patient developing it by 2.5-fold. If the relative was diagnosed under age 50 the increase in risk is 4.0-fold.5 Even having a second-degree relative with bowel cancer is associated with a significant increase in risk. People with multiple affected relatives are at especially high risk and should be considered for referral to the New Zealand Familial GI Cancer Programme.6 Please take a family history (ideally three generations) and refer a patient who has a positive family history for screening and possible genetic evaluation.
  2. New families. Don’t forget that each patient with a bowel cancer has a family. The risk of every member of that family for developing bowel cancer has just increased. Unfortunately, compliance with screening in such families is low. Colonoscopy should be performed 10 years prior to the age at which the youngest member of the family was diagnosed, or at age 50, whichever is younger. Dealing with the family of a newly diagnosed patient is difficult during the stress and anguish of a new diagnosis, but the patient’s family has to be made aware of their risk.7
  3. Personal history of colorectal neoplasia. A personal history of colorectal neoplasia is a risk factor for metachronous lesions. If a patient has already had an adenoma, adenocarcinoma or sessile serrated lesion removed from their large bowel they are at higher than average risk of developing more. The risk is highest with advanced adenomas and multiple adenomas. Such patients need colonoscopic surveillance.8
  4. Other risk factors. There are other risk factors for bowel cancer that can be measured and that are part of a full cancer risk assessment. These include gender, ethnicity, age, body mass index, diet, alcohol and activity level. Algorithms are available to assess and assign risk on an individual basis, but in a busy practice it is probably easier to focus on personal and family history.9
  5. Symptoms. Pay attention to symptoms. Rectal bleeding is never normal and needs to be promptly investigated. Bleeding can be triaged according to its pattern (Table 1)10 and suspicious bleeding mandates colonoscopy. In patients with typical outlet rectal bleeding a flexible sigmoidoscopy is a reasonable way to check for rectal and sigmoid neoplasms.10 Only when cancer is excluded can the diagnosis of more common benign conditions be made. A transitory change in bowel habits is usually due to readily identifiable factors such as changes in diet or medications, stress and travel, and is insignificant for cancer. A more lasting, progressive, or quickly recurrent change is more significant and should be investigated. Abdominal pain is also a common symptom but pain due to a bowel cancer usually does not resolve. It hangs around and gradually gets worse. Therefore, any abdominal pain that bears some relation to gastrointestinal function and lasts for more than a few days should be investigated. Unintentional weight loss and anorexia are significant symptoms, especially when there is concomitant change in bowel habits.
  6. Examination. Do a digital rectal examination as part of your patients’ annual physical exam. Start in the 30-year old. I know that they don’t like it, and that you don’t like doing it, but with the predominance of rectal cancer in the young it is a useful exam to do.11 Your exam can be more effective and better tolerated if you follow the ‘Open Sesame’ technique.12 A careful abdominal exam to rule out colonic masses is also cheap and easy.

While these suggestions will not solve the problem of bowel cancer in New Zealand, we all owe it to our patients to enquire about risk factors, pay attention to them when they are present, to do a thoughtful and thorough physical exam, and to exclude a cancer when patients present with symptoms that could have cancer as their cause. As general practitioners you are on the front lines of the war against bowel cancer. These are weapons that you can easily use.

Table 1: Definitions of rectal bleeding.10

Type of bleeding

Definition

Outlet-type

Bright red blood seen during or after defecation, on the toilet paper or in the toilet bowl, with no family or personal history of colorectal neoplasia, and no change in bowel habit.

Suspicious

Dark red blood, and/or blood mixed with or streaked on stool. Any sort of bleeding with a personal or family history of colorectal neoplasia. Bleeding associated with a change in bowel habit or passage of mucus.

Haemorrhage

Large volume bleeding needing urgent admission to hospital and transfusion of one or more units of blood.

Occult

Positive fecal occult blood test without visible bleeding

Type of bleeding

Definition

Outlet-type

Bright red blood seen during or after defecation, on the toilet paper or in the toilet bowl, with no family or personal history of colorectal neoplasia, and no change in bowel habit.

Suspicious

Dark red blood, and/or blood mixed with or streaked on stool. Any sort of bleeding with a personal or family history of colorectal neoplasia. Bleeding associated with a change in bowel habit or passage of mucus.

Haemorrhage

Large volume bleeding needing urgent admission to hospital and transfusion of one or more units of blood.

Occult

Positive fecal occult blood test without visible bleeding

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

James Church, Colorectal Surgeon, Cleveland Clinic, Cleveland, Ohio, USA.

Acknowledgements

Correspondence

James Church, Department of Colorectal Surgery, Desk A 30, 9500 Euclid Ave, Cleveland, Ohio 44195, USA.

Correspondence Email

churchj@ccf.org

Competing Interests

Nil.

  1. Church JM. Dealing with colorectal cancer in New Zealand. N Z Med J. 2013; 126:7–10.
  2. Potter JD. Rising rates of colorectal cancer in younger adults. BMJ. 2019; 365:l4280.
  3. Gandhi J, Davidson C, Hall C, Pearson J, Eglinton T, Wakeman C, Frizelle F. Population-based study demonstrating an increase in colorectal cancer in young patients. Br J Surg. 2017; 104:1063–1068.
  4. Windner Z, Crengle S, de Graaf B, Samaranayaka A, Derrett S. New Zealanders’ experiences and pathways to a diagnosis of bowel cancer: a cross-sectional descriptive study of a younger cohort. N Z Med J. 2018; 131:30–39.
  5. Johns LE, Houlston RS. A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol 2001; 96:2992–3003.
  6. Parry S, Ow M, Bergman R, Griffiths B, Keating J, Chalmers-Watson T, Wakeman C. Update from the New Zealand Familial GI Cancer Service 2018. N Z Med J. 2018; 131:54–57.
  7. Courtney RJ, Paul CL, Carey ML, Sanson-Fisher RW, Macrae FA, D’Este C, et al. A population-based cross-sectional study of colorectal cancer screening practices of first-degree relatives of colorectal cancer patients. BMC Cancer 2013 Jan 10; 13:13. doi: 10.1186/1471-2407-13-13.
  8. Cottet V, Jooste V, Fournel I, Bouvier AM, Faivre J, Bonithon-Kopp C. Long-term risk of colorectal cancer after adenoma removal: a population-based cohort study. Gut 2012; 61:1180–6.
  9. Walker JG, Macrae F, Winship I, Oberoi J, Saya S, Milton S, et al. The use of a risk assessment and decision support tool (CRISP) compared with usual care in general practice to increase risk-stratified colorectal cancer screening: study protocol for a randomised controlled trial. Trials. 2018; 19:397
  10. Marderstein EL, Church JM. Classic “outlet” rectal bleeding does not require full colonoscopy to exclude significant pathology. Dis Colon Rectum. 2008; 51:202–6.
  11. Segev L, Kalady MF, Church JM. Left-Sided Dominance of Early-Onset Colorectal Cancers: A Rationale for Screening Flexible Sigmoidoscopy in the Young. Dis Colon Rectum. 2018; 61:897–902.
  12. Farmer KC, Church JM. Open sesame: tips for traversing the anal canal. Dis Colon Rectum. 1992; 35:1092–3.

Contact diana@nzma.org.nz
for the PDF of this article

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