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Difficulty: HardPreventive Care and Screening

A 54-year-old male presents to the clinic to establish care. He recently moved to the area and has not seen a physician in several years. His past medical history is significant for left-sided ulcerative colitis, which was diagnosed 15 years ago. His gastrointestinal symptoms have been well-controlled on daily oral mesalamine. The patient has a 30-pack-year smoking history and continues to smoke one pack of cigarettes daily. He drinks alcohol socially and does not use illicit drugs. Vital signs are within normal limits. Physical examination reveals a soft, non-tender abdomen with no organomegaly. Review of his medical records indicates that his last colonoscopy was performed 6 years ago; it showed quiescent colitis with no evidence of dysplasia. He has never been screened for lung cancer. He received a tetanus, diphtheria, and acellular pertussis (Tdap) booster 2 years ago and an influenza vaccine last month. Which of the following is the most appropriate next step in this patient's preventive care?

  1. Recommend a surveillance colonoscopy now and order a low-dose computed tomography scan of the chestAnswer
  2. B
    Recommend a screening colonoscopy in 4 years and order a low-dose computed tomography scan of the chest
  3. C
    Recommend a surveillance colonoscopy now and order a posterior-anterior chest radiograph
  4. D
    Recommend annual fecal immunochemical testing now and order a low-dose computed tomography scan of the chest
  5. E
    Recommend a surveillance colonoscopy now and advise the patient to return at age 55 for lung cancer screening

Answer

Recommend a surveillance colonoscopy now and order a low-dose computed tomography scan of the chest
This patient requires both a surveillance colonoscopy and a low-dose computed tomography (LDCT) scan of the chest. Patients with left-sided or extensive ulcerative colitis are at high risk for colorectal cancer and require a surveillance colonoscopy beginning 8 years after disease onset. Following the initial surveillance exam, subsequent colonoscopies should be performed every 1 to 3 years. Because this patient's last colonoscopy was 6 years ago, he is overdue and requires one now. Furthermore, updated USPSTF guidelines recommend annual lung cancer screening with LDCT for adults aged 50 to 80 years who have a 20 pack-year or greater smoking history and currently smoke or have quit within the past 15 years. At age 54 with a 30-pack-year history, this patient meets all criteria and should undergo LDCT today.

Step-by-Step Solution

1
Determine the appropriate colorectal cancer screening modality and interval for a patient with a 15-year history of ulcerative colitis.
The patient requires a surveillance colonoscopy every 1 to 3 years; since his last was 6 years ago, he is overdue and needs one today.
Inflammatory bowel disease significantly increases the risk of colorectal cancer, mandating direct visualization at frequent intervals starting 8 years after diagnosis, which supersedes average-risk screening intervals.
2
Determine the appropriate lung cancer screening indication for a 54-year-old with a 30-pack-year smoking history.
The patient requires annual low-dose computed tomography (LDCT) of the chest.
Current USPSTF guidelines recommend LDCT for adults aged 50-80 with a 20 pack-year or greater smoking history who currently smoke or quit within the past 15 years.
3
Synthesize the indicated preventive care interventions into a single management plan.
Recommend a surveillance colonoscopy now and order a low-dose computed tomography scan of the chest.
Both interventions are currently indicated and overdue based on the integration of disease-specific high-risk guidelines and updated age-based screening guidelines.

Key Concept

Preventive screening in high-risk populations (inflammatory bowel disease) and updated age criteria for lung cancer screening.
Estimated Time:1m 30s
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Topics

Preventive Care and Screening

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