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Difficulty: MediumPreventive Care and Screening

A 34-year-old woman presents to the clinic to establish primary care. She recently moved to the area and has not seen a physician in three years. She feels well and has no current symptoms. She exercises regularly, does not smoke, and consumes alcohol occasionally. Her family history is significant for a father who was diagnosed with colon cancer at age 42, and a paternal aunt who was diagnosed with breast cancer at age 60. Her mother is alive and healthy. Vital signs include a blood pressure of 118/74 mm Hg, heart rate of 70/min, and a BMI of 23 kg/m². Physical examination is unremarkable. A review of her medical records shows that a Pap smear with human papillomavirus (HPV) co-testing performed one year ago was normal, and a one-time screening for hepatitis C virus antibody was non-reactive. Which of the following is the most appropriate next step in the preventive care of this patient?

  1. Referral for screening colonoscopyAnswer
  2. B
    Fecal immunochemical testing
  3. C
    Advise screening colonoscopy starting at age 40
  4. D
    Screening mammography
  5. E
    Genetic risk assessment for BRCA mutations

Answer

Referral for screening colonoscopy
The correct answer is referral for a screening colonoscopy. This patient is at high risk for colorectal cancer due to her father's diagnosis at age 42. According to guidelines from the US Multi-Society Task Force on Colorectal Cancer, individuals with a single first-degree relative diagnosed with colorectal cancer or advanced adenoma before age 60 should undergo screening colonoscopy every 5 years. This screening should begin at age 40, or 10 years younger than the earliest diagnosis in their family, whichever comes first. In this patient's case, 10 years prior to her father's diagnosis is age 32. Since she is currently 34 years old, she is overdue for screening and should be referred for a colonoscopy immediately.

Step-by-Step Solution

1
Identify the patient's risk factors for colorectal cancer.
The patient has a first-degree relative (father) diagnosed with colorectal cancer at age 42.
Family history dictates the modality and timing of colorectal cancer screening.
2
Apply the appropriate screening guideline for the identified risk level.
For a first-degree relative diagnosed before age 60, screening must start at age 40 or 10 years before the relative's age at diagnosis, whichever is earlier.
This rule ensures early detection in populations with aggressive or early-onset familial cancer patterns.
3
Calculate the indicated screening age for this specific patient.
10 years before the father's diagnosis (age 42) is age 32. Since 32 is earlier than 40, screening should begin at 32.
Determines if the patient is currently due for screening.
4
Determine the appropriate screening modality.
Colonoscopy is required; non-invasive tests like FIT are inappropriate.
High-risk patients require direct visualization to adequately assess and remove precancerous lesions.

Key Concept

Colorectal cancer screening in high-risk patients (first-degree relative diagnosed at <60 years of age) should begin with a colonoscopy at age 40 or 10 years before the relative's diagnosis, whichever is earlier.
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Topics

Preventive Care and Screening

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