11. Screening for Colorectal Cancer in SCI Patients

Actionable Nuggets for SCI (3rd ed., 2016)

Initiate colorectal cancer screening for patients with SCI using the same principles as those for the general population.

The Problem:

The incidence of colorectal cancer in individuals with spinal cord injury (SCI) is similar to the general population; however, diagnosis of these tumours often occurs at an advanced stage in the SCI population. Sensory deficits and motor limitations can prevent individuals with SCI from recognizing symptoms that would be evident to individuals who are neurally intact. The high prevalence of rectal bleeding among individuals with SCI means that it is not a good indicator for screening; instead routine screening for colorectal cancer is essential.

Evidence-based Best Practice:

As with the general population, individuals with SCI between the ages of 50 and 74 years and with a negative family history should be screened for colorectal cancer according to current Canadian guidelines:

1) Fecal occult blood test (FOBT) every 2 years, or

2) Flexible sigmoidoscopy every ten years.

Individuals over 75 years of age should not be screened.

Screening with FOBT can reduce mortality from colorectal cancer by 15-33%. Screening with sigmoidoscopy can reduce colorectal cancer mortality by up to two thirds for lesions within reach of the sigmoidoscope.

Colonoscopy is not recommended to screen for colorectal cancer.  Preparation for colonoscopy is a significant ordeal for someone with neurogenic bowel, to the extent that it is often incomplete and produces compromised results.  It is recommended only in the case of a positive screening test (above), because it permits direct visualization of the large bowel in its entirety.  For patients with SCI, consultation with the gastroenterologist may be required.

Key Reference:

    Hayman, A. V, Guihan, M., Fisher, M. J., Murphy, D., Anaya, B. C., Parachuri, R., … D.J., B. (2013). Colonoscopy is high yield in spinal cord injury. Journal of Spinal Cord Medicine, 36(5), 436–442. http://doi.org/10.1179/2045772313Y.0000000091

Additional References (chronological order):

    Kao, C.-H. C.-H., Sun, L.-M., Chen, Y.-S., Lin, C.-L., Liang, J.-A., Kao, C.-H. C.-H., & Weng, M.-W. (2016). Risk of nongenitourinary cancers in patients with spinal cord injury. Medicine, 95(2), e2462. http://doi.org/10.1097/MD.0000000000002462
    Canadian Task Force on Preventive Health Care. (2016). Guidelines for colorectal cancer. Accessed August 18, 2016 from http://canadiantaskforce.ca/ctfphc-guidelines/2015-colorectal-cancer/
    Morris, B., Kucchal, T., & Burgess, N. (2015). Colonoscopy after spinal cord injury: a case-control study. Spinal Cord, 53, 32–35. http://doi.org/10.1038/sc.2014.164
    Stillman, M. D., Frost, K. L., Smalley, C., Bertocci, G., Williams, S., Stillman, D., … Williams, S. (2014). Health care utilization and barriers experienced by individuals with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 95(6), 1114–1126. http://doi.org/10.1016/j.apmr.2014.02.005
    Weaver, F.M., & LaVela, S.L. (2007). Preventative care in spinal cord injuries and disorders: Examples of research and implementation. Physical Medicine and Rehabilitation Clinics of North America, 18(2007), 297-316.
    Leddin, D., et al. (2004). Canadian Association of Gastroenterology and the Canadian Digestive Health Foundation: Guidelines on colon cancer screening. Canadian Journal of Gastroenterology, 18(2), 93-9. http://www.pulsus.com/journals/abstract.jsp
    Winawer, S., et al. (2003). Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology, 124(2), 544-60. http://dx.doi.org/10.1053/gast.2003.50044
    Winawer, S.J., et al. (2000). A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National Polyp Study Work Group. New England Journal of Medicine, 342(24), 1766-72. http://content.nejm.org/cgi/content/full/342/24/1766
    Mandel, J.S., et al. (1999). Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood. Journal of the National Cancer Institute, 91(5), 434-7. http://dx.doi.org/10.1093/jnci/91.5.434
    Consortium for Spinal Cord Medicine (1998). Clinical practice guidelines: Neurogenic bowel management in adults with spinal cord injury. Journal of Spinal Cord Medicine, 21(3), 248-93.
    Hardcastle, J.D., et al. (1996). Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet, 348(9040), 1472-7. http://dx.doi.org/10.1016/S0140-6736(96)03386-7
    Kronborg, O., et al. (1996). Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet, 348(9040), 1467-71. http://dx.doi.org/10.1016/S0140-6736(96)03430-7
    Stratton, M.D., et al. (1996). Colorectal cancer in patients with previous spinal cord injury. Diseases of the Colon & Rectum, 39(9), 965-8. http://dx.doi.org/10.1007/BF02054682
    Selby, J.V., et al. (1992). A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. New England Journal of Medicine, 326(10), 653-7. http://content.nejm.org/cgi/content/abstract/326/10/653