Meet Your Patient
rxPassport Pharmacy Newsletter
June 2015
What C.A.R.E. can you provide to your patients to help prevent Colorectal Cancer?
Meet Your Patient
Maria (30 yo) walks into your pharmacy looking very distraught. After a brief discussion, she shares that her father (58 yo) was recently diagnosed with Stage III colorectal cancer “out of the blue”. After researching online, she found information suggesting that she is at increased risk of developing colorectal cancer. Since she does not have a family physician, she wants to speak with you about ways to reduce her risk of developing cancer.
What do you tell her?
The Scope of the Issue
Colorectal cancer is a disease that is characterized by the formation of malignant cells in the tissues of the colon or rectum1. Malignant cells can arise from previously normal cells or precancerous adenomatous polyps1.
Colorectal cancer represents approximately 14% of estimated new cancer cases in males and 12% in females2. Of the estimated 78,000 annual deaths due to cancer across Canada, colorectal cancer represents the 2nd leading cause for males and 3rd leading cause for females2.
Focusing on prevention strategies is paramount in order to reduce the morbidity and mortality of this highly prevalent disease.
What are the Risk Factors?
Colorectal cancer is associated with a host of non-modifiable and modifiable risk factors (Figure 1). Patients should focus on addressing modifiable risk factors, especially if they have several non-modifiable risk factors.
Figure 1: Non-modifiable and Modifiable Risk Factors1:

*Click to enlarge

† Also called hereditary non-polyposis colorectal cancer (HNPCC). Individuals carry a mutation in 1 of 4 Mismatch Repair Genes (MMR), which increases the risk of developing colorectal cancer3.
‡ Individuals carry a mutation in the adenomatous polyposis coli (APC) tumour suppressor gene, leading to the development of hundreds of polyps lining the colon and rectum, which increases the risk of developing colorectal cancer3.
Clinical Practice Tip!
Many of your patients may believe that colorectal cancer primarily affects men. It is important to clarify that both men and women have approximately equal risk of developing colorectal cancer2
Assess Your Patient
Upon further discussion, you discover that Maria has no medical conditions and is not currently taking any prescription medications. However, you notice red flags within her social history:
Smokes ½ pack of cigarettes per day for the last 13 years
Drinks 2 to 4 glasses of wine (almost every evening) to help her relax
Commutes to her job at a downtown law firm, and does not have time for planned physical activity throughout her busy work week
Target the Modifiable Risk Factors
Limit Alcohol Consumption
Research has shown that consuming 3½ alcoholic drinks per day, increases the risk of developing colorectal cancer by 1½ times compared to non-drinkers1. This association is stronger in men compared to women4.
Canada’s Low Risk Alcohol Drinking Guidelines provides suggestions for safer alcohol consumption5.
Quit Smoking
Although there is sufficient evidence to validate that tobacco smoke is a risk factor for the development of colorectal cancer, all current tobacco users should be encouraged to quit4. There appears to be a stronger link in long term tobacco users (i.e. smoking tobacco for 20 years)1.
Pharmacists play a large role in addressing this risk factor, given their frequent interactions with patients. Every individual should be asked about their tobacco use, advised to quit and provided with appropriate smoking cessation strategies.

*Click to enlarge
Improve Physical Activity
Epidemiological evidence has shown that the risk of developing colorectal cancer decreases with increasing levels of physical activity4. Meta-analyses conducted by the Continuous Update Project, report 30 minutes of recreational physical activity per day, reduced colorectal cancer risk by 11%4.
The Canadian Society for Exercise Physiology provides physical activity guidelines directed at achieving maximal health benefits in adults6.
Getting Screened
Screening is overall, the most effective way to reduce the risk of developing colorectal cancer. A patient has a 90% cure rate, if colorectal cancer is detected in the early phases of its trajectory7. Precancerous polyps in the early stages of colorectal cancer do not often cause symptoms in the patient 8. This emphasizes the importance of screening.
Clinical Practice Tip!
When conducting a risk assessment, ask your patient if they are experiencing any signs and/or symptoms suggestive of colorectal cancer such as8:
Blood in the stool
Persistent abdominal pain, aches, and cramps
Unexplained weight loss
These patients require referral for a diagnostic work-up9
Four diagnostic tools are available to screen patients for colorectal cancer9:
Stool tests: gFOBT (guaiac-based fecal occult blood test) and FIT (fecal immunochemical test)
Flexible sigmoidoscopy
Double arium enema
Screening recommendations have been developed based on an individual’s level of risk (Table 1).

*Click to enlarge
Many average or low risk patients are advised to perform a stool test once they reach 50 years of age, as this test is easy to perform, conducted in the privacy of their home, and much less invasive compared to other tests. Provincial screening guidelines provide information on the types of tests available. Both tests require the collection of stool samples by the patient and subsequent delivery to a medical laboratory. Pharmacists should be proficient with counselling a patient on how to use a stool test, as patients will often have many questions.
Stool tests are designed to detect blood in the stool that is not visible to the human eye11. Polyps in the colon or rectum contain small surface blood vessels which can break with the passage of stool, releasing small amounts of blood11. Therefore, stool tests improve early colorectal cancer diagnosis and prognosis by helping to detect polyps before they have the opportunity to become malignant.
Clinical Practice Tip!
The gFOBT and FIT are conducted differently. For patients using the gFOBT, important patient counselling points include11:
Do not eat red meats, radishes, turnips or broccoli beginning 3 days prior to testing†
Avoid Vitamin C in excess of 250 mg (supplements, citrus fruits or juices) beginning 3 days prior to testing
Avoid Aspirin and other anti-inflammatory medications beginning 7 days prior to testing
† Not an exhaustive list
Counsel Your Patient
After assessing Maria’s social history, 6 key pieces of advice can be given to her to help reduce her risk of developing colorectal cancer:
1. Suggest she limit her alcohol consumption to 2 or less drinks per day
2. Assess her readiness and confidence to quit smoking, and provide appropriate options
3. Recommend that she begin incorporating planned physical activity throughout the day
4. Suggest she consume a diet that is rich in fruits, vegetables and soluble fibre
5. Discuss the importance of screening and early cancer detection
6. Suggest that a colonoscopy be performed every 5 years beginning at 40 yo, as Maria is at a higher risk of colorectal cancer compared to the general population (she has one first degree relative who was diagnosed with colorectal cancer before the age of 60)9.
Bottom Line: Pharmacists are Key Players
Often times, patients are embarrassed to discuss this inherently sensitive subject. They are also frequently unaware of the importance of screening and ways to mitigate modifiable risk factors. Furthermore, they usually hold negative preconceived beliefs surrounding screening method procedures and bowel preparations.
Pharmacists are often cited as one of the most trusted and accessible health care providers. Maximize your time with your patient by providing valuable C.A.R.E.:
Communicate the importance of colorectal cancer screening
Assess the patient’s colorectal cancer risk level
Relay information on ways to reduce risk
Educate on screening procedures to alleviate anxiety and dispel myths
As such, pharmacists can play an unprecedented role in colorectal cancer prevention.
By Daniella Santaera, PharmD Student
With appreciation to Mike Boivin
In this issue
What Are The Risk Factors?
Assess Your Patient
Target the Modifiable Risk Factors
Counsel Your Patient
The C.A.R.E. Model
Pharmacy Student Blog
1. What is colorectal cancer? Canadian Cancer Society (2015). View Source
2. Canadian Cancer Statistics 2015. Special topic: Predictions of the future burden of cancer in Canada. Canadian Cancer Society, Statistics Canada, Public Health Agency of Canada (2015). View Source
3. Genetic risk and cancer. Canadian Cancer Society (2015). View Source
4. World Cancer Research Fund / American Institute for Cancer Research. Continuous Update Report. Food, Nutrition, Physical Activity and the Prevention of Colorectal Cancer (2011). View Source
5. Canada’s Low-Risk Alcohol Drinking Guidelines. Canadian Centre on Substance Abuse (n.d.). View Source
6. Canadian Physical Activity and Sedentary Behaviour Guidelines. Canadian Society for Exercise Physiology (2012). View Source
7. Colorectal Cancer Screening. Cancer Care Ontario (2015). View Source
8. Colorectal Cancer Screening: Basic Fact Sheet. U.S. Department of Health and Human Services Centers for Disease Control and Prevention (2014). View Source
9. Desmond, L. et. al. (2004). Canadian Association of Gastroenterology and the Canadian Digestive Health Foundation: Guidelines on colon cancer screening . Canadian Journal of Gastroenterology, 18 (2). View Source
10. Colon Cancer Check. Cancer Care Ontario (2008). View Source
11. Screening and Diagnostics: A guide to FOBT and FIT tests. Colorectal Cancer Association of Canada (n.d). View Source
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