One of the things I wanted to discuss with you because you probably have not heard about this and a lot of us haven’t either, classic familial adenomatous polyposis, the number of adenomas are usually thousands. The attenuated familial adenomatous polyposis or the FAP, only 1 to 50 cases of polyps, are never more than 100 as you can see. The morphology of the classic FAP is polyploid and the attenuated is flat and the fact that it’s flat makes it hard to realize that you’re dealing with a genetic type of disease. The location of the FAP is through the colon and proximal to the splenic flexure in the attenuated variety. The location is through the colon for the classic and proximal to the splenic flexure for the attenuated. Colorectal cancer is through the colon and proximal splenic flexure for the attenuated.

Here’s where you again can see the difficulties in making sure you’ve got the right diagnosis. Classic FAP age of onset is 39, pretty early. It makes you think about cancer. The attenuated familial adenomatous polyposis is at age 55. So it’s a little bit later and it looks a little bit more like classic but it’s not.

Fundic gland polyps is a constant feature in the classic and in the attenuated. Extracolonic cancers are preampullary, thyroid sarcomas, brain tumors and small bowel are in the classic and periampullary in the nonclassic.

Desmoid tumors are common in the classic and not identified in the attenuated. Hypertrophy of the retina is found in 70% of these patients and absent to almost gone. When we’re looking at these patients with the flat polyps, when we look for the incidence, you’ll notice that percent of the total is over 50,000 in the cecal area and it slowly goes down to the rectum where it’s less than 10%. So this is a group of patients that you should be looking for and I think you can really do some good in taking care of these people.

Guidelines for screening and surveillance then for the early detection of colorectal polyps and cancer. Repeat FOB every year. Flexible sigmoidoscopy every five years. Colonoscopy every ten years. A double contrast barium enema can be used every five to ten years.

Screening costs are really something else with this disease. As you can see, 50-70_year_olds screen every five years and the cost is over $1 billion. So we’ve got to do a little bit more conservatively than what we’re doing at the present time.

We’re talking here about breasts and breast self examination should be started at 20 and over every month. Breast physical 20-40 and over 40 every year and every three years from 20-40. Mammography 35-39 baseline and 40-49 every one to two years. As you probably know, it’s now been established that 40-49 is the way we should do this and we don’t need to do it every year for 35-39, just the baseline. But 40-49 is going to be every year now and 50 and over, of course, we’ve already talked about that being every year. So we should have an annual mammography beginning at age 40. Guidelines for women age 50 and over remain unchanged and then we just discussed the 40-49.

Mammography screening. 30% reduction of breast cancer mortality and 20% false negative are found. It’s very important to keep this in mind because I have seen a number of patients that were in litigation because they had decided that it was a false negative and nothing to worry about but it wasn’t nothing to worry about.

The typical breast has normal fat tissue. Everybody can see this one has carcinoma here. It’s spiculated and irregular in shape and a classic cancer of the breast.

The other thing that you all now know is the study on using tamoxifen in breast attenuation and decreasing of breast cancer has now been easily picked up as being very important. It does increase the likelihood of us being able to cure these patients and this has been a very significant improvement in our care of these particular patients.

Now, when we talk of cancer of the cervix, we all know that that pap smear is the best type of study that we can do – better than anything else. Here’s an area in 1994 with the number of cases being 15,000, the number of deaths being 46,000. Cancer of the cervix risk factors include early sex, parity over five, multiple partners, papilloma virus, DES in utero and non-Jewish.