In a patient with familial adenomatous polyposis, what is the most appropriate management?

• A. Colonoscopy now, repeat every 3-5 years
• B. Occult blood/CEA annually
• C. Prophylactic colectomy
• D. Chemoprevention with NSAIDs

Answer: (C)

In familial adenomatous polyposis, the colon carries thousands of adenomatous polyps due to an APC mutation, and the risk of colorectal cancer approaches 100% if the colon is not removed. Because endoscopic removal of every polyp is impractical and cancer is nearly inevitable, removing the colon prophylactically is the best management to prevent cancer. After colectomy, many patients have an ileal pouch-anal anastomosis to maintain continuity, but they require ongoing surveillance of the pouch.

Surveillance with colonoscopy now and repeated every few years isn’t enough in this condition because the polyps are so numerous that stopping progression to cancer with endoscopic management alone isn’t reliable. Annual occult blood tests or CEA don’t provide the necessary protective effect or reliable early cancer detection in FAP. Chemoprevention with NSAIDs can reduce polyp burden to some extent, but it does not prevent cancer and cannot substitute for removing the colon in this high-risk syndrome.