TABLE 4.
An example of problem-based learning
| A 68-year-old man with hypertension, diabetes mellitus type 2 and asthma was referred for a screening colonoscopy. The patient participated in an FIT-based national screening program for colorectal cancer. He had a positive test. His medication consists of metformin, digoxin, gliclazide, and antihypertensive medication. | |
| During the colonoscopy, 6 polyps were removed. Polypectomy of a large polyp in the sigmoid colon led to arterial bleeding, which was stopped by using argon plasma coagulation and hemoclips. Histopathology showed tubular adenomas with low-grade dysplasia. Because there was a limited inspection of the distal colon due to the bleeding, a repeat colonoscopy was performed. During this colonoscopy, 5 additional polyps were removed, which were tubular adenomas with low-grade dysplasia. The patient was recommended to undergo surveillance colonoscopy at 1 year and 3 years after the index examination. Each examination showed additional tubular adenomas with low-grade dysplasia. Because of the large cumulative number of polyps, the patient was referred for genetic testing to rule out a polyposis syndrome. APC gene mutation and MUTYH gene mutation analyses results were negative. | |
| Step 1. Clarification of unknown terms | |
| FIT: fecal immunochemical test | |
| APC: argon plasma coagulation: treatment for bleeding | |
| APC mutation: adenomatous polyposis coli gene mutation leading to an autosomal recessive polyposis syndrome | |
| MUTYH: a base excision repair gene that plays a significant role in detecting and protecting against oxidative DNA damage, leading to an autosomal recessive polyposis syndrome | |
| Step 2. Questions raised by the case | |
| What are familial syndromes associated with the occurrence of colorectal cancer? | |
| What is the rationale of screening for colorectal cancer? | |
| How is a national screening program organized? | |
| What is FIT testing? What is the sensitivity and specificity of FIT? | |
| What is the risk of bleeding after polypectomy? | |
| What are risk factors for bleeding after polypectomy? | |
| How is post-polypectomy bleeding managed? | |
| Step 3. Brainstorm | |
| National screening program: age 55–75 years, primary test: FIT every 2 years | |
| High specificity >90% | |
| Symptoms of colorectal cancer: Blood per rectum, anemia, fatigue, weight loss | |
| Adenomas with high-grade dysplasia turn into cancer sooner. Different mutations can lead to a higher grade of dysplasia or ingrowth of the tumor into deeper layers of the colon wall. | |
| Different types of adenomas: villous vs tubular adenoma. Pedunculated or sessile polyps | |
| Different classifications for histopathology and morphology | |
| Treatment of bleeding in this case: epinephrine, APC, hemostatic clips | |
| Hereditary causes for colorectal cancer: Different mutation pathways exist. APC gene, p53 gene mutations, familial syndromes: familial adenomatous polyposis, Lynch syndrome (hereditary nonpolyposis colorectal cancer) | |
| During the brainstorm, it was found that the trainees were already well-informed about the national screening program. | |
| Step 4. Learning goals | |
| What are stages in progression of colorectal adenomas to colorectal cancer? | |
| What are the main genetic events in colorectal cancer progression? | |
| What are polyp factors associated with increased risk of progression to colorectal cancer? | |
| What are polyposis syndromes? What are the diagnostic criteria for attenuated familial adenomatous polyposis? What are the diagnostic criteria for MUTYH-associated polyposis? | |
| What are the possible adverse events of colonoscopy? What are risk factors for bleeding after polypectomy? | |
| How to manage post-polypectomy bleeding | |
| Step 5. Clustering | |
| Three main topics: colorectal cancer progression, polyposis syndromes, and adverse events | |
| Step 6. Individual research | |
| The mentor may provide advice regarding literature | |
| Trainees perform extensive searches and read the most relevant references | |
| Step 7. Discussion | |
| Second meeting | |
| The learning goals are discussed | |
| After discussion, a new case is provided | |
FIT, Fecal immunochemical test.