Attenuated Familial Adenomatous Polyposis (AFAP)

Dr. Priya Kishnani, MD - Clinical Genetics, Genomics, Cytogenetics, Biochemical Genetics Specialist Dr. Priya Kishnani, MD - Clinical Genetics, Genomics, Cytogenetics, Biochemical Genetics Specialist
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Rx Cancer (A - Z)

Attenuated familial adenomatous polyposis (AFAP) is an inherited condition that causes a person to grow fewer colon and rectal polyps than the classic form of FAP—usually between about 10 and 100 adenomatous polyps over time. These polyps can turn into colorectal cancer if they are not found and treated. People with AFAP usually develop polyps and cancer later in life than people with classic FAP. Many develop colorectal cancer around age 50–55 if not carefully checked. The condition is usually caused by a harmful change (pathogenic variant) in the APC gene that you inherit in an autosomal dominant way (a 50% chance to pass it to each child). AFAP can also be found in someone with no family history if a new gene change happens for the first time. Careful colonoscopy checks and removal of polyps can prevent cancer in many people. NCBI+2Cancer.gov+2

AFAP can also involve polyps in the upper digestive tract (especially the duodenum), and sometimes features outside the gut like thyroid nodules, dental or bone growths (osteomas), skin findings, or desmoid tumors. These extra features are variable and less common than in classic FAP, but they can occur and need awareness during follow-up. NCBI

Other names

  • Attenuated FAP (AFAP) – most common short name. NCBI

  • APC-associated polyposis, attenuated type – emphasizes the APC gene cause. NCBI

  • A milder variant of familial adenomatous polyposis – a descriptive phrase used in clinics and reviews. Cancer.gov

Note: Some conditions look similar to AFAP but are different diseases with different inheritance, like MUTYH-associated polyposis (MAP) (autosomal recessive) and NTHL1-related polyposis. They can produce an “attenuated” polyp picture but are not AFAP because they are not caused by APC. Doctors test for these to make the correct diagnosis. Cancer.gov+2Rare Diseases Information Center+2

Types

  1. By APC mutation location (genotype-phenotype pattern).
    AFAP is most often linked to pathogenic variants at the 5′ end of APC (codons 1–233), the alternatively spliced region of exon 9 (codons ~311–412), or beyond codon 1595 at the 3′ end. These regions are associated with fewer polyps and later cancer than classic FAP. Still, there is overlap—some people with these variants can show classic FAP and need colectomy. NCBI

  2. By clinical severity.
    Doctors sometimes speak of “attenuated” (10–100 life-time adenomas, later cancer) versus “classic” (>100 adenomas, earlier cancer). AFAP sits on the milder end of this spectrum. Cleveland Clinic

  3. By family pattern.
    Many people have a clear autosomal dominant family history. Others have de novo (first-in-family) cases. Rarely, mosaic APC changes (present in some cells but not all) produce an AFAP picture. These patterns matter for how we test relatives. NCBI

Causes and contributors

The primary cause of AFAP is a harmful change in the APC gene that reduces the gene’s tumor-suppressor function, allowing polyps to form more slowly and in fewer numbers than classic FAP. The items below explain how and why the AFAP picture appears or varies from person to person.

  1. APC pathogenic variant (core cause). A germline (born-with) APC mutation weakens a key tumor-suppressor pathway, so adenomas develop over years. NCBI

  2. Mutation near the 5′ end of APC. Variants in codons 1–233 often produce an attenuated picture. NCBI

  3. Mutation in exon 9 (alternatively spliced region). These can limit polyp number and delay cancer age. NCBI

  4. Mutation beyond codon 1595 (3′ end). Also linked to the attenuated phenotype. NCBI

  5. Large APC deletions/duplications. Some broader structural changes can still present as AFAP depending on where they occur. NCBI

  6. Somatic “second hit.” Cancer usually requires a second, acquired hit in APC (or related genes) in colon cells; the timing and location affect when and where cancer appears. PMC

  7. APC mosaicism. If only some cells carry the APC variant, polyp number may be lower, mimicking AFAP. NCBI

  8. Genetic modifiers. Other genes can modify risk or polyp count (for example, DNA repair pathways), shaping an attenuated course. (Inference from polyposis genetics reviews.) PMC

  9. De novo mutation. A new APC change can start AFAP in a person with no family history. Mayo Clinic

  10. Environmental modifiers—diet. Diet patterns may influence adenoma growth rate over time; surveillance remains key regardless. (General inference supported by CRC risk literature.) PMC

  11. Smoking. Smoking is associated with more adenomas in general populations; it may modify polyp burden in APC carriers. (Inference from adenoma risk data.) PMC

  12. NSAID exposure. Some NSAIDs (e.g., sulindac, eflornithine in trials) can lower polyp counts; this modifies expression but is not a cause—still important for management. Cleveland Clinic

  13. Hormonal factors. Hormones can alter gut physiology and bile acids; effects are modest but can influence phenotype expression. (General inference.) PMC

  14. Gut microbiome differences. Microbiome patterns can promote or slow polyp growth; research is ongoing. (General inference from CRC biology.) PMC

  15. Age. AFAP is “slower,” so adenomas and cancer usually appear later (50–55 on average if not prevented). Age is thus a “driver” of when disease becomes visible. NCBI

  16. Sex. Overall CRC risks are similar; some extracolonic risks (e.g., desmoid risk in women after surgery) can differ and modify the course. NCBI

  17. Location of polyps. AFAP tends to have right-sided colon emphasis; missed polyps on the right can change outcomes if colonoscopy quality is poor. (Common teaching from polyposis reviews.) PMC

  18. Health system factors. Access to high-quality colonoscopy and experienced endoscopists affects polyp control and cancer prevention. (Guideline-based inference.) NCBI

  19. Family screening timing. Late or missed testing in relatives can lead to more advanced disease, shaping “severity” seen in a family. NCBI

  20. Differential diagnoses. MAP (MUTYH) and NTHL1-related polyposis look “attenuated” but are separate causes with different inheritance; ruling them out ensures the label “AFAP” fits. Cancer.gov+2Rare Diseases Information Center+2

Common symptoms and signs

  1. No symptoms for years. Many people feel fine while small polyps slowly grow. That’s why screening is vital. NCBI

  2. Rectal bleeding or blood in stool. Small amounts over time can be easy to miss. Mayo Clinic

  3. Iron-deficiency anemia. Slow blood loss can cause tiredness, pale skin, and shortness of breath. Mayo Clinic

  4. Change in bowel habits. Diarrhea, constipation, or narrower stools may occur as polyps enlarge. Mayo Clinic

  5. Abdominal pain or cramping. Can come from large polyps, inflammation, or (rarely) blockage. Mayo Clinic

  6. Mucus in stool. Polyps can produce mucus. (General CRC symptom education.) Mayo Clinic

  7. Unexplained weight loss. A warning sign if cancer develops. Mayo Clinic

  8. Fatigue. Often due to anemia or chronic blood loss. Mayo Clinic

  9. Symptoms from duodenal polyps. Upper belly discomfort, reflux, or bleeding can occur if upper-GI polyps grow. NCBI

  10. Palpable abdominal mass (desmoid). Rare; desmoid tumors can cause pain or fullness. NCBI

  11. Thyroid nodule. Usually found on exam or ultrasound rather than causing symptoms. NCBI

  12. Dental or jaw changes, osteomas. Sometimes noticed on exam or imaging. NCBI

  13. Skin bumps or lesions. Benign skin findings can occur but are less common than in classic FAP. NCBI

  14. Family pattern. A parent or multiple relatives with “many polyps” or early colon cancer is a clinical clue. NCBI

  15. Later age of onset vs classic FAP. In AFAP, cancer often appears around 50–55 if unchecked, which can falsely reassure families until a case appears. NCBI

Diagnostic tests

A) Physical examination (what the clinician can find)

  1. General exam and vital signs. Looks for anemia signs (pale skin, fast heart rate), weight loss, or general illness. This supports the need for urgent endoscopy. Mayo Clinic

  2. Abdominal exam and palpation. Checks for tenderness or a mass that could be a desmoid tumor or advanced cancer. NCBI

  3. Thyroid exam (palpation). AFAP can include thyroid nodules; early palpation may prompt ultrasound. NCBI

  4. Skin, dental, and bone exam. Looks for osteomas, dental changes, or skin lesions that support an APC-associated syndrome. NCBI

B) “Manual” or bedside tests / office-based procedures

  1. Digital rectal exam (DRE). A quick check that may detect low rectal polyps or masses; not a replacement for scoping. Mayo Clinic

  2. Office proctoscopy/anoscopy (when available). Can visualize the very distal rectum/anus for obvious lesions before full colonoscopy. (General practice.) PMC

  3. Fecal occult blood or FIT test. Simple stool tests can show hidden blood; not diagnostic for AFAP but may prompt colonoscopy sooner. Mayo Clinic

  4. Family pedigree assessment. Building a three-generation family tree helps decide on APC testing and surveillance for relatives. NCBI

C) Laboratory & pathology tests

  1. Complete blood count (CBC) and ferritin. Looks for iron-deficiency anemia from slow bleeding polyps. Mayo Clinic

  2. Germline genetic testing of APC. Key test. Uses sequencing plus deletion/duplication analysis to detect APC variants typical of AFAP. Guides care and family testing. NCBI

  3. Reflex testing for other genes (when APC is negative). Testing for MUTYH, NTHL1 and other polyposis genes helps distinguish AFAP from MAP or NTHL1-related polyposis. Cancer.gov+1

  4. Polyp biopsy with histology. Confirms adenomatous polyps and checks for dysplasia or cancer. (Standard endoscopic pathology.) PMC

  5. MMR IHC/MSI on cancer tissue (if cancer present). Helps rule out Lynch syndrome if the tumor suggests that possibility; clarifies the broader hereditary picture. Cancer.gov

D) Electrodiagnostic tests

  1. No routine electrodiagnostic test is used for AFAP. Nerve or muscle electrical tests are not part of AFAP diagnosis; this category is usually not applicable in polyposis. (Standards from guidelines and clinical practice.) NCBI

E) Endoscopic & imaging tests

  1. Full colonoscopy (gold standard). Finds and removes polyps, maps their number and size, and sets the follow-up plan. In AFAP, colonoscopy starts in late adolescence and repeats every 1–2 years. NCBI

  2. Flexible sigmoidoscopy. Sometimes used, but colonoscopy is preferred because AFAP can be right-sided and would be missed by limited exams. PMC

  3. Upper endoscopy (EGD) with side-view of ampulla. Starts around age 20–25 (or before colon surgery) and repeats based on Spigelman stage to manage duodenal polyps. NCBI

  4. Video capsule endoscopy or CT/MR enterography. Considered when duodenal polyposis is advanced, to visualize the rest of the small bowel. NCBI

  5. Thyroid ultrasound. Used every 2–5 years in late adolescence and beyond to assess nodules found on exam. NCBI

  6. Cross-sectional imaging (MRI/CT) when needed. If symptoms suggest desmoid tumors after surgery or an abdominal mass is suspected, imaging helps make the diagnosis and plan treatment. NCBI

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: September 28, 2025.

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References

 

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