Professional Guidelines: Colorectal Cancer Screening

CLINICAL ACTIONS:

Colorectal cancer (CRC) is the third most common new site and cause of cancer death in the US. Screening is recommended for all patients 50 to 75 years of age, based on USPSTF guidance. There are currently multiple screening strategies available and professional guidelines may differ in approach.

The USPSTF recommends the following

Who to Screen

Asymptomatic adults ≥50 years
Average risk of CRC
- No family history of known genetic disorders predisposing to high lifetime risk of CRC (e.g., Lynch syndrome or familial adenomatous polyposis)
- Note: An individual with a family history of multiple relatives with CRC, especially at an early age, may benefit from a genetic risk assessment for a heritable cancer syndrome
- No personal history of IBD, previous adenomatous polyp, or previous CRC
- No personal history of getting radiation to the abdomen or pelvic area to treat a prior cancer (ACS)
Along with the above, the American Cancer Society considers a personal history of radiation cancer treatment to the abdomen/pelvic area or a family history of CRC to be above-average risk factors for CRC

When to Screen

Adults 50 to 75 years
- Screen for CRC starting at age 50
- Grade A recommendation | Offer or provide this screening
Adults 76 to 85 years
- Grade C recommendation | Offer or provide this service for selected patients depending on individual circumstances
- Adults in this age group who have never been screened for colorectal cancer are more likely to benefit
- Screening most appropriate for the following
  - Healthy enough to undergo CRC treatment if cancer detected
  - No comorbid conditions that would significantly limit their life expectancy

Screening Tests

Stool-Based Tests

Tests other than colonoscopies that can be used for screening of average risk patients

Guaiac based Fecal Occult Blood test (gFOBT)
- Annual
- Requires dietary restrictions and three stool samples
- Does not require bowel preparation, anesthesia, transportation
Fecal Immunochemical Test (FIT)
- Frequency: Annual
- Single stool sample
- Does not require bowel preparation, anesthesia, transportation
FIT- DNA/stool DNA test ‘Cologuard’ (identifies altered DNA and/or blood in stool)
- Every 1 to 3 years
- Single stool sample

Direct Visualization Tests

Colonoscopy
- Every 10 years
- Requires bowel preparation, anesthesia or sedation and transportation to and from the screening examination
CT colonography (radiographic)
- Every 5 years
- Requires bowel preparation, no anesthesia or transportation to and from the screening examination
Flexible sigmoidoscopy (not commonly available)
- Every 5 years
- Only visualizes rectum and lower third of colon
- Availability decreasing
Flexible sigmoidoscopy with annual FIT (not commonly available)
- Every 10 years
- Only visualizes rectum and lower third of colon

Note: Colorectal cancer almost always develops from precancerous polyps in the colon or rectum | Direct visualization test only screening test that can remove precancerous lesions.

KEY POINTS:

Additional Guidelines

U.S. Multi-Society Task Force on Colorectal Cancer Recommendations (2017)

Note: Represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy

Begin screening at age 50 | In African Americans begin at age 45
Discontinue at age 75 or <10 years of life expectancy
Test selection
- First-tier: Colonoscopy every 10 years or annual FIT
- Second-tier for patients who refuse colonoscopy: CT colonography every 5 years or FIT-fecal DNA every 3 years or Flexible sigmoidoscopy every 5 to 10
- Third-tier for patients who refuse second tier: Capsule colonoscopy every 5 years

Note: Can consider sequential approach with colonoscopy the test of choice and FIT for those who decline colonoscopy | Colonoscopy or FIT when multiple options are presented

Canadian Guidelines (2016)

Recommendations apply to adults aged ≥50 years who are not at high risk for colorectal cancer (CRC)

50 to 59 years
- gFOBT or FIT every two years or
- Flexible sigmoidoscopy every 10 years
60 to 74 years
- gFOBT or FIT every two years or
- Flexible sigmoidoscopy every 10 years
≥75 years
- Recommend against screening

Note: Recommend not using colonoscopy

American Cancer Society (2018)

45 to 75 years
- Patients in good health with life expectancy of more than 10 years
- Screen with stool-based or direct visualization test
76 to 85 years
- Base screening decision on
  - Personal preferences | Life expectancy | Overall health | Prior screening history
85 years
- Should no longer get CRC screening

ACP (2019)

50 to 75 years
- Screen average-risk adults for CRC
Suggested screening tests and intervals based on discussion of “benefits, harms, costs, availability, frequency and patient preferences”
- FIT or high-sensitivity guaiac-based fecal occult blood testing: Every 2 years
- Colonoscopy: Every 10 years
- Flexible sigmoidoscopy every 10 years plus FIT every 2 years
>75 years or life expectancy ≤ 10 years
- Discontinue screening