Professional Guidelines: Colorectal Cancer Screening

CLINICAL ACTIONS:

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and second leading cause of cancer death in the US. While most cases will be diagnosed between the ages of 65 and 74 years, approximately 10.5% will occur in individuals <50 years with significant racial and ethnic disparities in CRC incidence and mortality. CRC is now the leading cause of cancer death in men <50 years. There are currently multiple screening strategies available and professional guidelines may differ in approach. Several new tests offer less invasive screening options for the general population.

Who to Screen

Asymptomatic adults ≥45 years to 75 years (with life expectancy >10 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)
- No personal history of IBD, previous adenomatous polyp, or previous CRC
- No personal history of radiation to abdomen or pelvis

Note: An individual with a family history of multiple relatives with CRC is not a candidate for average CRC screening | Such an individual should be considered at higher risk and would benefit from further assessment, including genetic counseling for a heritable cancer syndrome

When to Screen

Adults 50 to 75 years
- High certainty there is net benefit
- Grade A recommendation | Offer or provide this service
Adults 45 to 49 years
- Moderate certainty there is net benefit
- Grade B recommendation | Offer or provide this service
Adults 76 to 85 years
- Small net benefit for those previously screened | More likely to be of benefit to those not previously screened
- Grade C recommendation | Offer or provide this service for selected patients depending on individual circumstances
- Screening most appropriate for the following
  - Healthy enough to undergo CRC treatment if cancer detected
  - No comorbid conditions that would significantly limit life expectancy
86 years or older
- Screening is not recommended | Benefits would outweigh the harms

Screening Tests

Most effective screening test is the one patient completes. Utilize joint decision-making to choose an option below

Stool-Based Tests

All the stool tests require follow-up colonoscopy if positive

High-sensitivity guaiac based fecal occult blood test (gFOBT)
- Annual
- Requires dietary restrictions and three stool samples
- Does not require bowel preparation, anesthesia, transportation
High-sensitivity fecal immunochemical test (FIT)
- Frequency: Annual
- Single stool sample
- Does not require bowel preparation, anesthesia, transportation
Multitarget stool (mt-sDNA) DNA test (Cologuard) OR Next Generation mt-sDNA (Cologuard Plus)
- Every 3 years
- Single stool sample
- Can be done at home
Multitarget stool RNA test
- Every 3 years
- New test with limited data
- Single stool sample

Direct Visualization Tests

Colonoscopy
- Every 10 years
- Requires full bowel preparation, anesthesia or sedation and transportation to and from the screening examination
- Risk of bowel perforation/bleeding and cardiopulmonary complications of anesthesia
- Offers detection and prevention through polypectomy (if indicated)
CT colonography (radiographic)
- Every 5 years
- Requires bowel preparation, no anesthesia or transportation to and from the screening examination
- Exposure to low-dose radiation
- Positive test requires follow-up colonoscopy with a second bowel prep
Flexible sigmoidoscopy (not commonly available)
- Every 5 years
- Only visualizes rectum and lower third of colon
- Requires enema before procedure
- Availability decreasing
- Concerns about lack of quality standards
- Positive test requires screening colonoscopy

Note: Colorectal cancer almost always develops from precancerous polyps in the colon or rectum | Only colonoscopy can remove precancerous lesions

Blood-Based Tests

Cell-free DNA blood test
- Every 3 years
- Simple blood test
- Not preferred at this time
- Lower sensitivity than other tests
- Specificity declines with advancing age
- Positive test still requires follow-up colonoscopy
- Should be recommended only to those who decline a preferred method

KEY POINTS:

Advising Black Adults

Colorectal Cancer Burden

Highest incidence of and mortality from colorectal cancer
- Incidence (2013 to 2017): 43.6 cases per 100,000 Black adults | 39.0 cases per 100,000 American Indian/Alaska Native adults | 37.8 cases per 100,000 White adults | 33.7 cases per 100 000 Hispanic/Latino adults | 31.8 cases per 100,000 Asian/Pacific Islander adults
- Colorectal cancer death rates (2014 to 2018): 18.0 deaths per 100,000 Black adults | 15.1 deaths per 100,000 American Indian/Alaska Native adults | 13.6 deaths per 100,000 non-Hispanic White adults | 10.9 deaths per 100,000 Hispanic/Latino adults | 9.4 deaths per 100,000 Asian/Pacific Islander adults

Advising Black Adults

Due to limited evidence no specific screening recommendations for Black adults

The USPSTF recognizes the higher colorectal cancer incidence and mortality in Black adults and strongly encourages clinicians to ensure their Black patients receive recommended colorectal cancer screening, follow-up, and treatment

The USPSTF encourages the development of systems of care to ensure adults receive high-quality care across the continuum of screening and treatment, with special attention to Black communities, which historically experience worse colorectal cancer health outcomes