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. While most cases will be diagnosed between the ages of 65 and 74 years, approximately 10.5% will occur in individuals <50 years. USPSTF has updated guidelines that recommend screening starting at age 45 (Grade B), however there are currently multiple screening strategies available and professional guidelines may differ in approach.
The USPSTF recommends the following:
Who to Screen
- Asymptomatic adults ≥45 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 getting radiation to the abdomen or pelvic area to treat a prior cancer (ACS)
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 45 to 49 years
- Moderate certainty there is net benefit
- Grade B recommendation | Offer or provide this service
- Adults 50 to 75 years
- High certainty there is net benefit
- Grade A 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 their life expectancy
- 86 years or older
- evidence on benefits and harms of colorectal cancer screening is lacking | Benefits would outweigh the harms
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 are the only screening tests that can remove precancerous lesions.
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
- USPSTF, due to limited evidence, does not have separate recommendations for colorectal cancer screening among Black adults
- In addition
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
American College of Gastroenterology (2021)
- 50 to 75 years
- “Recommend” CRC screening in average-risk individuals
- 45 and 49 years
- “Suggest” CRC screening in average-risk individuals
- ≥75 years
- “The decision to continue or discontinue screening in the elderly should not be solely based on chronological age but should also take into account health status, screening history, benefits and harms of screening, and values and preferences of the patient”
- Test selection
- Primary screening modalities
- Colonoscopy every 10 years or
- Annual FIT
- Second-tier for patients who refuse or are unable to undergo primary modalities
- Multitarget stool DNA test every 3 years
- CT colonography every 5 years
- Flexible sigmoidoscopy every 5 to 10
- Capsule colonoscopy every 5 years
- Primary screening modalities
- Recommend against use of Septin 9 for screening
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 (2023)
- 50 to 75 years
- Screen average-risk adults for CRC
- 45 to 49 years
- Consider NOT screening asymptomatic average-risk adults between the ages of 45 to 49 years
- Discuss the uncertainty around benefits and harms of screening in this population
- 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
- Recommend against
- Stool DNA | Computed tomography colonography | Capsule endoscopy | Urine, or serum screening tests
- >75 years or life expectancy ≤ 10 years
- Discontinue screening
Learn More – Primary Sources:
JAMA: Screening for Colorectal Cancer US Preventive Services Task Force Recommendation Statement
ACG Clinical Guidelines: Colorectal Cancer Screening 2021
Canadian Task Force on Preventive Health Care
American Cancer Society Guideline for Colorectal Cancer Screening
ACP: Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults (Version 2)
BMJ State of the Art Review: Screening and prevention of colorectal cancer
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