Professional Guidelines: Colorectal Cancer Screening

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the USPTF recommended age for colorectal cancer screening
2. Describe the various screening tests currently available for colorectal cancer screening

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 1/15/2020 through 1/15/2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

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
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
Fecal Immunochemical Test (FIT)
- Frequency: Annual
FIT- DNA (identifies altered DNA and/or blood in stool)
- Every 3 years

Direct Visualization Tests

Colonoscopy
- Every 10 years
CT colonography (radiographic)
- Every 5 years
Flexible sigmoidoscopy
- Every 5 years
Flexible sigmoidoscopy with annual FIT (not commonly available)
- Every 10 years

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)

60 to 74 years
- gFOBT or FIT every two years or
- Flexible sigmoidoscopy every 10 years
50 to 59 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
- 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

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