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. 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

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
  • Fecal Immunochemical Test (FIT)
    • Frequency: Annual
  • FIT- DNA (identifies altered DNA and/or blood in stool)
    • Every 1 to 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:

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

Additional Guidelines

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
  • Recommend against use of Septin 9 for screening

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

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

Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians

BMJ State of the Art Review: Screening and prevention of colorectal cancer