Colorectal Cancer Prevention and Early

Detection
What is colorectal cancer?
Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the
body can become cancer, and can spread to other areas of the body. To learn more about how
cancers start and spread, see What Is Cancer?
Colorectal cancer is a term used to refer to cancer that develops in the colon or the rectum. These
cancers are sometimes called colon cancer or rectal cancer, depending on where they start. Colon
cancer and rectal cancer are often grouped together because they have many features in common.

Importance of colorectal cancer screening

Screening is the process of looking for cancer or pre-cancer in people who have no symptoms of
the disease. Regular colorectal cancer screening is one of the most powerful weapons against
colorectal cancer. Excluding skin cancers, colorectal cancer is the third most common cancer
diagnosed in both men and women in the United States. Overall, the lifetime risk for developing
colorectal cancer is a little less than 1 in 20 (5%). This risk is slightly lower for women than for
men.
Colorectal cancer is the second leading cause of cancer death when numbers for both men and
women are combined.
The death rate (the number of deaths per 100,000 people per year) of colorectal cancer has been
dropping for several decades. One reason for this is that today, colorectal polyps are more often
found by screening and removed before they can develop into cancers.
It can take as many as 10 to 15 years for a polyp to develop into colorectal cancer. Regular
screening can prevent many cases of colorectal cancer altogether by finding and removing

certain types of polyps before they have the chance to turn into cancer. Screening can also help
find colorectal cancer early, when its small, hasnt spread, and is easier to treat.
When colorectal cancer is found at an early stage before it has spread, the 5-year relative survival
rate is about 90%. But only about 4 out of 10 colorectal cancers are found at this early stage.
When cancer has spread outside the colon or rectum, survival rates are lower.
Unfortunately, only a little more than half of people who should get tested for colorectal cancer
get the tests that they should. This may be due to things like lack of public and health care
provider awareness of screening options, costs, and health insurance coverage issues.
See Colorectal cancer screening tests for more on the tests used to screen for colorectal cancer.
The section American Cancer Society recommendations for colorectal cancer early detection
has our guidelines for using these tests to find colorectal cancer and polyps.

Colorectal cancer risk factors

A risk factor is anything that affects your chance of getting a disease such as cancer. Different
cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like
a persons age or family history, cant be changed.
But having a risk factor, or even many risk factors, does not mean that youll get the disease.
And some people who get the disease may not have any known risk factors.
Researchers have found risk factors that might increase a persons chance of having colorectal
polyps or colorectal cancer.

Risk factors you can change

Many lifestyle-related factors have been linked to colorectal cancer. In fact, the links between
diet, weight, and exercise and colorectal cancer risk are some of the strongest for any type of
cancer.

Being overweight or obese

If you are overweight or obese (very overweight), your risk of developing and dying from
colorectal cancer is higher. Being overweight raises the risk of colon cancer in both men and
women, but the link seems to be stronger in men.

Physical inactivity
If youre not physically active, you have a greater chance of developing colorectal cancer. Being
more active might help lower your risk.

Certain types of diets

A diet thats high in red meats (beef, pork, lamb, or liver) and processed meats (such as hot dogs
and some luncheon meats) can raise your colorectal cancer risk.
Cooking meats at very high temperatures (frying, broiling, or grilling) creates chemicals that
might raise your cancer risk, but its not clear how much this might increase your risk.
Diets high in vegetables, fruits, and whole grains have been linked with a lower risk of colorectal
cancer, but fiber supplements have not been shown to help.
Its not clear if other dietary components (for example, certain types of fats) affect colorectal
cancer risk.

Smoking
People who have smoked for a long time are more likely than non-smokers to develop and die
from colorectal cancer. Smoking is a well-known cause of lung cancer, but its also linked to
other cancers, like colorectal cancer. If you smoke and would like to learn more about quitting,
see our Guide to Quitting Smoking.

Heavy alcohol use

Colorectal cancer has been linked to heavy alcohol use. Limiting alcohol use to no more than 2
drinks a day for men and 1 drink a day for women could have many health benefits, including a
lower risk of colorectal cancer.

Colorectal cancer risk factors you cannot change

Older age
The risk of colorectal cancer goes up as you age. Younger adults can develop colorectal cancer,
but the chances increase markedly after age 50.

Personal history of colorectal polyps or colorectal cancer

If you have a history of adenomatous polyps (adenomas) in the colon or rectum, you have a
higher risk of developing colorectal cancer. This is especially true if the polyps are large or if
there are many of them.
If youve had colorectal cancer, even though it has been completely removed, youre more likely
to develop new cancers in other areas of the colon and rectum. The chances of this happening are
greater if you first had colorectal cancer when you were younger.

Personal history of inflammatory bowel disease

If you have inflammatory bowel disease (IBD), including either ulcerative colitis or Crohns
disease, you have a higher risk of colorectal cancer.
IBD) is a condition in which the colon is inflamed over a long period of time. People who have
had IBD for many years often develop dysplasia. Dysplasia is a term used to describe cells in the
lining of the colon or rectum that look abnormal (but not like true cancer cells) when seen under
a microscope. These cells can change into cancer over time.
If you have IBD, you may need to start colorectal cancer screening at a younger age and be
screened more often.
Inflammatory bowel disease is different from irritable bowel syndrome (IBS). IBS is not linked
to an increased risk for colorectal cancer.

Family history of colorectal cancer or adenomatous polyps

Most colorectal cancers are found in people without a family history of colorectal cancer. Still,
as many as 1 in 5 people with colorectal cancer have other family members who have had it.
People with a history of colorectal cancer in a first-degree relative (parent, sibling, or child) are
at increased risk. The risk is even higher if the first-degree relative was diagnosed when they
were younger than 45, or if more than one first-degree relative is affected.
The reasons for the increased risk are not clear in all cases. Cancers can run in the family
because of inherited genes, shared environmental factors, or some combination of these.
Having family members who have had adenomatous polyps is also linked to a higher risk of
colon cancer. (Adenomatous polyps are the kind of polyps that can become cancer.)
If you have a family history of adenomatous polyps or colorectal cancer, ask your doctor if you
should start screening before age 50. If you have had adenomatous polyps or colorectal cancer,
its important to tell your close relatives so that they can pass along that information to their
doctors and start screening at the right age.

Inherited syndromes
About 5% to 10% of people who develop colorectal cancer have inherited gene defects
(mutations) that can cause family cancer syndromes and lead to them getting the disease.
The most common inherited syndromes linked with colorectal cancers are familial adenomatous
polyposis (FAP) and Lynch syndrome (hereditary non-polyposis colorectal cancer or HNPCC),
but other rarer syndromes can also increase colorectal cancer risk.

Familial adenomatous polyposis (FAP): FAP is caused by changes (mutations) in the APC
gene that a person inherits from his or her parents. About 1% of all colorectal cancers are caused
by FAP.
In the most common type of FAP, hundreds or thousands of polyps develop in a persons colon
and rectum, usually starting in their teens or early adulthood. Cancer usually develops in 1 or
more of these polyps as early as age 20. By age 40, almost all people with FAP will have colon
cancer if their colon hasnt been removed to prevent it. People with FAP also have an increased
risk of cancers of the stomach, small intestines, and some other organs.
In attenuated FAP, which is a subtype of this disorder, patients have fewer polyps (less than
100) and colorectal cancer tends to occur at a later age.
Gardner syndrome is a type of FAP that also leads to benign (non-cancer) tumors of the
skin, soft tissue, and bones.
Lynch syndrome (hereditary non-polyposis colon cancer, or HNPCC): Lynch syndrome
accounts for about 2% to 4% of all colorectal cancers. In most cases, this disorder is caused by
an inherited defect in either the MLH1 or MSH2 gene, but changes in other genes can also cause
Lynch syndrome. These genes normally help repair DNA damage.
The cancers in this syndrome develop when people are relatively young. People with Lynch
syndrome can have polyps, but they tend to only have a few, not hundreds as in FAP. The
lifetime risk of colorectal cancer in people with this condition may be as high as 80%, but this
depends on which gene is affected.
Women with this condition also have a very high risk of cancer of the endometrium (lining of the
uterus). Other cancers linked to Lynch syndrome include cancer of the ovary, stomach, small
intestine, pancreas, kidney, brain, ureters (tubes that carry urine from the kidneys to the bladder),
and bile duct.
For more information on Lynch syndrome, see Genetic testing, screening, and prevention for
people with a strong family history of colorectal cancer.
Turcot syndrome: This is a rare inherited condition in which people are at increased risk of
adenomatous polyps and colorectal cancer, as well as brain tumors. There are actually 2 types of
Turcot syndrome:
One is caused by gene changes similar to those seen in FAP, in which cases the brain tumors
are medulloblastomas.
The other is caused by gene changes similar to those seen in Lynch syndrome, in which cases
the brain tumors are glioblastomas.
Peutz-Jeghers syndrome: People with this rare inherited condition tend to have freckles around
the mouth (and sometimes on their hands and feet) and a special type of polyps (called

hamartomas) in their digestive tracts. These people are at a greatly increased risk for colorectal
cancer, as well as several other cancers, which usually appear at a younger than normal age. This
syndrome is caused by mutations in the STK1 gene.
MUTYH-associated polyposis: People with this syndrome develop colon polyps which will
become cancer if the colon is not removed. These people also have an increased risk of cancers
of the small intestine, skin, ovary, and bladder. This syndrome is caused by mutations in the
MUTYH gene.
People with these inherited syndromes often get cancer at a younger age than usual. These
syndromes are also linked to some other types of cancer. Identifying families with these
syndromes is important because it lets doctors recommend specific steps such as screening and
other preventive measures at an early age.
Information on risk assessment, and genetic counseling and testing for some of these syndromes
can be found in Genetic testing, screening, and prevention for people with a strong family
history of colorectal cancer.

Racial and ethnic background

African Americans have the highest colorectal cancer incidence and mortality rates of all racial
groups in the United States. The reasons for this are not yet understood.
Jews of Eastern European descent (Ashkenazi Jews) have one of the highest colorectal cancer
risks of any ethnic group in the world. Several gene mutations leading to an increased risk of
colorectal cancer have been found in this group. The most common of these gene changes, called
the I1307K APC mutation, is present in about 6% of American Jews.

Type 2 diabetes
People with type 2 (usually non-insulin dependent) diabetes have an increased risk of colorectal
cancer. Both type 2 diabetes and colorectal cancer share some of the same risk factors (such as
being overweight or obese). But even after taking these factors into account, people with type 2
diabetes still have an increased risk. They also tend to have a less favorable prognosis (outlook)
after diagnosis.

Factors with less clear effects on colorectal cancer risk

Night shift work
Results of one study suggested working a night shift at least 3 nights a month for at least 15
years may increase the risk of colorectal cancer in women. The study authors suggested this

might be due to changes in levels of melatonin (a hormone that responds to changes in light) in
the body. More research is needed to confirm or refute this finding.

Previous treatment for certain cancers

Some studies have found that men who survive testicular cancer seem to have a higher rate of
colorectal cancer and some other cancers. This might be due to the treatments they had.
Several studies have suggested that men who had radiation therapy to treat prostate cancer may
have a higher risk of rectal cancer because the rectum receives some radiation during treatment.
Most of these studies are based on men treated in the 1980s and 1990s, when radiation
treatments were less precise than they are today. The effect of more modern radiation methods
on rectal cancer risk is not clear.

Can colorectal cancer be prevented?

Theres no sure way to prevent colorectal cancer. But there are things you can do that might help
lower your risk of getting it, such as being screened for it and changing the risk factors that you
can control.

Colorectal cancer screening

Screening is the process of looking for cancer or pre-cancer in people who have no symptoms of
the disease. Regular colorectal cancer screening is one of the most powerful ways to prevent
colorectal cancer.
From the time the first abnormal cells start to grow into polyps, it usually takes about 10 to 15
years for them to turn into colorectal cancer. With regular screening, most polyps can be found
and removed before they become cancer. Screening can also find colorectal cancer early, when it
is highly curable.
Its recommended that people who are not at increased risk of colorectal cancer start screening at
age 50. There are many screening tests available. People at higher risk, such as those with a
strong family history of colorectal cancer, might benefit from starting screening at a younger age.
If you have a family history or other risk factors for colorectal cancer, such as inflammatory
bowel disease, talk with your doctor about your risk and your screening options. (See our
screening guidelines in American Cancer Society recommendations for colorectal cancer early
detection.) You might also benefit from genetic counseling to look at your family medical tree
to see how likely it is that you have a family cancer syndrome.

Body weight, physical activity, and diet

You might be able to lower your risk of colorectal cancer by managing some of the risk factors
that you can control, like diet and physical activity.
Weight: Being overweight or obese increases the risk of colorectal cancer in both men and
women, but the link seems to be stronger in men. Having more belly fat (that is, a larger
waistline) has also been linked to colorectal cancer.
Physical activity: Increasing your level of activity can lower your risk of colorectal cancer and
polyps. Regular moderate activity (doing things that make you breathe as hard as you would
during a brisk walk) lowers the risk, but vigorous activity might have an even greater benefit.
Diet: Overall, diets that are high in vegetables, fruits, and whole grains (and low in red and
processed meats) have been linked with lower colorectal cancer risk, although its not exactly
clear which factors are important. Many studies have found a link between red meats (beef, pork,
and lamb) or processed meats (such as hot dogs, sausage, and lunch meats) and increased
colorectal cancer risk.
In recent years, some large studies have suggested that fiber in the diet, especially from whole
grains, may lower colorectal cancer risk. Research is still being done in this area.
Alcohol: Several studies have found a higher risk of colorectal cancer with increased alcohol
use, especially among men.
At this time, the best advice about diet and activity to possibly reduce your risk of colorectal
cancer is to:
Avoid obesity and weight gain around the midsection.
Increase the intensity and amount of your physical activity.
Limit red and processed meats.
Eat more vegetables and fruits.
Get the recommended levels of calcium and vitamin D (see below).
Avoid excess alcohol.
For more about diet and physical activity, see the American Cancer Society Guidelines on
Nutrition and Physical Activity for Cancer Prevention.

Not smoking
Long-term smoking is linked to an increased risk of colorectal cancer, as well as many other
cancers and health problems. If you smoke and would like help quitting, call the American
Cancer Society at 1-800-227-2345.

Vitamins, calcium, and magnesium

Some studies suggest that taking a daily multi-vitamin containing folic acid, or folate, may lower
colorectal cancer risk, but not all studies have found this. In fact, some studies have hinted that
folic acid might help existing tumors grow. More research is needed in this area.
Some studies have suggested that vitamin D, which you can get from being in the sun, in certain
foods, or in a vitamin pill, can lower colorectal cancer risk. Because of concerns that excess sun
exposure can cause skin cancer, most experts dont recommend this as a way to lower colorectal
cancer risk at this time.
Other studies suggest that increasing calcium in your diet may lower colorectal cancer risk.
Calcium is important for a number of health reasons aside from possible effects on cancer risk.
But because of the possible increased risk of prostate cancer in men who take in a lot of calcium,
the American Cancer Society doesnt recommend increasing calcium specifically to try to lower
cancer risk.
Calcium and vitamin D might work together to reduce colorectal cancer risk, because vitamin D
helps the body absorb calcium. Still, not all studies have found that supplements of these
nutrients reduce risk.
A few studies have found a possible link between a diet thats high in magnesium and reduced
colorectal cancer risk, especially among women. More research is needed to determine if this
link exists.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Many studies have found that people who regularly take aspirin and other non-steroidal antiinflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Advil) and naproxen (Aleve),
have a lower risk of colorectal cancer and polyps. Most of these studies looked at people who
took these medicines for reasons such as to treat arthritis or prevent heart attacks. Other studies
have provided strong evidence that aspirin can help prevent the growth of polyps in people who
were treated for early stages of colorectal cancer or had polyps removed in the past.
But aspirin and other NSAIDs can cause serious or even life-threatening side effects such as
bleeding from stomach irritation, which may outweigh the benefits of these medicines for the
general public. For this reason, most experts dont recommend taking NSAIDs just to lower
colorectal cancer risk if you are at average risk. But other possible benefits of aspirin, such as

lowering the chances of getting some types of heart disease, might outweigh the risks in certain
groups of people, such as those at higher risk for heart disease.
The value of these drugs for people at increased colorectal cancer risk is being studied.
Celecoxib (Celebrex) has been approved by the US Food and Drug Administration (FDA) for
reducing polyps in people with familial adenomatous polyposis (FAP). This drug may cause less
bleeding in the stomach than other NSAIDs, but it may increase the risk of heart attacks and
strokes.
Aspirin and other NSAIDs can have serious side effects, so check with your doctor before
starting to take any of them on a regular basis.

Menopausal hormone therapy for women

Taking estrogen and progesterone after menopause (sometimes called menopausal hormone
therapy or combined hormone replacement therapy) may reduce a womans risk of colorectal
cancer, but cancers found in women taking these hormones after menopause may be at a more
advanced stage.
Taking estrogen and progesterone after menopause also lowers the risk of osteoporosis (bone
thinning). But it can also increase a womans risk of heart disease, blood clots, and cancers of the
breast and lung.
If you are considering using menopausal hormone therapy, be sure to discuss the pros and cons
with your doctor.

Genetic testing, screening, and prevention for

people with a strong family history of colorectal
cancer
If you have a family history of colorectal polyps or cancer, you have a higher risk of getting
colorectal cancer yourself. This risk can be even higher in people with a strong family history of
colorectal cancer. While cancer in close (first-degree) relatives such as parents, brothers, and
sisters is most concerning, cancer in more distant relatives can also be important. Having 2 or
more relatives with colorectal cancer is more concerning than having only one relative with it.
Its also more concerning if your relatives were diagnosed with cancer at a younger age than
usual.
If you have a family history of colorectal cancer, talk with your doctor. You might benefit from
speaking with a genetic counselor or other health professional who is trained in genetic
counseling. They can review your family history to see how likely it is that you have a family
cancer syndrome. The counselor can also help you decide if genetic testing is right for you. If

you have testing and are found to have an abnormal gene, there might be steps you can take to
help lower your risk of colorectal cancer, such as getting screened at an early age or even having
surgery.
But before getting genetic testing, its important to know ahead of time what the results may or
may not tell you about your risk. Genetic testing is not perfect, and for some people the tests may
not provide clear answers. This is why meeting with a genetic counselor or cancer genetics
professional is important before deciding to be tested. To learn more about this, see Genetic
Testing: What You Need to Know.
Genetic tests can help show if members of certain families have inherited a high risk of
colorectal cancer due to inherited cancer syndromes such as Lynch syndrome (also known as
hereditary non-polyposis colorectal cancer, or HNPCC) or familial adenomatous polyposis
(FAP).
In families known to have one of these inherited syndromes, family members who decide not to
get tested are still usually advised to start being screened for colorectal cancer at an early age,
and to get screened more often. Family members who are tested and are found not to have the
mutated gene may be able to be screened at the same age and frequency as people at average
risk.

Testing for Lynch syndrome (hereditary non-polyposis colorectal

cancer, or HNPCC)
Lynch syndrome can greatly increase a persons risk for colorectal cancer. The lifetime risk of
colorectal cancer in people with this condition can range from about 10% to about 80%,
depending on which mutated gene is causing the syndrome.
People with Lynch syndrome are also at increased risk for some other cancers, such as cancers of
the uterus (endometrium), ovaries, stomach, small bowel, pancreas, kidneys, brain, ureters (tubes
that carry urine from the kidneys to the bladder), and bile duct.

Amsterdam criteria
Doctors have found that many families with Lynch syndrome tend to have certain characteristics,
which are known as the Amsterdam criteria:
At least 3 relatives have colorectal cancer (or another cancer linked with Lynch syndrome).
One is a first-degree relative (parent, sibling, or child) of the other 2 relatives.
At least 2 successive generations are involved.
At least 1 relative had their cancer when they were younger than age 50.

If all of these apply to your family, then you might want to seek genetic counseling. But even if
your family history satisfies the Amsterdam criteria, it doesnt always mean you have Lynch
syndrome. Only about half of families who meet the Amsterdam criteria have Lynch syndrome.
The other half do not, and although their colorectal cancer rate is about twice as high as normal,
its not as high as that of people with Lynch syndrome. On the other hand, many families with
Lynch syndrome do not meet the Amsterdam criteria.

Revised Bethesda guidelines

A second set of criteria, called the revised Bethesda guidelines, can be used to determine whether
a person with colorectal cancer should have his or her cancer tested for genetic changes that are
seen with Lynch syndrome. (These changes are called microsatellite instability or MSI.) These
criteria include at least one of the following:
The person is younger than 50 years.
The person has or had a second colorectal cancer or another cancer (endometrial, stomach,
pancreas, small intestine, ovary, kidney, brain, ureters, or bile duct) linked to Lynch
syndrome.
The person is younger than 60 years, and the cancer has certain characteristics seen with
Lynch syndrome when its viewed under a microscope.
The person has a first-degree relative (parent, sibling, or child) younger than 50 who was
diagnosed with colorectal cancer or another cancer linked to Lynch syndrome (endometrial,
stomach, pancreas, small intestine, ovary, kidney, brain, ureter, or bile duct).
The person has 2 or more first- or second-degree relatives (aunts, uncles, nieces, nephews, or
grandparents) who had colorectal cancer or another Lynch syndrome-related cancer at any
age.
If a person with colorectal cancer has any of the Bethesda criteria, testing for MSI may be
advised. If MSI is found, the doctor will recommend that the patient be tested for a Lynch
syndrome-associated gene mutation.
Its important to know that most people who meet the Bethesda criteria do not have Lynch
syndrome, and that you can have Lynch syndrome and not meet any of the criteria listed. Not all
doctors use the Bethesda guidelines to decide who should have MSI testing. In fact, some experts
recommend that all colorectal cancers be tested for MSI. Most doctors recommend genetic
testing for Lynch syndrome for anyone whose cancer tests positive for MSI.
Even if you dont have cancer, your doctor may suspect that Lynch syndrome runs in your
family based on cases of colorectal cancer and other cancers associated with this syndrome in
your relatives. In that case, your doctor may recommend genetic counseling to evaluate your
risk.

In families known to carry a Lynch syndrome gene mutation, doctors recommend that family
members who have tested positive for the mutation and those who have not been tested should
start colonoscopy screening during their early 20s to remove any polyps and find any cancers at
the earliest possible stage. (See the section American Cancer Society recommendations for
colorectal cancer early detection.) People known to carry one of the gene mutations may also be
offered the option of removal of most of the colon.

Testing for familial adenomatous polyposis (FAP)

FAP typically causes hundreds of polyps in the colon and rectum, which over time leads to
colorectal cancer. Because FAP causes polyps and cancer earlier than the usual age to start
colorectal cancer screening, sometimes FAP isnt diagnosed until the colon is examined in
someone who has cancer. If changes in the gene that causes FAP are found in one person,
doctors will recommend that his or her close relatives (brothers, sisters, and children) be tested.
FAP may also be suspected if a person is found to have many polyps during a colonoscopy that
was done because of problems like rectal bleeding or anemia.
Genetic counseling and testing is available for people who may have FAP based on their
personal or family history. Their lifetime risk of developing colorectal cancer is near 100%, and
in most cases it develops before the age of 40. People who test positive for the gene change
linked to FAP should start being screened with colonoscopy in their teens. (See American
Cancer Society recommendations for colorectal cancer early detection.) Most doctors
recommend that people with FAP have their colon removed when theyre in their 20s to prevent
cancer from developing.

Testing for other inherited cancer syndromes

Certain other inherited syndromes, such as MUTYH-associated polyposis and Peutz-Jeghers
syndrome, can also greatly increase a persons risk of colorectal cancer. If you have certain
criteria that suggest you might have one of the syndromes, your doctor might suggest genetic
counseling and testing to look for the gene changes that cause them.

Signs and symptoms of colorectal cancer

Early colorectal cancers may not cause any symptoms. This is why screening is recommended
for most people, starting at age 50.
If colorectal cancer does cause symptoms, they may include:
A change in bowel habits, such as diarrhea, constipation, or narrowing of the stool, that lasts
for more than a few days
A feeling that you need to have a bowel movement that doesnt go away when you do so

 Rectal bleeding
Blood in the stool, which may make it look dark
Cramping or abdominal (belly) pain
Weakness and fatigue
Unintended weight loss
Colorectal cancers can often bleed into the digestive tract. While sometimes you can see blood in
the stool or it looks darker, often the stool looks normal. But over time, the blood loss can build
up and can lead to low red blood cell counts (anemia). Sometimes the first sign of colorectal
cancer is a blood test showing a low red blood cell count.
Most of these problems are more often caused by conditions other than colorectal cancer, such as
infection, hemorrhoids, or irritable bowel syndrome. Still, if you have any of these problems, its
important to see a doctor right away so the cause can be found and treated, if needed.

Colorectal cancer screening tests

Screening is the process of looking for cancer in people who have no symptoms of the disease.
Several tests can be used to screen for colorectal cancers. These tests can be divided into:
Tests that can find both colorectal polyps and cancer: These tests look at the structure of
the colon itself to find any abnormal areas. This is done either with a scope put into the
rectum or with special imaging (x-ray) tests. Polyps found during these tests can be removed
before they become cancerous, so these tests may prevent colorectal cancer. Because of this,
these tests are preferred if they are available and you are willing to have them.
Tests that mainly find cancer: These tests check the stool (feces) for signs of cancer. These
tests are less invasive and easier to have done, but they are less likely to detect polyps.
These tests as well as others also can be used when people have symptoms of colorectal cancer
and other digestive diseases.

Tests that can find both colorectal polyps and cancer

Flexible sigmoidoscopy
During this test, the doctor looks at part of the colon and rectum with a sigmoidoscope a
flexible, lighted tube about the thickness of a finger with a small video camera on the end. Its
put in through the rectum and moved into the lower part of the colon. Images from the scope are
seen on a display monitor.

Using the sigmoidoscope, your doctor can look at the inside of the rectum and part of the colon
to detect (and possibly remove) any abnormality. The sigmoidoscope is only 60 centimeters
(about 2 feet) long, so the doctor is able to see the entire rectum but less than half of the colon
with this procedure.
Before the test: Be sure your doctor knows about any medicines you are taking. You might need
to change how you take them before the test. Your colon and rectum must be empty and clean so
your doctor can see the lining of the sigmoid colon and rectum. You will get specific instructions
to follow to clean them out. You may be asked to follow a special diet (such as drinking only
clear liquids) for a day before the test. You may also be asked to use enemas or to use strong
laxatives to clean out your colon before the test. Be sure to tell your doctor about any medicines
you are taking, as you might need to change how you take them before the test.
During the test: A sigmoidoscopy usually takes about 10 to 20 minutes. Most people dont need
to be sedated for this test, but this might be an option you can discuss with your doctor. Sedation
may make the test less uncomfortable, but youll need some time to recover from it and youll
need someone with you to take you home after the test.
Youll probably be asked to lie on a table on your left side with your knees pulled up near your
chest. Before the test, your doctor may put a gloved, lubricated finger into your rectum to
examine it. For the test itself, the sigmoidoscope is first lubricated to make it easier to insert into
the rectum. The scope may feel cold as its put in. Air will be pumped into the colon through the
sigmoidoscope so the doctor can see the walls of the colon better.
During the procedure, you might feel pressure and slight cramping in your lower belly. To ease
discomfort and the urge to have a bowel movement, it helps to breathe deeply and slowly
through your mouth. Youll feel better after the test once the air leaves your colon.
If a small polyp is found during the test, the doctor may remove it with a small instrument passed
through the scope. The polyp will be sent to a lab to be looked at. If a pre-cancerous polyp (an
adenoma) or colorectal cancer is found, youll need to have a colonoscopy later to look for
polyps or cancer in the rest of the colon.
Possible complications and side effects: This test may be uncomfortable because of the air put
into the colon, but it should not be painful. Be sure to let your doctor know if you feel pain
during the procedure. You might see a small amount of blood in your first bowel movement after
the test. More serious bleeding and puncture of the colon are possible complications, but they are
very uncommon.

Colonoscopy
For this test, the doctor looks at the entire length of the colon and rectum with a colonoscope, a
thin, flexible, lighted tube with a small video camera on the end. Its basically a longer version of
a sigmoidoscope. Its put in through the anus and into the rectum and colon. Special instruments

can be passed through the colonoscope to biopsy (sample) or remove any suspicious-looking
areas such as polyps, if needed.
Colonoscopy may be done in a hospital outpatient department, in a clinic, or in a doctors office.
Before the test: Be sure your doctor knows about any medicines you are taking. You might need
to change how you take them before the test. The colon and rectum must be empty and clean so
your doctor can see their inner linings during the test. This can be done many ways, but the most
common involves drinking large amounts of a liquid laxative the evening before and the morning
of the procedure. This leads to spending a lot of time in the bathroom.
Your doctor will give you specific instructions. Its important to read these carefully a few days
ahead of time, since you may need to follow a special diet for at least a day before the test and to
shop for supplies and laxatives. If youre not sure about any of the instructions, call the doctors
office and go over them with the nurse.
You will probably also be told not to eat or drink anything after midnight the night before your
test. If you normally take prescription medicines in the mornings, talk with your doctor or nurse
about how to manage them for the day.
Because a sedative is used during the test, youll need to arrange for someone you know to take
you home from the test (not just a cab or Uber).
During the test: The test itself usually takes about 30 minutes, but it may take longer if a polyp
is found and removed. Before it starts, youll be given a sedating medicine (into a vein) to make
you feel relaxed and sleepy during the procedure. For most people, this medicine makes them
unaware of whats going on and unable to remember the procedure afterward. Youll wake up
after the test is over, but might not be fully awake until later in the day.
During the test, youll be asked to lie on your side with your knees pulled up. A drape will cover
you. Your blood pressure, heart rate, and breathing rate will be monitored during and after the
test.
Your doctor might insert a gloved finger into the rectum to examine it before putting in the
colonoscope. The colonoscope is lubricated so it can be inserted easily into the rectum. Once in
the rectum, the colonoscope is passed all the way to the beginning of the colon, called the cecum.
If youre awake, you may feel an urge to have a bowel movement when the colonoscope is
inserted or pushed further up the colon. The doctor also puts air into the colon through the
colonoscope to make it easier to see the lining of the colon and use the instruments to perform
the test. To ease any discomfort, it may help to breathe deeply and slowly through your mouth.
The doctor will look at the inner walls of the colon as he or she slowly removes the colonoscope.
If a small polyp is found, it may be removed. This is because some small polyps may become
cancer over time. Removing the polyp is usually done by passing a wire loop through the

colonoscope to cut the polyp from the wall of the colon with an electric current. The polyp is
then sent to a lab to be checked to see if it has any areas that have changed into cancer.
If your doctor sees a larger polyp or tumor or anything else abnormal, a biopsy may be done. A
small piece of tissue is taken out through the colonoscope. The tissue is checked in the lab to see
if its cancer, a benign (non-cancerous) growth, or a result of inflammation.
Possible side effects and complications: The bowel preparation before the test is unpleasant.
The test itself might be uncomfortable, but the sedative usually helps with this, and most people
feel normal once the effects of the sedative wear off. Because air is pumped into the colon during
the test, people sometimes feel bloated, have gas pains, or have cramping for a while after the
test until the air passes out.
Some people may have low blood pressure or changes in heart rhythm due to the sedation during
the test, but these are rarely serious.
If a polyp is removed or a biopsy is done during the colonoscopy, you might notice some blood
in your stool for a day or 2 after the test. Serious bleeding is uncommon, but in rare cases,
bleeding might need to be treated or can even be life-threatening.
Colonoscopy is a safe procedure, but in rare cases the colonoscope can puncture the wall of the
colon or rectum. This is called a perforation. Symptoms can include severe abdominal (belly)
pain, nausea, and vomiting. This can be a major (or even life-threatening) complication, because
it can lead to a serious abdominal (belly) infection. The hole may need to be repaired with
surgery. Ask your doctor about the risk of this complication.
You can read more about colonoscopy and sigmoidoscopy in Frequently Asked Questions About
Colonoscopy and Sigmoidoscopy.

Double-contrast barium enema (DCBE)

This test is also called an air-contrast barium enema or a barium enema with air contrast. It may
also be called a lower GI series. Its basically a type of x-ray test. Barium sulfate, which is a
chalky liquid, and air are put into the colon and rectum to outline the inner lining. This can show
abnormal areas on x-rays. If suspicious areas are seen on this test, a colonoscopy will be needed
to explore them further.
Before the test: Its very important that the colon and rectum are empty and clean so they can be
seen during the test. Youll be given specific instructions on how to prepare for the test. For
example, you may be asked to clean your bowel the night before with laxatives and/or take
enemas the morning of the exam. Youll probably be asked to follow a clear liquid diet for at
least a day before the test. You may also be told to avoid eating or drinking dairy products the
day before the test, and to not eat or drink anything after midnight on the night before the test.

During the test: The test takes about 30 to 45 minutes, and sedation isnt needed. You lie on a
table on your side in an x-ray room. A small, flexible tube is put into your rectum, and barium
sulfate is pumped in to partially fill and open up the colon and rectum. You are then turned on
the x-ray table so the barium moves throughout the colon and rectum. Then air is pumped into
the colon and rectum through the same tube to expand them. This might cause some cramping
and discomfort, and you may feel the urge to have a bowel movement.
X-ray pictures of the lining of your colon and rectum are then taken to look for polyps or
cancers. You may be asked to change positions to help move the barium and so that different
views of the colon and rectum can be seen on the x-rays.
If polyps or other suspicious areas are seen on this test, youll probably need a colonoscopy to
remove them or to explore them fully.
Possible side effects and complications: You may have bloating or cramping after the test, and
will probably feel the need to empty your bowels soon after the test is done. The barium can
cause constipation for a few days, and your stool may look grey or white until all the barium is
out. Theres a very small risk that inflating the colon with air could injure or puncture it, but this
risk is thought to be much less than with colonoscopy. Like other x-ray tests, this test also
exposes you to a small amount of radiation.

CT colonography (virtual colonoscopy)

This test is an advanced type of computed tomography (CT or CAT) scan of the colon and
rectum. A CT scan uses x-rays to make detailed cross-sectional images of your body. Instead of
taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you
while you lie on a table. A computer then combines these pictures into images of slices of the
part of your body being studied.
For CT colonography, special computer programs create both 2-dimensional x-ray pictures and a
3-dimensional fly-through view of the inside of the colon and rectum, which lets the doctor
look for polyps or cancer.
This test may be especially useful for some people who cant have or dont want to have more
invasive tests such as colonoscopy. It can be done fairly quickly, and sedation isnt needed. But
even though this test is not invasive like colonoscopy, the same type of bowel prep is needed.
Also, a small, flexible tube is put in the rectum to fill the colon with air. Another possible
drawback is that if polyps or other suspicious areas are seen on this test, a colonoscopy will still
probably be needed to remove them or to explore them fully.
Before the test: Its important that the colon and rectum are emptied before this test to get the
best images. Youll probably be told to follow a clear liquid diet for at least a day before the test.
There are a number of ways to clean out the colon before the test. Often, the evening before the
procedure, you drink large amounts of a liquid laxative solution. This often results in spending a

lot of time in the bathroom. The morning of the test, sometimes more laxatives or enemas may
be needed to make sure the bowels are empty.
During the test: This test is done in a special room with a CT scanner. It takes about 10 minutes.
You may be asked to drink a contrast solution before the test to help tag any stool left in the
colon or rectum, which helps the doctor when looking at the test images. Youll be asked to lie
on a thin table thats part of the CT scanner, and will have a small, flexible tube put into your
rectum. Air is pumped through the tube into the colon and rectum to expand them to provide
better images. The table then slides into the CT scanner, and youll be asked to hold your breath
while the scan is done. Youll likely have 2 scans: one while youre lying on your back and one
while youre on your stomach. Each scan usually takes only about 10 to 15 seconds.
Possible side effects and complications: There are usually few side effects after this test. You
may feel bloated or have cramps because of the air in the colon and rectum, but this should go
away once the air passes from the body. Theres a very small risk that inflating the colon with air
could injure or puncture it, but this risk is thought to be much less than with colonoscopy. Like
other types of CT scans, this test also exposes you to a small amount of radiation.

Tests that mainly find colorectal cancer

These tests look at the stool (feces) for signs of cancer. Most people find these tests easier to
have than tests like colonoscopy, and these tests can often be done at home. But these tests arent
as good at finding polyps as tests like colonoscopy. And if the result from one of these stool tests
is positive (abnormal), youll probably still need a colonoscopy to see if you have cancer.

Guaiac-based fecal occult blood test (gFOBT)

One way to test for colorectal cancer is to look for occult (hidden) blood in stool. The idea
behind this test is that blood vessels in larger colorectal polyps or cancers are often fragile and
easily damaged by the passage of feces. The damaged vessels usually bleed into the feces, but
only rarely is there enough bleeding for blood to be seen in the stool.
The guaiac-based fecal occult blood test (gFOBT) detects blood in the stool through a chemical
reaction. This test cant tell if the blood is from the colon or from other parts of the digestive
tract (such as the stomach). If this test is positive, a colonoscopy will be needed to find the
reason for the bleeding. Although blood in the stool can be from cancers or polyps, it can also
have other causes, such as ulcers, hemorrhoids, diverticulosis (tiny pouches that form at weak
spots in the colon wall), or inflammatory bowel disease (colitis).
Over time, this test has improved so that its now more likely to find colorectal cancer. The
American Cancer Society recommends the more modern, highly sensitive versions of this test
for screening.

This test is done with a kit that you can use in the privacy of your own home that allows you to
check more than one stool sample. A FOBT done during a digital rectal exam in the doctors
office (which only checks one stool sample) is not sufficient for screening. Also, unlike some
other tests (like colonoscopy), this test must be done every year.
People having this test will get a kit with instructions from their doctors office or clinic. The kit
will explain how to take stool samples at home (usually samples from 3 consecutive bowel
movements are smeared onto small squares of paper). The kit is then returned to the doctors
office or medical lab (usually within 2 weeks) for testing.
Before the test: Some foods or drugs can affect the results, so you may be instructed to avoid
the following before this test:
Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil), naproxen
(Aleve), or aspirin (more than 1 adult aspirin per day), for 7 days before testing. (They can
cause bleeding, which can lead to a false-positive result.) Acetaminophen (Tylenol) can be
taken as needed. Note: People should try to avoid taking NSAIDs for minor aches. But if you
take these medicines daily for heart problems or other conditions, dont stop them for this test
without talking to your doctor first.
Vitamin C in excess of 250 mg daily from either supplements or citrus fruits and juices for 3
days before testing. (This can affect the chemicals in the test and make the result negative,
even if blood is present.)
Red meats (beef, lamb, or liver) for 3 days before testing. (Components of blood in the meat
may cause a positive test result.)
Some people who are given the test never do it or dont return it because they worry that
something they ate may affect the test. For this reason, many doctors tell their patients its not
critical that they follow the diet restrictions. The most important thing is to get the test done.
Collecting the samples: Have all of your supplies ready and in one place. Supplies typically
include a test kit, test cards, either a brush or wooden applicator, and a mailing envelope. The kit
will give you detailed instructions on how to collect the stool samples. Be sure to follow the
instructions that come with your kit, as different kits might have different instructions. If
you have any questions about how to use your kit, contact your doctors office or clinic. Once
you have collected the samples, return them as instructed in the kit.
If this test finds blood, a colonoscopy will be needed to look for the source. Its not enough to
simply repeat the gFOBT or follow up with other types of tests.

Fecal immunochemical test (FIT)

The fecal immunochemical test (FIT) is also called an immunochemical fecal occult blood test
(iFOBT). It tests for occult (hidden) blood in the stool in a different way than a guaiac-based

FOBT. This test reacts to part of the human hemoglobin protein, which is found in red blood
cells.
Early versions of this test were not as good at finding colorectal cancers. Highly sensitive
versions, which the American Cancer Society recommends for screening, have been around for
at least 10 years.
The FIT is done much like the gFOBT, in that small amounts of stool are collected on cards (or
in tubes). Some people may find this test easier because there are no drug or dietary restrictions
(vitamins and foods do not affect the FIT), and collecting the sample may be easier. This test is
also less likely to react to bleeding from other parts of digestive tract, such as the stomach.
Like the gFOBT, the FIT may not detect a tumor thats not bleeding, so multiple stool samples
should be tested. And if the results are positive for hidden blood, a colonoscopy will be needed
to investigate further. This test must be done every year.
Collecting the samples: Have all of your supplies ready and in one place. Supplies typically
include a test kit, test cards or tubes, long brushes or other collecting devices, waste bags, and a
mailing envelope. The kit will give you detailed instructions on how to collect the samples. Be
sure to follow the instructions that come with your kit, as different kits might have
different instructions. If you have any questions about how to use your kit, contact your
doctors office or clinic. Once you have collected the samples, return them as instructed in the
kit.

Stool DNA test

A stool DNA test looks for certain abnormal sections of DNA (genetic material) from cancer or
polyp cells. Colorectal cancer cells often have DNA mutations (changes) in certain genes. Cells
from colorectal cancers or polyps with these mutations often get into the stool, where tests may
be able to detect them. Cologuard, the test currently available, also tests for blood in the stool.
Collecting the samples: Youll get a kit in the mail to use to collect your entire stool sample.
The kit will have a sample container, a bracket for holding the container in the toilet, a bottle of
liquid preservative, a tube, labels, and a shipping box. The kit contains detailed instructions on
how to collect the sample. Be sure to follow the instructions that come with your kit. If you
have any questions about how to use your kit, contact your doctors office or clinic. Once you
have collected the sample, return it as instructed in the kit.
This test should be done every 3 years. If the test is positive (if it finds DNA changes or blood), a
colonoscopy will be needed.

What are some of the pros and cons of these screening tests?
Test

Pros

Cons

Flexible sigmoidoscopy

Fairly quick and safe

Looks at only about a third of the colon

Usually doesnt require full bowel

prep

Can miss small polyps

Sedation usually not used

May be some discomfort

Does not require a specialist

Done every 5 years

Cant remove all polyps

Very small risk of bleeding, infection, or
bowel tear
Colonoscopy will be needed if abnormal

Colonoscopy

Can usually look at the entire colon

Can miss small polyps

Can biopsy and remove polyps

Full bowel prep needed

Done every 10 years

Costs more on a one-time basis than other

forms of testing

Can help find some other diseases

Sedation is usually needed

You will need someone to drive you home
You may miss a day of work
Small risk of bleeding, bowel tears, or
infection
Double-contrast barium
enema (DCBE)

Can usually see the entire colon

Can miss small polyps

Relatively safe

Full bowel prep needed

Done every 5 years

Some false positive test results

No sedation needed

Cant remove polyps during testing

Colonoscopy will be needed if abnormal

CT colonography (virtual
colonoscopy)

Fairly quick and safe

Can miss small polyps

Can usually see the entire colon

Full bowel prep needed

Done every 5 years

Some false positive test results

No sedation needed

Cant remove polyps during testing

Colonoscopy will be needed if abnormal
Still fairly new may be insurance issues

Guaiac-based fecal occult

blood test (gFOBT)

No direct risk to the colon

Can miss many polyps and some cancers

No bowel prep

Can produce false-positive test results

Sampling done at home

Pre-test diet changes are needed

Inexpensive

Needs to be done every year

Colonoscopy will be needed if abnormal

Fecal immunochemical test

(FIT)

No direct risk to the colon

Can miss many polyps and some cancers

No bowel prep

Can produce false-positive test results

No pre-test diet changes

Needs to be done every year

Sampling done at home

Colonoscopy will be needed if abnormal

Fairly inexpensive
Stool DNA test

No direct risk to the colon

Can miss many polyps and some cancers

No bowel prep

Can produce false-positive test results

No pre-test diet changes

Should be done every 3 years

Sampling done at home

Colonoscopy will be needed if abnormal

Still fairly new may be insurance issues

American Cancer Society recommendations for

colorectal cancer early detection
People at average risk
The American Cancer Society believes that preventing colorectal cancer (and not just finding it
early) should be a major reason for getting tested. Having polyps found and removed keeps some
people from getting colorectal cancer. Tests that have the best chance of finding both polyps and
cancer are preferred if these tests are available to you and you are willing to have them.
Starting at age 50, men and women at average risk for developing colorectal cancer should use
one of the screening tests below:

Tests that find polyps and cancer

Flexible sigmoidoscopy every 5 years*
Colonoscopy every 10 years
Double-contrast barium enema every 5 years*
CT colonography (virtual colonoscopy) every 5 years*

Tests that mainly find cancer

Guaiac-based fecal occult blood test (gFOBT) every year*,**
Fecal immunochemical test (FIT) every year*,**
Stool DNA test every 3 years*

*Colonoscopy should be done if test results are positive.

** Highly sensitive versions of these tests should be used with the take-home multiple sample method. A gFOBT or
FIT done during a digital rectal exam in the doctors office is not enough for screening.

Is a rectal exam enough to screen for colorectal cancer?

In a digital rectal examination (DRE), a health care provider examines your rectum with a
lubricated, gloved finger. Although a DRE is often included as part of a routine physical exam,
its not recommended as a stand-alone test for colorectal cancer. This simple test, which is not
usually painful, can find masses in the anal canal or lower rectum. But by itself, its not a good
test for detecting colorectal cancer because it only checks the lower rectum.
Doctors often find a small amount of stool in the rectum when doing a DRE. But testing this
stool for blood with a gFOBT or FIT is not an acceptable way to screen for colorectal cancer.
Research has shown that this type of stool exam will miss more than 90% of colon abnormalities,
including most cancers.

People at increased or high risk

If you are at an increased or high risk of colorectal cancer, you might need to start colorectal
cancer screening before age 50 and/or be screened more often. The following conditions make
your risk higher than average:
A personal history of colorectal cancer or adenomatous polyps
A personal history of inflammatory bowel disease (ulcerative colitis or Crohns disease)
A strong family history of colorectal cancer or polyps (see Colorectal cancer risk factors)
A known family history of a hereditary colorectal cancer syndrome such as familial
adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or
HNPCC)
The table below suggests screening guidelines for people with increased or high risk of
colorectal cancer based on specific risk factors. Some people may have more than one risk
factor. Refer to the table below and discuss these recommendations with your health care
provider. Your provider can suggest the best screening option for you, as well as any changes in
the schedule based on your individual risk.

American Cancer Society Guidelines on Screening and Surveillance for the Early
Detection of Colorectal Adenomas and Cancer in People at Increased Risk or High Risk
INCREASED RISK People who have a history of polyps on prior colonoscopy
Risk category

When to test

Recommended
test(s)

Comment

People with small

rectal hyperplastic
polyps

Same age as those

at average risk

Colonoscopy, or
other screening
options at same
intervals as for
those at average
risk

Those with hyperplastic

polyposis syndrome are at
increased risk for
adenomatous polyps and
cancer and should have more
intensive follow-up.

Colonoscopy

Time between tests should be

based on other factors such as
prior colonoscopy findings,
family history, and patient
and doctor preferences.

People with 1 or 2
5 to 10 years after
small (less than 1 cm) the polyps are
tubular adenomas with removed
low-grade dysplasia
People with 3 to 10
adenomas, or a large
(at least 1 cm)
adenoma, or any
adenomas with highgrade dysplasia or
villous features

3 years after the

Colonoscopy
polyps are removed

Adenomas must have been

completely removed. If
colonoscopy is normal or
shows only 1 or 2 small
tubular adenomas with lowgrade dysplasia, future
colonoscopies can be done
every 5 years.

People with more than Within 3 years after Colonoscopy

10 adenomas on a
the polyps are
single exam
removed

Doctor should consider

possible genetic syndrome
(such as FAP or Lynch
syndrome).

People with sessile

adenomas that are
removed in pieces

If entire adenoma has been

removed, further testing
should be based on doctors
judgment.

2 to 6 months after Colonoscopy

adenoma removal

INCREASED RISK People who have had colorectal cancer

Risk category

When to test

People diagnosed with At time of

colon or rectal cancer colorectal surgery,
or can be 3 to 6
months later if
person doesnt
have cancer spread
that cant be
removed
People who have had
colon or rectal cancer
removed by surgery

Recommended
test(s)

Comment

Colonoscopy to
look at the entire
colon and remove
all polyps

If the tumor presses on the

colon/rectum and prevents
colonoscopy, CT
colonoscopy (with IV
contrast) or DCBE may be
done to look at the rest of the
colon.

Within 1 year after Colonoscopy

cancer resection (or
1 year after
colonoscopy to
make sure the rest
of the colon/rectum
was clear)

If normal, repeat in 3 years.

If normal then, repeat test
every 5 years. Time between
tests may be shorter if polyps
are found or theres reason to
suspect Lynch syndrome.
After low anterior resection
for rectal cancer, exams of
the rectum may be done
every 3 to 6 months for the
first 2 to 3 years to look for
signs of recurrence.

INCREASED RISK People with a family history

Risk Category

Age to start
testing

Colorectal cancer or
adenomatous polyps in
any first-degree
relative before age 60,
or in 2 or more firstdegree relatives at any
age (if not a hereditary
syndrome).

Age 40, or 10 years Colonoscopy

before the youngest
case in the
immediate family,
whichever is earlier

Colorectal cancer or
Age 40
adenomatous polyps in
any first-degree

Recommended
test(s)

Same options as
for those at

Comment
Every 5 years.

Same intervals as for those at

average risk.

relative aged 60 or
older, or in at least 2
second-degree relatives
at any age

average risk.

HIGH RISK
Risk category

Age to start
testing

Recommended
test(s)

Familial adenomatous
polyposis (FAP)
diagnosed by genetic
testing, or suspected
FAP without genetic
testing

Age 10 to 12

Yearly flexible
If genetic test is positive,
sigmoidoscopy to removal of colon (colectomy)
look for signs of should be considered.
FAP; counseling
to consider
genetic testing if it
hasnt been done

Lynch syndrome
(hereditary nonpolyposis colon
cancer or HNPCC), or
at increased risk of
Lynch syndrome based
on family history
without genetic testing

Age 20 to 25 years,
or 10 years before
the youngest case
in the immediate
family

Colonoscopy
every 1 to 2 years;
counseling to
consider genetic
testing if it hasnt
been done

Genetic testing should be

offered to first-degree
relatives of people found to
have Lynch syndrome
mutations by genetic tests. It
should also be offered if 1 of
the first 3 of the modified
Bethesda criteria is met.*

Inflammatory bowel
disease:

Cancer risk begins

to be significant 8
years after the
onset of pancolitis
(involvement of
entire large
intestine), or 12-15
years after the
onset of left-sided
colitis

Colonoscopy
every 1 to 2 years
with biopsies for
dysplasia

These people are best

referred to a center with
experience in the surveillance
and management of
inflammatory bowel disease.

-Chronic ulcerative
colitis
-Crohns disease

Comment

The Bethesda criteria can be found in Genetic testing, screening, and prevention for people with a strong family
history of colorectal cancer.

Colorectal cancer screening: Insurance coverage

The American Cancer Society believes that all people should have access to cancer screenings,
without regard to health insurance coverage. Limitations on coverage should not keep someone
from the benefits of early detection of cancer. The Society supports policies that give all people
access to and coverage of early detection tests for cancer. Such policies should be age- and riskappropriate and based on current scientific evidence as outlined in the American Cancer
Societys early detection guidelines.

Federal law
Coverage of colorectal cancer screening tests is required by the Affordable Care Act (ACA), but
the ACA doesnt apply to health plans that were in place before it was passed (called
grandfathered plans). You can find out your insurance plans grandfathered status by
contacting your health insurance company or your employers human resources department. If
your plan started on or after September 23, 2010, it must cover colonoscopies and other
colorectal cancer screening tests. If a plan started before September 23, 2010, it may still have
coverage requirements from state laws, which vary, and other federal laws.

Private health insurance coverage for colorectal cancer screening

The Affordable Care Act requires health plans that started on or after September 23, 2010 to
cover colorectal cancer screening tests.
Although many private insurance plans cover the costs for colonoscopy as a screening test, you
still might be charged for some services. Review your health insurance plan for specific details,
including if your doctor is on your insurance companys list of in-network providers. If the
doctor is not in the plans network, you may have to pay more out-of-pocket.
Colonoscopies that are done to evaluate specific problems, such as belly (abdominal) pain,
intestinal bleeding, or low red blood cell counts (anemia), are usually classified as diagnostic
and not screening procedures. If thats the case, you may have to pay any required deductible
and co-pay. The same is true if colonoscopy is done after a positive stool test (such as the
gFOBT or FIT) or an abnormal double-contrast barium enema or CT colonography. Some
insurance plans also consider a colonoscopy diagnostic if something is found (like a polyp)
during the procedure that needs to be removed or biopsied.
Before you get a screening colonoscopy, ask your insurance company how much (if anything)
you should expect to pay for it. Find out if this amount could change based on whats found
during the test. This can help you avoid surprise costs. If you do have large bills afterward, you
may be able to appeal the insurance companys decision.

Medicare coverage for colorectal cancer screening

Medicare covers an initial preventive physical exam for all new Medicare beneficiaries. It must
be done within one year of enrolling in Medicare. The Welcome to Medicare physical includes
referrals for preventive services already covered under Medicare, including colon cancer
screening tests.
If youve had Medicare Part B for longer than 12 months, a yearly wellness visit is covered
without any cost. This visit is used to develop or update a personalized prevention plan to
prevent disease and disability. Your provider should discuss a screening schedule (like a
checklist) with you for preventive services you should have, including colon cancer screening.

What colorectal cancer screening tests does Medicare cover?

Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year for all
Medicare beneficiaries 50 years and older.
Stool DNA test (Cologuard) every 3 years for Medicare beneficiaries 50 to 85 years old who do
not have symptoms of colorectal cancer and who do not have an increased risk of colorectal
cancer.
Flexible sigmoidoscopy every 4 years for those 50 years and older, but not within 10 years of a
previous colonoscopy.
Colonoscopy
Every 2 years for those at high risk (regardless of age)
Every 10 years for those who are at average risk
4 years after a flexible sigmoidoscopy for those who are at average risk
Double-contrast barium enema if a doctor determines that its screening value is equal to or
better than flexible sigmoidoscopy or colonoscopy:
Once every 2 years for those 50 years and older who are at high risk
Once every 4 years for those 50 years and older who are at average risk
At this time, Medicare does not cover the cost of virtual colonoscopy (CT colonography).
If you have questions about your costs, including deductibles or co-pays, its best to speak with
your insurance company.

What would a Medicare beneficiary expect to pay for a colorectal cancer

screening test?
FOBT/FIT: Covered at no cost* for those age 50 years or older (no co-insurance or Part B
deductible).
Stool DNA test (Cologuard): Covered at no cost* for those age 50 to 85 as long as they are
not at increased risk of colorectal cancer and dont have symptoms of colorectal cancer (no
co-insurance or Part B deductible).
Flexible sigmoidoscopy: Covered at no cost* for those age 50 or older (no co-insurance, copayment, or Part B deductible) when the test is done for screening. If the test results in the
biopsy or removal of a growth, its no longer a screening test, and you will be charged coinsurance and/or a co-pay (although your deductible is waived).
Colonoscopy: Covered at no cost* at any age (no co-insurance, co-payment, or Part B
deductible) when the test is done for screening. If the test results in the biopsy or removal of
a growth its no longer a screening test, and you will be charged co-insurance and/or a copay (although you still dont have to pay the deductible).
Double-contrast barium enema: Beneficiary pays 20% of the Medicare approved amount
for the doctor services. If the test is done in an outpatient hospital department or ambulatory
surgical center, the beneficiary also pays the hospital co-payment.
If youre getting a screening colonoscopy, be sure to find out how much you might have to pay
for it. This can help you avoid surprise costs. Patients may still have to pay for the bowel prep
kit, anesthesia or sedation, pathology costs, and facility fee. Patients may get one or more bills
for different parts of the procedure from different practices and hospital providers. Tests
including colonoscopy are not classified by Medicare as screening procedures if they are done to
evaluate specific problems, such as belly (abdominal) pain, intestinal bleeding, or low red blood
cell counts (anemia). If you are getting a test for such a reason, you may have to pay the usual
deductible and co-pay.
*This service is covered at no cost as long as the doctor accepts assignment (the amount Medicare pays as the full
payment). Doctors that do not accept assignment are required to tell you up front.

Medicaid coverage for colorectal cancer screening

States are authorized to cover colorectal screening under their Medicaid programs. But unlike
Medicare, theres no federal assurance that all state Medicaid programs must cover colorectal
cancer screening in people without symptoms. Medicaid coverage for colorectal cancer screening
varies by state. Some states cover fecal occult blood testing (FOBT), while others cover
colorectal cancer screening if a doctor determines the test to be medically necessary. In some
states, coverage varies according to which Medicaid managed care plan a person is enrolled in.

Additional resources
More information from your American Cancer Society
We have a lot more information that you might find helpful. Explore www.cancer.org or call our
National Cancer Information Center toll-free number, 1-800-227-2345. Were here to help you
any time, day or night.

Other national organizations and websites*

Along with the American Cancer Society, other sources of information and support include:
American College of Gastroenterology
Website: www.acg.gi.org
American Gastroenterological Association
Website: www.gastro.org
American Society of Colon and Rectal Surgeons
Website: www.fascrs.org
C3: Colorectal Cancer Coalition
Toll-free number: 1-877-427-2111 (1-877-4CRC-111)
Website: www.fightcolorectalcancer.org
Centers for Medicare & Medicaid Services
Toll-free number: 1-800-633-4227 (1-800-MEDICARE)
Website: www.cms.hhs.gov
Colon Cancer Alliance
Toll-free number: 1-877-422-2030
Website: www.ccalliance.org
National Colorectal Cancer Research Alliance
Website: www.eifoundation.org/programs/eifs-national-colorectal-cancer-research-alliance
*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are, we can help. Contact us anytime, day or night, for information and
support. Call us at 1-800-227-2345 or visit www.cancer.org.

References: Colorectal cancer prevention and

early detection
American Cancer Society. Cancer Facts & Figures 2016. Atlanta, Ga: American Cancer
Society; 2016.
American Cancer Society. Colorectal Cancer Facts & Figures 2014-2016. Atlanta, Ga:
American Cancer Society; 2014.
American Cancer Society. Detailed Guide: Colon and Rectum Cancer. 2016. Accessed at
www.cancer.org/Cancer/ColonandRectumCancer/DetailedGuide/index.
Aune D, Chan DS, Lau R, et al. Dietary fibre, whole grains, and risk of colorectal cancer:
Systematic review and dose-response meta-analysis of prospective studies. BMJ.
2011;343:d6617.
Frazier AL, Colditz GA, Fuchs CS, Kuntz KM. Cost-effectiveness of screening for colorectal
cancer in the general population. JAMA. 2000;284:1954-1961.
Hawk ET, Levin B. Colorectal cancer prevention. J Clin Oncol. 2005;23:378-388.
Hendriks YM, deJong AE, Morreau H, et al. Diagnostic approach and management of Lynch
syndrome (hereditary nonpolyposis colorectal carcinoma): A guide for clinicians. CA Cancer J
Clin. 2006;56:213-225.
Kelloff GJ, Schilsky RL, Alberts DS, et al. Colorectal adenomas: A prototype for the use of
surrogate end points in the development of cancer prevention drugs. Clin Cancer Res.
2004;10:3908-3918.
Kushi LH, Doyle C, McCullough M, et al. American Cancer Society Guidelines on nutrition and
physical activity for cancer prevention: Reducing the risk of cancer with healthy food choices
and physical activity. CA Cancer J Clin. 2012;62:30-67.
Levin B, Lieberman DA, McFarland, et al. Screening and surveillance for the early detection of
colorectal cancer and adenomatous polyps, 2008: A joint guideline from the American Cancer
Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of
Radiology. CA Cancer J Clin. 2008;58:130-160.
National Cancer Institute. Physician Data Query (PDQ). Colorectal Cancer Screening. 2015.
Accessed at www.cancer.gov/types/colorectal/hp/colorectal-screening-pdq on October 7, 2015.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology:
Genetic/Familial High-Risk Assessment: Colorectal. V.1.2015. Accessed at
www.nccn.org/professionals/physician_gls/pdf/genetics_colon.pdf on October 5, 2015.

Medicare.gov. Your Medicare Coverage: Colorectal Cancer Screening. Accessed at

www.medicare.gov/coverage/colorectal-cancer-screenings.html on October 7, 2015.
Rex DK, Kaho CJ, Levin B, et al. Guidelines for colonoscopy surveillance after cancer resection:
A consensus update by the American Cancer Society and US Multi-Society Task Force on
Colorectal Cancer. CA Cancer J Clin. 2006;56:160-167.
Winawer, SJ, Zauber AG, Fletcher RH, et al. Guidelines for colonoscopy surveillance after
polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer and
the American Cancer Society. CA Cancer J Clin. 2006;56:143-159.
Last Medical Review: 1/27/2016
Last Revised: 6/24/2016
2016 Copyright American Cancer Society