Screening For Colorectal Cancer

Screening for colorectal cancer: Strategies in patients at average risk
Author: Chyke Doubeni, MD, FRCS, MPH

Section Editors: J Thomas Lamont, MD, Joann G Elmore, MD, MPH Deputy Editor: Judith A Melin, MA, MD, FACP
All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Feb 2019. |This
topic last updated: Jun 07, 2018.
INTRODUCTION
Colorectal cancer (CRC) is a common and lethal cancer. Screening provides benefit because removal of premalignant
adenomas can prevent CRC and removal of localized cancer may prevent CRC-related death. CRC is infrequent
before age 40; the incidence rises progressively thereafter to 3.7/1000 per year by age 80 (figure 1). The lifetime
incidence for patients at average risk in the United States is 4.4 percent [1,2], with 90 percent of cases occurring after
age 50.
Worldwide, CRC is the second most commonly diagnosed cancer in women and third most common in men,
accounting for over 694,000 deaths in 2012 [3]. In the United States, CRC is the second leading cause of cancer death
and accounts for approximately 8.3 percent of cancer deaths overall [4]. Approximately one in three people who
develop CRC die of this disease.
Both the incidence of and mortality rates from CRC have been declining in the United States [5-7], with death rates
from CRC declining on average 2.7 percent each year between 2004 and 2013 [1]. One microsimulation model,
MISCAN-Colon, suggests that screening may account for 53 percent of the observed reduction in CRC mortality [8].
A study of temporal trends in CRC incidence and screening rates in the United States reported that approximately
250,000 to 500,000 CRC cases may have been prevented from 1987 to 2010, along with a shift from late- to early-
stage disease [7]. There are many contributing factors to this changing epidemiology, including prevention of some
cancers from detection and removal of adenomatous polyps during screening. (See
“Colorectalcancer: Epidemiorilskofgacyto,rs, andprotectivefactors")
Screening rates for CRC rose in the United States to over 60 percent and are reasonably stable, generally below
national targets [9], with over 20 percent of CRC diagnosed when distant/metastasized. Colonoscopy was the most
commonly used screening test (nearly 61 percent). Screening rates are higher in adults who have insurance or a usual
source of medical care, have higher levels of education or income, or are Asians or non-Hispanic whites [10-12].
This topic addresses the rationale and modalities recommended for CRC screening in the general patient population
who are at average risk for the disease. Screening recommendations for patients at increased risk, as well as
surveillance for CRC in patients with colon polyps, are addressed separately.
°(See "Overview of colonpolyps".)

* (See "Familial adenomatous polyposis: Screening and management of patients and families".)
screening'.)
* (See "Juvenile polyposis syndrome", section on ‘Cancer screening'.) *(See"Peutszynd-
romJe:eScgreehninegarndsmanagement",s‘ecGtiaonsotnrointesticnancaerl’)
* (See "Peutz-Jeghers syndrome: Epidemiology, clinical manifestations, and diagnosis", section on ‘Gastrointestinal
cancers'.) ° (See "MUTYH-associated polyposis", section on ‘Colorectal cancer surveillance’.)
Specific tests used to screen for colorectal cancer are described in detail separately. (See "Tests for screening for
colorectal cancer: Stool tests, radiologic imaging eandoscopy.)
PATHOGENESIS
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Adenoma-carcinoma sequence — Most colorectal cancers (CRCs) arise from adenomas, many of which are polyps
that progress from small (<8 mm) to large (28 mm) polyps, and then to dysplasia and cancer. Neoplastic changes
result from both inherited and acquired genetic defects [13].
The progression from adenoma to carcinoma, when itoccurs, apparently takes at least 10 years on average [14],
although polyps are ordinarily removed when found so this estimate is imprecise. Polyps and cancers are distributed
approximately evenly throughout the colon and rectum but tend to be more proximal in women and with increasing
age.
Some colon cancers arise from nonpolypoid adenomas that are flat or depressed and account for 22 to 36 percent of
identified adenomas [15-17]. Flat and depressed lesions are difficult to detect and are recognizable by subtle
distortion of the mucosal pattern and special stains [16]. Large, flat adenomas 28 mm may be more likely to contain
dysplastic changes [16] or cancer [15] than polypoid ones of comparable size.
Most colorectal polyps are either adenomatous or hyperplastic, which cannot be distinguished reliably by gross
appearance; biopsy is required for diagnosis (picture 1). Hyperplastic polyps usually do not progress to cancer. (See
"Overview of colon polyps".)
Two-thirds of polyps are adenomas. Adenomas are found in over 30 percent of men and 20 percent of women, and
the prevalence increases with age [18,19]. Hyperplastic polyps account for most of the remaining polyps and are
typically small (<1 cm) and distal. They are generally not premalignant, although there are rare reports of cancers
arising from isolated hyperplastic polyps. Patients with small (<1 cm) colorectal hyperplastic polyps are considered to
have normal colonoscopies [20]. A rare syndrome, hyperplastic
polyposis,isassociatedwithalargenumberofhyperplasticpolypsandanincreasedriskofCRC[21].(See"Overvoficeolwon
polyps")
The risk of CRC increases with adenoma size, number, and histology (eg, villous adenomas are a greater risk than
tubular adenomas) [22,23]. The finding ofone adenomatous polyp suggests apropensity toform polyps, especially
ifitislarge (28 mm), and the patient should be evaluated for other lesions in the colon and rectum. The number and
types of lesions found will determine the appropriate interval for subsequent surveillance colonoscopy.
The incidence of CRC varies about 15-fold across regions of the world, and people who move from low- to high-risk
regions acquire higher rates during their lifetime [24], suggesting environmental causes.
Removal of adenomatous polyps prevents cancer. The National Polyp Study followed 1418 patients in whom
colonoscopic examination led to the removal of one or more polyps [25]. During a mean follow-up of six years, the
incidence of colon cancer was 88 to 90 percent lower than in patients reported in other studies who had polyps that
were not removed and 76 percent lower than in the general population.
Right-sided versus left-sided lesions — A gradual shift toward right-sided or proximal colon cancers has been
observed both in the United States [26-28] and internationally [29,30], with the greatest relative increase in incidence
in the cecum [31,32]. This change in the anatomic distribution of CRCs may be partly due to improvements in
diagnosis and treatment, and increased screening by flexible sigmoidoscopy with removal of adenomatous polyps in
the descending colon, but there also appears to be a true increase in the incidence of ascending colon and cecal
cancers [30,33]. Colonoscopy also may be more effective in preventing left-sided than right-sided CRCs [34,35],
which could contribute to a shift in distribution of cancers in the colon.
RISK FACTORS
Age and family history are the most important risk factors for colorectal cancer (CRC). Other risks for developing
CRC are largely acquired, although genetic factors also play a role and include geographic area, race, gender, dietary
habits, and smoking. Lifestyle issues that may have an impact on CRC risk are shown ina table(table 1). Risk factors
other than age and family history are not taken into account in most screening recommendations.
Some findings related to risk factors are presented below. A detailed discussion of risk factors for CRC is presented
separately. (See "Colorectal cancer: Epidemiology, risk factors, and protective factors" and "Cancer prevention".)
Family history risk factors
° Family history — A family history of CRC is present in about 10 percent of adults [36,37] and about 20 percent of
those who have CRC [38,39]. The increase in lifetime risk related to family history ranges from about two- to sixfold.
Results of a systematic review providing estimates of these risks are shown in a figure (figure 2) [40]. The effect of
family history on risk of
colorectal cancer decreases as a person ages [41], and is no longer seen after age 70 (figure 3). Risk for family
members remains increased, however, even ifthe index case (the first-degree relative with colorectal cancer) was
older at the time of diagnosis [41,42]. (See "Screening for colorectal cancer in patients with a
family history of colorectal cancer or advanced polyp")
All CRCs should be tested for Lynch syndrome mutations by immunohistochemistry at the time of pathologic
examination. Patients whose tumor is positive for Lynch syndrome should be advised to inform family members so
the family members may undergo genetic counseling and testing for Lynch syndrome and be tested and/or screened,
as indicated [43]. (See "Lynch syndrome(hereditarynonpolyposiscolorectalcancer):
Clinicalmanifestations and diagnosis"and“Lynchsyndrome (hereditary nonpolyposis colorectal
cancer): Screening and management", section on ‘Colorectal cancer’.)
A family history of adenomatous polyps before age 60 years has been reported to increase risk [43,44], but the effect
is small
cancer or advanced polyp".) Demographic risk factors
* Age — The incidence of CRC is generally higher with increasing age (figure 4). However, in the United States, the
incidence of CRC, particularly rectal cancer, has been increasing in younger adults. The impact of age on the
incidence of CRC is described
Race — In the United States, the incidence and mortality rates for CRC are higher among black patients than in other
racial or ethnic groups [45] (see “Colorectal cancer: Epidemiology, risk factors, and protective factors",
section on ‘Race and gender’). The underlying reasons are complex and are likely related to differences in health
care utilization, including screening rates [46- 48]. There may also be differences in biologic risk related to
environmental and genetic factors.
One large observational study of screening colonoscopy found that larger polyps (>9 mm) were detected more
frequently in black patients than in white patients (adjusted odds ratio [OR] 1.16 for black men and 1.62 for black
women) [49]. For patients over age 60, these larger polyps >9 mm were found in the proximal colon more frequently
in black patients than in white patients.
In another large cohort study of Medicare beneficiaries, black patients were also more likely to be diagnosed with
CRC in the 6 to 59 months after a colonoscopy (“interval CRC”) than were white patients (hazard ratio [HR] 1.31)
[50]. There were also higher rates of interval advanced/metastatic CRC (HR 1.60) among black patients and higher
rates of distal CRC (HR 1.70 for rectal cancer, HR 1.45 for distal colon cancer). However, there was no difference in
risk between black and white patients for interval cancers diagnosed in the proximal colon [50].
Gender — Comparing data from screening colonoscopies in men and women, the prevalence of advanced adenoma
(8.0 versus
4.3 percent) and CRC (1.4 versus 0.6 percent) is higher in men, and adenomas are found at an earlier age in men than
women
[18,51-53] (see "Colorectalcancer: Epidemiology,riskfactors,andprotectivefactors",

sectionon'Raceand gender’). Inone cohort study of 44,350 participants, the number needed to screen for the
detection of advanced adenoma was the same for
men aged 45 to 49 years and for women aged 55 to 59 years (26.1 and 26.0, respectively) [18]. A study of a large,
relatively unscreened population in Germany showed that the prevalence of CRC increased with age, was higher at
any given age in men than women, and was higher in later birth cohorts [54,55]. This suggests an increasing
incidence of CRC over calendar time, after taking age into account. Two studies found the relative risk (RR) of
finding an advanced adenoma by colonoscopy screening in men compared with women to be 1.83 (95% Cl 1.69-
1.97) and 1.91 (1.42-2.56) [56,57]. Among people with a negative family history and negative guaiac test, advanced
neoplasia was found in 8.6 percent of men and 4.5 percent of women [57].
Specific clinical risk factors
 * Inflammatory bowel disease — The association between inflammatory bowel disease (IBD) of the colon
(ulcerative colitis or Crohn disease) and increased risk of CRC is well documented for extensive
(pancolitis) and longstanding disease. Cancers develop in areas of dysplasia, rather than from polyps. The
epidemiology and approach to surveillance for CRC in patients with IBDarediscussedseparately.
(See"Surveillan ndmanagementofdysplasiainpatientswithinflambmowaeltdioserasey".)
 * Prior colorectal cancer or polyps —A prior history of CRC increases the risk of another primary
(metachronous) cancer. In the best available study, the CRC rate in patients who had a history of CRC was
1.4 times the rate in the general population [58]. A
history of adenomatous colorectal polyps also increases the risk of CRC, especially ifthe polyps are multiple, large, or
have villous architecture [59]. (See "Overview of colon polyps".)
Hamartomatous polyps — Hamartomatous polyps most often have litle malignant potential, but patients with
hamartomatous polyps in the colon may be ata slightly increased risk for colon cancer. However, patients with
Juvenile Polyposis Syndrome and Peutz-Jeghers Syndrome are at high risk for CRC. (See "Juvenile polyposis
syndrome" and "Peutz-Jeghers syndrome: Epidemiology, clinical manifestations, and diagnosis", section on 'Cancer
risk’ and "Peutz-Jeghers syndrome: Screening and management",‘seGctaionsotnrointestincaancler’and‘High-
riskgeneticsyndromesorincreased-riskfamilyhistory’belowand "Overview of colon polyps", section on 'Hamartomatous
polyps’.)
Abdominal radiation in childhood — Adult survivors of childhood malignancy who received abdominal radiation are
at increased risk of subsequent gastrointestinal neoplasms, the majority CRC. In two studies, the incidence of CRC in
individuals who received abdominal radiation for childhood cancer was approximately 11 times the incidence in
people not exposed to childhood radiation [60,61], and CRC occurred at a relative early age (<50 years old) [60].
Guidelines from the Children’s Oncology Group recommend colonoscopy every five years for survivors of childhood
cancer who received 30 Gy or more of abdominal radiation, with screening beginning 10 years after radiation or at
age 35 years, whichever is later [62].
Radiotherapy for prostate cancer — Radiotherapy for prostate cancer appears to be associated with increased risk for
rectal cancer; the HR was 1.7 in one study [63].
Endometrial cancer at a young age — A population-based study from Canada found a fourfold increase in risk of
CRC for women diagnosed with endometrial cancer at age 50 years or younger [64]. Some of those women may have
had Lynch syndrome. Genetic counseling and screening for CRC should be considered in women who have had
endometrial cancer at a young age, even in the absence of a diagnosis of Lynch syndrome.
HIV-infected male patients — HIV-infected male patients over 50 years may have a higher prevalence of colon
neoplasms and do have an increased risk for anal neoplasia compared with the general population [65]. (See "HIV
infection and malignancy:
section on 'Anogenital cancer and premalignant lesions’.)
Additional risk factors include acromegaly, renal transplantation, diabetes, androgen deprivation, alcohol use,
obesity, smoking and dietary factors [66-68]. A meta-analysis of observational studies concluded that smokers,
compared with never-smokers, had an increased risk for CRC of about 18 percent (RR 1.18, 95% Cl 1.11-1.25) [68].
These risk factors are discussed in greater detail
screening recommendations' and "Colorectal cancer: Epidemiology, _risk factors, and protective factors", section on 'Risk factors
that do not alter screening recommendations'.)
Detection of increased risk — Before deciding how best to screen and when to initiate screening, clinicians should
determine the individual patient's level of risk. A decision tool to determine risk for CRC, applicable to people of
several ethnicities, has been developed by the National Cancer Institute and incorporates data relevant to age, diet,
exercise, medication use, and colonoscopy results, as well as family history in first-degree relatives [69,70].
However, most guidelines take into account only age, some increased-risk conditions, and personal and family
history of polyps and cancer when recommending a screening program.
A few questions will help determine ifthe patient may be at increased risk for CRC [71]:
e Have you ever had CRC or an adenomatous polyp?
 ° Have you had inflammatory bowel disease (ulcerative colitis or Crohn disease)? Have you received
abdominal radiation for childhood cancer?
 ° Have any family members had CRC or an adenomatous polyp?
¢ Ifso, how many, were they first-degree relatives (parent, sibling, or child), and at what age was the cancer
or polyp first diagnosed?
The patient is considered at average risk ifal answers to the initial questions are "no." Patients answering "yes" to any
of these questions may be at increased risk and need to be evaluated further. (See "Screening for colorectal cancer in
patients with a family
disease".)
We suggest asking these questions by age 20 and every five years thereafter, although there are no published
guidelines specifying this age or frequency. One study from a US national population-based cancer registry found
that the number of patients who would meet criteria for high-risk screening based on family history significantly
increased from age 30 (2.1 percent) to age 50 (7.1 percent), supporting the need to update the family history at least
every 5 to 10 years [72]. Most high-risk patients should begin CRC
colcoancreroeracdvantcedapolyp".)
TESTS USED FOR SCREENING
Currently recommended tests are either stool-based or those that visualize the colon. Endoscopic and stool-based tests
can
improve disease prognosis by detecting early-stage treatable cancers (and sometimes advanced adenomas that can
progress to cancers). Endoscopic tests have the potential not only to detect but also to prevent cancer by removing
adenomatous polyps prior to malignant transformation.
Characteristics and effectiveness of the multiple tests available for colorectal cancer (CRC) screening are discussed in
detail separately (table 2). In practice, the best test for an individual patient is one that the person is willing to
undergo and then repeat over time, because the goal of a screening program for CRC should be to increase overall
rates of screening [73]. (See “Tests for screening for colorectal cancer: Stool tests, radiologic imaging
and endoscopy".)
Stool-based tests
 * Guaiac-based fecal occult blood test — The more sensitive guaiac-based fecal occult blood test (gFOBT)
should be used as a take-home test that the patient mails back, ifthis method is chosen. The office-based
gFOBT is not sensitive for CRC screening.
 * Fecal immunochemical test — The quantitative test should be used when available; may use the
qualitative test ifquantitative tests are not available.
e FIT-DNA — The FIT-DNA is a multitargeted stool DNA test (MT-sDNA), combining fecal DNA, fecal
immunochemical test (FIT), and DNA methylation assays, and is available as Cologuard assay in the United States.
Endoscopic and radiologic examinations
© Colonoscopy
* Computed tomography colonography (CTC; formerly referred to as "virtual colonoscopy") * Flexible
sigmoidoscopy; can be combined with FIT or sensitive gFOBT
* Capsule colonoscopy
Less effective test
° Septin-9 — The Septin-9 (Sept9) DNA plasma test is approved in the United States as an aid for detection of CRC,
but its sensitivity is considered inadequate as a primary screening strategy. Its role is limited to patients who refuse
screening by a more sensitive methodology [73,74]. (See "Tests for screening for colorectal cancer: | ,fadiologic
imaging and endosectsioncon'oBloopd-baysed"mar,kers'.)
Tests not recommended to screen for CRC
* Office-based gFOBT —A single office-based gFOBT performed following a digital rectal examination (DRE) is
not an adequate screen due to low sensitivity for advanced neoplasia or CRC [75].
° Digital rectal examination — Although one in four CRCs is in the rectum, there is litle evidence to support
effectiveness of DRE for detection of rectal cancer, and itis not recommended in CRC screening guidelines.
e Barium enema — Barium enema (BE) and double-contrast BE are no longer recommended for CRC screening
because they are not sufficiently sensitive or specific compared with other screening techniques. These tests are no
longer available in most radiology departments and most practicing radiologists have limited or no experience with
BE.
An important distinction among CRC screening tests is that, during a flexible sigmoidoscopy or colonoscopy,
visualization and evaluation of a finding can occur at the same time (eg, polyp removal or lesion biopsy), whereas
ifabnormalities are found on any
1/4/2019 Screening for colorectal cancer: Strategies in patients at average risk - UpToDate other CRC screening test, a second
step (typically a colonoscopy) is needed to evaluate the findings [11].
COMPARISON OF TESTS
Test attributes — Many factors influence the choice of a screening test: strength of the evidence of effectiveness,
magnitude of the effect (eg, reduction in incidence or mortality from colorectal cancer [CRC]), safety, convenience,
comfort, availability, cost, and cost per year of life saved (cost-effectiveness).
All tests that are recommended by guidelines groups (see ‘Guidelines for average-risk screening’ below) are
acceptable options, but the best test is one that the patient is willing to do with high quality after an informed shared
decision-making process.
Screening with guaiac-based fecal occult blood test (gFOBT) and sigmoidoscopy has been demonstrated to reduce
mortality from CRC in randomized trials. Observational studies indicate that colonoscopy is associated with a
decreased risk of CRC mortality [76,77]. The effectiveness of fecal immunochemical test (FIT) and multitargeted
stool DNA (MT-sDNA) (FIT-DNA) is inferred because of greater sensitivity for advanced adenomas and early CRC
compared with gFOBT. Effectiveness of each test is discussed separately. (See “Tests for screening for
colorectal cancer: Stool tests, radiologic imaging and endoscopy", section on ‘Evidence of
effectiveness’.)
In modelling studies, some testing strategies were found to be more “efficient” in increasing predicted life expectancy
(colonoscopy, FIT, computed tomography colonography [CTC], sigmoidoscopy plus FIT) than others (FIT-DNA,
gFOBT, or sigmoidoscopy alone), although there are no trials comparing head-to-head effectiveness of tests [78].
Testing options for CRC screening are discussed in detail separately. (See "Tests for screening for col | cancer: | .
radiologic imaging_and endoscopy" and"Wireless video capsule endoscopy", sectionon ‘Coloncapsule
endoscopy’.)
Characteristics of CRC screening strategies are shown in a table (table 2), and a summary of the tests and their
relative benefits and disadvantages follows:
* Stool guaiac tests (gFOBT) have low sensitivity for polyps and relatively low specificity for clinically important
disease, leading to workup for many false-positive results. The test is noninvasive and inexpensive but needs to be
repeated annually if negative. When the gFOBT is positive, a timely diagnostic colonoscopy is indicated. A second
gFOBT should not be done instead of the diagnostic colonoscopy, because a subsequent negative gFOBT result does
not mean that the first result was a false positive.
Stool samples obtained by office rectal examination are not sufficient for screening. Samples of three consecutive
stool samples should be collected by the patient, usually at home. gFOBT should be performed using a sensitive
guaiac test (eg, Hemoccult SENSA) without rehydration. Older guaiac tests (eg, Hemoccult I) are not sufficiently
sensitive for use in screening.
The need for diet restrictions prior to gFOBT is uncertain, although avoiding nonsteroidal antiinflammatory drugs
(NSAIDs; including more than one aspirin per day) for seven days and eliminating high-dose (1000 or more mg/day)
vitamin C and red meat for three days is recommended by the manufacturer. Tests sent in the mail have the potential
to degrade ifexposed to excessive ambient temperature.
FIT is more expensive than guaiac-based tests but more convenient and has the potential to be more cost-effective
iffewer colonoscopies are needed for follow-up. Studies have suggested that immunochemical tests, compared with
stool guaiac tests, may have better performance characteristics for screening, with increased sensitivity without loss
of specificity, and provide better detection of advanced adenomas [79-81]. The quantitative versions of the test are
processed using standardized automated analyzers in certified laboratories, which have the potential to produce more
consistent results.
More patients may be willing to be tested with FIT compared with screening by stool guaiac [82], flexible
sigmoidoscopy [82], or colonoscopy [83].
Immunochemical-based stool testing is usually performed on a single stool sample, which is usually self-collected at
home. FIT does not require modification of diet or medications. Positive tests should be followed by colonoscopy.
(See 'A suggested approach’ below.)
Itis prudent to advise patients to return the stool tests immediately upon collection and avoid mailing when ambient
temperatures are particularly high [84]. When exposed to high ambient temperatures, the hemoglobin in the sample
has the
potential to degrade, lowering the sensitivity of the test, although the impact of temperature on sample positivity rates
is relatively small [80].
Stool DNA testing is available as part of a composite test (Cologuard), including an immunochemical assay (same as
FIT), molecular assays for DNA (KRAS) mutations, and methylation biomarkers associated with colorectal
neoplasia. Stool DNA testing has a higher single-application sensitivity and a lower specificity than FIT for CRC and
advanced precancerous lesions [85], but itis more expensive than FIT. Appropriate follow-up for patients with a
positive stool DNA test and negative diagnostic colonoscopy is uncertain, with the potential to lead to unnecessary
ongoing surveillance testing.
Testing requires collection of a single bowel movement to send to a laboratory for processing.
Flexible sigmoidoscopy can only identify lesions in the distal 60 cm of the bowel but can be performed with minimal
patient preparation, does not require sedation, and can be performed by trained clinicians, including non-
gastroenterologists. Abnormal findings in the distal bowel may require colonoscopy for visualization of the entire
colon.
Benefit may be enhanced when combined with annual stool (FIT) testing.
A pooled analysis of randomized trials found that sigmoidoscopy decreased the incidence of CRC in men and in
younger women, but did not significantly reduce the incidence of CRC in women over age 60, compared with not
receiving sigmoidoscopy [86]. (See “Tests for screeningfor col _ cancer: | ,radiologic imaging_and endoscopy", section on
‘Eviden f effectiveness’)
Colonoscopy has the benefit of high sensitivity and specificity. Also, lesions can often be removed during the same
procedure; polyps >6 mm should be removed. However, colonoscopy requires conscious sedation and a vigorous
bowel preparation. The procedure carries a risk of perforation and bleeding, and bowel preparation can lead to
dehydration and electrolyte abnormalities. Some polyps and cancers may be difficult to detect because of their
location.
Some studies have called into question how well screening colonoscopy prevents death from CRC in the right colon
[87,88] or how well colonoscopy protects against the onset of right-sided CRC [34,35].
CT colonography is nearly as sensitive as colonoscopy. It generally requires aggressive bowel preparation, but newer
techniques that tag stools and subtract their image electronically may overcome this disadvantage. CTC does not
require sedation and does not risk bowel perforation iffindings are negative; positive findings require colonoscopy
follow-up. Extracolonic findings often trigger further evaluation with litle evidence of benefit. The cumulative dose
of radiation, with repeated screenings, may increase cancer risk.
Capsule colonoscopy is a technique where the patient swallows a double-ended capsule containing a tiny wireless
video device that views the colon during the device’s transit. The procedure requires no sedation and does require a
bowel preparation preceding the capsule’s ingestion. Colonic capsule endoscopy does not allow for biopsy or polyp
removal, so patients with lesions detected typically require subsequent colonoscopy for evaluation and/or treatment.
Studies of the efficacy of capsule colonoscopy report varying sensitivities (range 39 to 88 percent) and specificities
(range 64 to 93 percent). The US Food and Drug Administration (FDA) has approved capsule colonoscopy only for
patients who had an incomplete colonoscopy. (See “Wireless video capsule endoscopy”, section on
‘Colon capsule endoscopy’)
Although some initial screening modalities are noninvasive, itshould be recognized that positive findings on tests
other than colonoscopy lead to follow-up colonoscopy, so that al screening modalities are associated with the
potential for some procedure risk. In a meta-analysis of over 335,000 individuals who were screened by either stool
guaiac or flexible sigmoidoscopy, a major complication from screening was recorded in 0.08 percent of participants,
including 0.03 percent who initiated screening with stool
testing[89].BenefitsandharmsoftestsusedforCRCscreeningaredescribedelsewhere.(See"Teforssctreesning_cforlorectal
cancer: Stool tests, radiologic imaging and endoscopy".)
Cost and cost-effectiveness — The cost of the various screening tests for CRC varies over a wide range, from a few
US dollars for guaiac-based FOBT to USD $1000 or more for colonoscopy. Upfront costs for screening tests matter
most to a patient in the short term but are less relevant in the long term.
Mathematical models were used to estimate the cost-effectiveness (cost per year of life saved) of a screening test in
relation to no screening and to the other tests, as well as to estimate the comparative effectiveness of the various tests.
Various models have come to somewhat different conclusions, in part because they make different assumptions. The
cost per year of life saved is within
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the generally accepted range in the United States (USD $50,000), relative to no screening, for al of the recommended
CRC screening tests [90]. For example, in one analysis the cost per year of life saved was USD <$15,000 for al
recommended tests, compared with no screening [91].
Patient preference — Patient preferences have also been evaluated. Randomized trials have found that participation
rates in screening were greater for patients who were assigned to screening with fecal immunochemistry than to stool
guaiac or flexible sigmoidoscopy [82] or to colonoscopy [83], suggesting that preference was greater for the
convenience of FIT than guaiac and greater for the ease of stool testing than more invasive procedures.
Findings from these studies represent the average preference for groups of patients. The clinical challenge is to
determine the test that each individual patient prefers and plan a screening strategy based on individual preference,
individual risk, test effectiveness, resource availability, and cost.
GUIDELINES FOR AVERAGE-RISK SCREENING
General principles — Prior to initiating a screening program for a patient, it is important to identify patients who may
have increased risk factors that would have an impact on: what age to initiate screening, the choice of testing, the
frequency of testing, and the need for genetic testing. It is also important to distinguish screening, intended for
patients without signs or symptoms of possible colorectal cancer (CRC), from diagnostic testing in patients for whom
there is a concern about possible malignancy.
Multiple groups have issued guidelines for screening for CRC. Specifics of these recommendations differ somewhat,
but most are in agreement with the following general principles, which we endorse:
 * Offer screening beginning at age 50 years for average-risk patients. Some expert groups suggest
screening at a younger age, but data to support this are limited.
 * Discontinue screening when the individual's estimated life expectancy is less than 10 years.
 * No single test is of unequivocal superiority. Incorporating patients’ personal preferences may increase
the likelihood that screening will occur.
® Screening should be supported by a program that assures proper follow-up of abnormal findings and
ongoing testing at identified intervals.
USPSTF guidelines — The US Preventive Services Task Force (USPSTF) makes a strong recommendation
for screening starting at age 50 for average-risk adults [73]. In a departure from prior recommendations, the
USPSTF does not give preference for any one screening test over another and advises that patients be
offered a choice among screening modalities including stool-based and colon visualization (endoscopic and
radiologic) tests (table3).
The guidelines support the following screening options:
* Colonoscopy
* Fecal immunochemical testing (FIT) for occult blood
® Sigmoidoscopy plus FIT
* Computed tomography colonography (CTC)
e FIT-DNA multitargeted stool DNA testing (MT-sDNA, also known as fecal immunochemical testing-
DNA) * Guaiac-based fecal occult blood testing (gFOBT)
* Sigmoidoscopy alone
USPSTF recommends using shared decision-making to determine which screening strategy would best
meet an individual patient's preferences and values [73]. Modelled life-expectancy gains in representative
populations are essentially equivalent for some strategies (colonoscopy, FIT, sigmoidoscopy plus FIT, and
CTC), minimally lower for FIT-DNA, and lower for gFOBT or sigmoidoscopy alone. Individual patient
preference and willingness to undergo regular screening should take precedence in determining which
strategy to elect for a specific patient.
USPSTF does not recommend low-sensitivity guaiac fecal tests because of low sensitivity. Double-contrast
barium enema (BE) is also not recommended because ithas not been shown to be effective and few
radiologists are specifically trained to do the procedure.
Other guidelines — A number of other groups have developed guidelines for screening for CRC. Guideline
recommendations vary, depending on the prevalence of disease in a given population, the availability of resources,
health care priorities, aggressiveness with which preventive health care is promoted, and other factors in addition to
the evidence base for screening effectiveness.
Multi-Society Task Force of Colorectal Cancer — The Multi-Society Task Force of Colorectal Cancer, composed of
the American College of Gastroenterology, the American Gastroenterological Association, and the American Society
for Gastrointestinal Endoscopy, issued updated CRC screening guidelines in 2017 [92-94]. They recommend
screening average risk patients beginning at age 50 years (age 45 years for African Americans, based on limited
evidence), and continue to age 75 years ifscreening is up to date. Ifscreening is not up to date, they consider screening
up to age 85 years. They also recommend discontinue screening in patients with shortened life expectancy (less than
10 years of remaining life). The guidelines categorize screening tests into three tiers. Those most highly
recommended are first-tier: colonoscopy every 10 years or FIT annually; second-tier are CTC every five years, FlT
—-fecal DNA every three years, and flexible sigmoidoscopy every 5 to 10 years; third-tier is capsule colonoscopy
every five years [92-94].
American Cancer Society — In 2018, the American Cancer Society (ACS) updated its guidelines for screening
people at average risk for CRC to add a “qualified” recommendation to begin screening at age 45 years (compared
with the previous starting age of 50 years) and a strong recommendation to screen those age 50 years and above
[95,96]. The rationale for a younger starting age for screening is the apparent increased incidence of CRC in younger
adults and support from modeling analyses [97]. The guidelines offer six screening tests to select among:
colonoscopy every 10 years, CTC every five years, sigmoidoscopy every five years, take-home high-sensitivity
guaiac-based fecal occult blood test (HSgFOBT) yearly, take-home FIT yearly, and multitarget stool-DNA test every
three years. ACS notes that al positive results on noncolonoscopy screening tests should be followed up with timely
colonoscopy. In including more tests in its updated recommendation, rather than continuing to prioritize screening
tests that could indicate both polyps and cancer, ACS notes (similarly to the USPSTF) that being screened with a test
acceptable to the patient is preferable to having the patient decline screening. The ACS makes a “qualified”
recommendation for continuing routine screening in average risk adults through age 75 for those withalife expectancy
of more than 10 years, individualizing screening decisions for ages 76 to 85 years, and discouraging screening over
age 85 years.
American Academy of Family Physicians — The American Academy of Family Physicians’ (AAFP) 2016 Clinical
Preventive Service Recommendation recommends only FIT, flexible sigmoidoscopy, or colonoscopy for average-risk
CRC screening starting at age 50 years and continuing until age 75 years [98].
National Comprehensive Cancer Network — The National Comprehensive Cancer Network (NCCN), a
multispecialty panel, issued revised screening guidelines for CRC in December 2013 [99]. These guidelines
recommend colonoscopy every 10 years, when available, as the preferred screening strategy. Suggested alternatives
are annual stool testing with guaiac or immunochemical reagent or sigmoidoscopy every five years with or without
annual stool testing. The NCCN did not come to consensus regarding CT colonography as a screening modality.
American College of Physicians — The American College of Physicians published CRC screening recommendations
in 2015 as a component of their cancer screening advice for high-value care [100]. They recommend screening
average risk adults aged 50 to 75 years, using one of four strategies: high-sensitivity FOBT or FIT every year;
flexible sigmoidoscopy every five years; combined FOBT or FIT every three years plus flexible sigmoidoscopy every
five years; or colonoscopy every 10 years.
Council of the European Union —As of 2012, the European Council has recommended only FOBT for screening
men and women aged 50 to 74 years [101]. However, while not specifically endorsing other modalities for screening,
the 2012 European Guidelines do provide quality assurance recommendations when using a variety of screening
modalities, including colonoscopy.
Canadian Task Force on Preventive Health Care — The 2016 Canadian Task Force on Preventive Health Care
recommends screening adults aged 50 to 74 years with FOBT every two years or flexible sigmoidoscopy every 10
years [102]. They do not recommend screening adults >75 years for CRC or using colonoscopy as a screening test.
A suggested approach —After identifying a patient as average risk for CRC, and reviewing risks and benefits of
screening options with the patient, we generally advise colonoscopy for those patients who are willing to undergo the
procedure.
Those who are unable or unwilling to have a colonoscopy could be offered initial screening by FIT or CTC, with the
understanding that ifthe result is positive, colonoscopy should be performed promptly. We prefer FIT and hand the
test to patients at the time of the office visit with a prepaid envelope, or mail itto patients, to be mailed back directly
to the laboratory.
Although the optimal time interval between a positive FIT and colonoscopy is not well known, prompt follow-up
colonoscopy minimizes the potential for progression of a preclinical to a less curable stage due to a delay in
diagnostic testing [103]. Performing the colonoscopy within three months is advised. In a retrospective cohort of
>70,000 patients aged 50 to 70 who had a positive FIT between 2010 and 2014, rates of detection of any CRC or
advanced CRC increased with increasing intervals between FIT and colonoscopy [104].
SCREENING IN OLDER ADULTS
Screening trials have included too few older patients to provide reliable estimates of screening effectiveness for older
adults. Randomized trials of colonoscopy screening have not been completed, and trials underway do not include
adults 75 years and older. A study of Medicare beneficiaries found that undergoing colonoscopy believed to be for
screening modestly decreased the risk of colorectal cancer (CRC; 2.2 versus 2.6 percent in the no-screening group)
over an eight-year period for those aged 70 to 74 years, with a smaller, but statistically non-significant, decrease in
risk (2.8 versus 3.0 percent in the no-screening group) for those 75 to 79 years [105]. Screening colonoscopy is
expected to decrease CRC incidence, as noted in this study, by detecting and removing precancerous polyps.
The decision whether to recommend screening for a patient at any age, but especially those over 75 years of age,
should depend upon the patient's health status, anticipated life expectancy, risk for CRC, and personal values [106-
108]. Therefore, the choice of screening tests and whether to screen in older adults should be based on shared
decision-making, taking into account comorbid conditions. The following factors should be considered in this
decision:
* Patients with a life expectancy less than 10 years (some would say five) would not be expected to benefit from
colorectal screening, since studies indicate benefit from screening starts to accrue after about five years. In a survival
meta-analysis of four studies of screening with flexible sigmoidoscopy, an absolute risk reduction of one CRC-related
death for every 5000 sigmoidoscopies was observed at 4.3 years, and an absolute risk reduction of one CRC-related
death for every 1000 sigmoidoscopies occurred by 9.4 years [109].
Colonoscopy carries increased risk in older adults, with significant complications occurring in 0.3 percent of 600
veterans aged 70 to 75 undergoing colonoscopy screening [110]. In a study of Medicare beneficiaries undergoing
screening colonoscopy, an adverse event (requiring hospitalization or emergency department visit within 30 days)
occurred in 0.56 percent of individuals 70 to 74 years old and in 1 percent of those 75 to 79 years old [105]. The risks
of colonoscopy increase with age and comorbidities including cardiopulmonary disease, diabetes mellitus, and history
of stroke [111]. Ifsuch patients are nevertheless expected to live long enough to benefit from screening, computed
tomography colonography (CTC) might be a preferred initial choice, although the incidence of incidental extra-
colonic findings rises with increasing age.
In a modeling study, assuming a population of adults 65 years at average risk of colon cancer, average life
expectancy, and with a negative colonoscopy at age 55, screening more intensively than current recommendations
(eg, extending screening beyond age 75, or screening more frequently than every 10 years), resulted in net harm (loss
of quality-adjusted life years) due to complications from colonoscopy [112].
* Sigmoidoscopy has reduced sensitivity in older adults because advanced neoplasias tend to occur more proximally
in this population.
Discontinuing screening — The decision to stop screening should depend upon whether an individual patient's life
expectancy justifies the risk and inconvenience of screening. Age alone is only one determinant of the impact of
screening; in one modeling study, screening individuals aged 67 to 69 with three or more comorbidities would save
fewer lives than screening individuals aged 75 to 79 with no comorbidity (81 versus 459 lives saved per 100,000)
[113].
Most guidelines recommend that screening for CRC stop when the patient's life expectancy is less than 10 years. The
US Preventive Services Task Force (USPSTF) recommends that patients over age 85 not be screened and
recommends that the decision to screen adults 76 to 85 years be individualized, taking into account the patient's
overall health and prior screening history.
Older adults with no prior screening — One-time screening in older adults who have never been screened appears to
be cost- effective up to age 86 years, based on results of a modeling study [114]. In this simulation study, assuming a
willingness to pay $100,000 per quality-adjusted life-year gained, colonoscopy was cost-effective to age 83 years,
sigmoidoscopy to 84 years, and
fecal immunochemistry testing (FIT) to 86 years for patients without comorbidity and at average risk for CRC.
Colonoscopy was the most effective, and most expensive, strategy for one-time screening.
Inappropriate screening — The implementation of screening in older patients appears not to be appropriately
targeted, with several studies finding that significant numbers of healthier patients are not screened, while many
patients who would not be expected to benefit receive screening [115-117]. As an example, a study of CRC screening
among US veterans aged 70 or older (n = 27,068) found that screening studies were done for only 47 percent of
patients whose life expectancy was greater than five years but were performed for 41 percent of patients with severe
comorbidity (eg, life expectancy less than five years) [115]. Another study in US veterans aged 70 and older found
that 38 percent of those who had a positive stool guaiac test without follow-up at one year either had comorbidity
precluding follow-up or declined complete colon evaluation [118]. Additionally, a study of Medicare patients who
had a negative screening colonoscopy found that repeat colonoscopies were performed within seven years of the
initial study in 46 percent of the sample, with marked geographic variation, indicating deviation from the guideline-
suggested frequency of screening (every 10 years) and likely overuse [119].
SCREENING PEOPLE AT INCREASED RISK
High-risk genetic syndromes or increased-risk family history — The evidence for how patients with high-risk genetic
syndromes or increased-risk familial history should be screened is weaker than for average-risk patients, and
guidelines are mainly inferred from knowledge of the biology of colorectal cancer (CRC):
 ® Ifthe patient is at risk for earlier-onset CRC (eg, first-degree relative with onset of CRC before age 50),
screening should begin earlier.
 ® Ifthe patient is at risk for more rapid progression of disease, screening should be performed more
frequently.
° Ifthe patient is at risk for more proximal lesions (eg, hereditary nonpolyposis colorectal cancer [HNPCC)]),
screening should be performed with colonoscopy.
® Ifthe patient is at risk for a greatly increased incidence of disease (eg, HNPCC or familial adenomatous polyposis
[FAP]), they should be screened with colonoscopy, the most sensitive test for complete examination of the colon.
Strategies for screening high-risk patients with a known genetic syndrome or with a sporadic family history of CRC
are discussed in
“Lynchsyndrome(hereditarynonpolyposiscolorectalcancer):Screeningandmanagement",‘secCtionlonorect
caanlcer’and "MUTYH-associatedpolyposis",sectionon'Managementand"Juvenilepolyposissyndrome",secont'Cioloorectnal’.)
SURVEILLANCE
Surveillance refers to follow-up testing in patients who havea history of polyps, cancer, or inflammatory bowel
disease. Surveillance is conceptually different than screening (which applies to patients without disease or symptoms)
and is discussed in separate topics.
 ® History of polyps — Once adenomatous or advanced polyps have been identified by screening, the
patient should be entered in a colonoscopy surveillance program. Recommendations for follow-up are
discussed separately. (See "Overview of colon
polyps".)
 ® History of colorectal cancer — Patients should have ful visualization of the colon at the time of
diagnosis or, ifnecessary, soon after surgery to exclude synchronous cancers and polyps, and then have
surveillance colonoscopy at regular short intervals. The surveillance interval would be determined by what
is found at each colonoscopy. (See "Surveillan rcol | cancer resection".)
* Inflammatory bowel disease — In patients with longstanding extensive inflammatory bowel disease, surveillance
colonoscopy should be considered to look for dysplasia as a marker of colorectal cancer (CRC) risk. (See
"Surveillance and management of dysplasiainpatientswithinflambmowaeltdioserasey".)
IMPLEMENTING A SCREENING PROGRAM https://Awww.uptodate.com/contents/screening-for-colorectal-

cancer-strategies-in-patients-at-average-risk/print?source=bookmarks_widget 11/30
Screening for colorectal cancer (CRC) requires an ongoing program of appropriate testing and follow-up. One-time
testing is insufficient; colon cancer incidence continues to increase with age into the ninth decade. Additionally,
patients who are initially screened with tests other than colonoscopy must be willing to undergo colonoscopy for
further evaluation of abnormal results and polyp removal as needed.
To maximize the impact of screening, itis important to recommend screening to patients and actively engage them in
shared decision-making about the screening options and in completing the screening process. Patients should be
encouraged to select a screening option that is right for them based on their preferences, personal circumstances, and
disease risk. Screening must be targeted to appropriate patients, performed properly at appropriate intervals, and
supported by patient education and systems to ensure implementation and follow-up.
Characteristics of a screening program — A robust screening program should assure that the following elements are
reliably implemented [120,121]:
* A system to identify and risk-stratify the population (patients in a practice or defined geographic area),
incorporating data on individual risk factors including age, gender, family history, and prior screening history.
Electronic medical records can facilitate creation of a population registry to target for screening.
° Identification of individuals eligible for screening and the appropriate screening strategy (eg, routine average- or
high-risk screening and genetic counseling or surveillance).
* A tracking system to update the screening history and disease risk over time.
® Initiation of screening at the appropriate age to identify those with cancer or precancerous lesions.
© Ongoing screening at specified intervals for people with negative initial findings.
* Follow-up of abnormal screening results with diagnostic testing to determine ifpolyps or cancer are present, with
biopsy or excision when necessary, including navigating patients through the follow-up process.
* Surveillance of high-risk people (typically those in whom a large (28 mm) adenomatous polyp has been found) for
new lesions.
* Access to treatment and follow-up of detected cancers.
Follow-up — Longitudinal studies show a high rate of failure to follow up after initial screening, compromising the
effectiveness of a screening intervention [122]. This failure occurs both as lack of follow-up of an abnormal
screening test and as lack of ongoing screening after first-round testing has been accomplished:
*Lackoffollow-uptestingiscommon [122,123].Inapopulationofveteransage70yearsandolderwhohadaninitialpositive
stool guaiac test, follow-up evaluation within one year was done in only 58 percent of the patients. In some cases,
follow-up does not occur in part due to comorbidities, indicating that screening should not have been initiated [118].
A systematic review evaluated interventions to improve diagnostic colonoscopy rate as follow-up for a positive fecal
stool test (fecal occult blood test [FOBT] or fecal immunochemical test [FIT]) [124]. Data were limited by poor
quality of the included studies; there is some evidence that patient navigators and clinician reminders or feedback of
performance data to clinicians improved follow-up colonoscopy rates.
* Adherence to continuing screening {regular rescreening) according to recommended schedules has also been found
to be low, as illustrated by studies of compliance with annual stool testing [125]. In one study, almost one-half of an
insured population who had an initial screening stool guaiac test failed to have a second screening procedure for
colon cancer over a two-year period [126]. In a study from a veteran's program, only 14 percent of those who were
screened by FOBT had submitted at least four annual samples over a five-year period [127].
Improving underutilization — Increasing screening rates depends on numerous factors, including clinician
recommendation, patient and clinician reminders, decision aids, and a program of patient education, monitoring,
outreach, and follow-up [128].
A systematic review evaluated strategies to increase the quality of CRC screening [129]. Interventions considered
were at the level of the patient, provider, or health care system. Those programs that involved changes in the system
of care, such as providing a patient navigator or eliminating barriers to providing FOBT cards, were most effective
and increased the absolute rate of screening from 7 to 28 percent. In a randomized trial involving patients identified
as high risk for nonadherence, patients assigned to a patient
navigator had higher rates of CRC screening than control patients (13.7 versus 7 percent), though rates were low in
both groups [130]. One randomized trial found that offering patients a choice of screening options (FOBT or
colonoscopy), compared with only offering colonoscopy, improved screening uptake, particularly among racial and
ethnic minority participants [131]. Another randomized trial in England found that compared with standard
information (invitation letter to screen and screening information), standard information plus a reminder letter
decreased inequality in screening by increasing screening uptake in the lowest socioeconomic quintile [132].
Overutilization — In addition to underutilization when screening is appropriate, CRC screening is overutilized in

patients with advanced age or comorbidities, as well as younger adults, who would not derive benefit, and mis-
utilized when abnormal results are not appropriately followed up on or inadequate testing is performed (eg, stool
testing on a sample from a rectal exam performed during an office visit). While most studies have evaluated
interventions to improve underutilization, less attention has been paid to limiting overuse and misuse of CRC
screening.
Screening practices consistent with guidelines were performed by a minority of US clinicians in one nationally
representative survey [133]. A study of timing of repeat colonoscopy after a negative screening colonoscopy in a
representative sample of 24,071 Medicare patients found that 46.2 percent had a repeat examination in less than seven
years, with no clear indication for early colonoscopy in nearly one-half and considerable geographic variation [119].
Additionally, studies find overuse of colonoscopy in shortened surveillance intervals following a positive study [134].
One study found that overuse of colonoscopy (interval shorter than guideline recommendations for either repeat
screening or surveillance) was strongly associated with the endoscopist performing the previous examination [135]. A
study in the Veterans Health Administration in the United States found that over 20 percent of FOBT tests could be
categorized as overuse (performed within 10 months of a prior FOBT, less than 9.5 years after a colonoscopy, or less
than 4.5 years after a barium enema [BE]) [136]. (See "Preventive care in adults: Recommendations".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Screening for colorectal cancer".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient
education pieces are written in plain language, at the 5“ to 6" grade reading level, and they answer the four or five
key questions a patient might have about a given condition. These articles are best for patients who want a general
overview and who prefer short, easy-to- read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10" to 12" grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics
to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info"
and the keyword(s) of interest.)
* Basics topics (see "Patient education: Colon and rectal cancer screening (The Basics)")
*BeyondtheBasicstopics(see"Patienteducation:Colonandrectalcancerscreening(Beyond
theBasics)"and“Patient education: Colonoscopy (Beyond the Basics)" and “Patient education: Flexible
sigmoidoscopy (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
° Screening for colorectal cancer (CRC) can identify premalignant lesions and detect asymptomatic early-stage
malignancy. ScreeninghasbeenshowntodecreasemortalityfromCRC.(See‘Introduction’aboveand'Ti for screening!
above.)
* Patient history must be assessed to determine ifa patient is at increased risk for CRC. We initiate risk assessment no
later than age 20 and update the information at a minimum of every five years.
° For average-risk patients: https://Awww.uptodate.com/contents/screening-for-colorectal-cancer-strategies-in-patients-at-

average-risk/print?source=bookmarks_widget 13/30
Screening for colorectal cancer: Strategies in patients at average risk - UpToDate
« We recommend that average-risk patients aged 50 and older be screened for CRC (Grade 1A). We suggest that
screening be continued until the life expectancy for an individual patient is estimated as less than 10 years (Grade
2C). For most patients, it is reasonable to stop screening at age 75 years or 85 years at the latest. For adults who have
never been screened for CRC, a one-time screening with colonoscopy (to age 83) or sigmoidoscopy (to age 84) is
advised. (See ‘Guidelines for average-risk screening’ above and ‘Screening in older adults' above and ‘Older adults
with no prior screening’ above.)
Guidelines from some organizations (the American College of Physicians and the Multi-Society Task Force [MSTF])
recommend initiating screening in African Americans at an earlier age (40 to 45 years). (See ‘Risk factors' above and
‘Other guidelines’ above.)
Patients should be actively engaged in informed decision-making about the screening options and be encouraged to
select a screening option based on their preferences, personal circumstances, and disease risk, weighing factors of
effectiveness, safety, cost, and availability of the tests. We agree with the US Preventive Services Task Force
(USPSTF) guidelines that endorsepatientschoosingfromthefollowingoptionsforscreening(table2)
(see‘Guidfeorlaviernage-rsiskscreening’ above and 'Tests used for screening! above and "Tests for screening for
colorectal cancer: Stool tests, radiologic imaging
aennddoscopy"):
- Colonoscopy every 10 years in patients with an initial negative colonoscopy - Computed tomographic colonography
(CTC) every five years
- Fecal immunochemistry stool testing (FIT) annually on a single sample
- Flexible sigmoidoscopy every 10 years plus FIT annually
- Multitargeted fecal DNA (FIT-DNA, Cologuard, every three years on one stool collection sample)
- Guaiac-based fecal occult blood (gFOBT) using a sensitive test (eg, Hemoccult SENSA), annually on three samples
- Sigmoidoscopy alone every five years (if the option of adding a stool-based test is not available or practical for a
patient to use in conjunction with sigmoidoscopy)
After identifying a patient as having average risk for CRC, and reviewing risks and benefits of screening options with
the patient, we generally advise colonoscopy for those patients who are willing to undergo the procedure. Those who
are unable or unwilling to have a colonoscopy could be offered initial screening by FIT or CTC, with the
understanding that if the result is positive, colonoscopy should be performed promptly; we prefer FIT
testing. (See 'A suggested approach’ above.)
Colorectal screening should not be based on results of a single office-based gFOBT performed following a digital
rectal examination. Serologic testing (Septin-9 DNA test) may be used in patients who refuse screening by any other
methodology. (See ‘Less effective test! above.)
* Patients at sufficiently-increased risk to change screening recommendations (eg, start screening at an earlier age
and/or perform screening more frequently) include those who have (see 'Risk factors’ above and "Screening for
colorectal cancer in
patiwiethnatfasmilyhistoryofcolorectalcanceror advancedpolyp"):
¢ A personal history of CRC or adenomatous polyp

« Agenetic syndrome predisposing to CRC (eg, hereditary nonpolyposis colorectal cancer [HNPCC], familial
adenomatous
polyposis [FAP])
« A first-degree relative with CRC or advanced adenoma
¢ Inflammatory bowel disease causing pancolitis or longstanding (>8 to 10 years) active disease
¢ Certain other clinical situations such as a personal history of childhood cancer requiring abdominal radiation
therapy
* Screening is best implemented by developing a system to identify patients in need of screening, including risk
factors, with regular updating of this information and tracking for receipt of screening and receipt of follow-up for
positive screening results. (See‘Characotfaesrcreiensintgpirocgrsam’above.)

Screening For Colorectal Cancer

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Screening for colorectal cancer: Strategies in patients at average risk

Author: Chyke Doubeni, MD, FRCS, MPH

“Colorectalcancer: Epidemiorilskofgacyto,rs, andprotectivefactors")

°(See "Overview of colonpolyps".)

Family history risk factors

cancer or advanced polyp".) Demographic risk factors

[18,51-53] (see "Colorectalcancer: Epidemiology,riskfactors,andprotectivefactors",

Specific clinical risk factors

section on 'Anogenital cancer and premalignant lesions’.)

e Have you ever had CRC or an adenomatous polyp?

TESTS USED FOR SCREENING

Endoscopic and radiologic examinations

Less effective test

Tests not recommended to screen for CRC

GUIDELINES FOR AVERAGE-RISK SCREENING

The guidelines support the following screening options:

SCREENING IN OLDER ADULTS

SCREENING PEOPLE AT INCREASED RISK

IMPLEMENTING A SCREENING PROGRAM https://Awww.uptodate.com/contents/screening-for-colorectal-

* Access to treatment and follow-up of detected cancers.

Overutilization — In addition to underutilization when screening is appropriate, CRC screening is overutilized in

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

° For average-risk patients: https://Awww.uptodate.com/contents/screening-for-colorectal-cancer-strategies-in-patients-at-

Screening for colorectal cancer: Strategies in patients at average risk - UpToDate

patient to use in conjunction with sigmoidoscopy)

¢ A personal history of CRC or adenomatous polyp

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