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Risk assessment prior to screening
Average risk: no personal hx/FHx CRC/advanced adenoma (≥1-cm lesion, ≥3 adenomas, any villous histology, high-grade dysplasia or submucosal cancer in a colonic polyp or a traditional serrated adenoma)1 Above-average risk: personal hx/FHx CRC or certain polyp types, hx IBD (UC, Crohn dz), confirmed/suspected syndrome (e.g., FAP, Lynch, HNPCC), abdomen/pelvis irradiation2,3 - Black pts have the highest incidence of and mortality from CRC; however, empirical data aren’t available on effectiveness of various screening strategies for this population4
- Clinicians should be attentive to race and ethnicity of pts who’ve experienced worse CRC health outcomes to ensure access to and receipt of recommended screening3
Footnotes 1 ACG 2021. Shaukat A, et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol. 2021 Mar 1;116(3):458-479. Full-text article
2 ACS 2024. American Cancer Society Guideline for Colorectal Cancer Screening. Updated January 29, 2024. Accessed June 20, 2024
3 ACP 2023. Qaseem A, et al. Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians (Version 2). Ann Intern Med. 2023 Aug;176(8):1092-1100. Full-text article
4 USPSTF 2021. Final Recommendation Statement: Colorectal Cancer: Screening. U.S. Preventive Services Task Force. Updated May 18, 2021. Accessed May 19, 2021
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Average risk: No FHx CRC/advanced adenoma
Screen average-risk1-3 adults ≥50 yo, per ACP3 - USPSTF4 and ACS2 recommend, and ACG5 suggests, starting at 45 yo
- ACP suggests NOT screening asymptomatic adults 45-49 yo; less-frequent screening (e.g., colonoscopy q15y) likely reasonable in pts who prefer less-frequent screening3
Choose screen type based on pt preference, costs, availability, and frequency; set frequency based on screen type.3 Empirical data aren’t available to demonstrate greater net benefit of one screening strategy over another.4 - 1st-line screens:4
• Colonoscopy q10y. Considerations: Dx occurs w/ screening. Reduced frequency. Requires bowel prep, sedation (w/ risk of aspiration/dehydration), transportation.3
• FIT or hs-gFOBT q1y1,2 (q2y, per ACP3). Not suitable if pt can’t f/u q2y.3 Considerations: voided stool/not DRE. If abnl, requires f/u colonoscopy. No bowel prep/sedation/transportation required. hs-gFOBT requires 3 samples and dietary restrictions. Can be done at home. High frequency vs. scope.3
• Flex sig q5y, per ACS2 and USPSTF,4 or flex sig q10y + FIT q1y, per USPSTF,4 or q2y, per ACP;3 per ACG,1 q5-10y but 2nd-tier. Considerations: requires bowel prep. If lesion found, may require f/u colonoscopy. Declining availability in U.S.3 - 2nd-line screens:4
• Stool DNA: mt-sDNA q3y, per ACG,1 ACS2
• CT colonography: q5y, per ACG,1 ACS,2 USPSTF4
• Colon capsule: also 2nd-tier, per ACG,1 w/ q5y interval - Not recommended:
• Per ACG: Septin 9 testing1
• Per ACP: Stool DNA, CT colonography, capsule endoscopy, urine, or serum tests3
Footnotes 1 ACG 2021. Shaukat A, et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol. 2021 Mar 1;116(3):458-479. Full-text article
2 ACS 2024. American Cancer Society Guideline for Colorectal Cancer Screening. Updated January 29, 2024. Accessed June 20, 2024
3 ACP 2023. Qaseem A, et al. Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians (Version 2). Ann Intern Med. 2023 Aug;176(8):1092-1100. Full-text article
4 USPSTF 2021. Final Recommendation Statement: Colorectal Cancer: Screening. U.S. Preventive Services Task Force. Updated May 18, 2021. Accessed May 19, 2021
5 ACG 2022. Patel SG, et al. Updates on Age to Start and Stop Colorectal Cancer Screening: Recommendations From the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2022 Jan;162(1):285-299. Full-text article
Consider stopping screening or individualize whether to continue average-risk1-5 pts based on previous screening hx/results, health status, risk factors, etc. Never-screened pts most likely to benefit.4 - Stop screens at 75 yo or if <10-yr life expectancy, per ACP;3 individualize, per ACS2
- Consider screening up to 85 yo if inadequate previous screening. Factor health status (e.g., healthy enough4 for colon CA tx), pt preference, etc., per USPSTF.4
- If >85 yo, don’t screen, per ACS,2 USPSTF4
If continued screening, factor pt preference; set frequency based on screen type. Empirical data aren’t available to demonstrate greater net benefit of one screening strategy over another.4 - 1st-line screens:4
• Colonoscopy q10y. Considerations: Dx occurs w/ screening. Reduced frequency. Requires bowel prep, sedation (w/ risk of aspiration/dehydration), transportation.3
• FIT or hs-gFOBT q1y1,2 (q2y, per ACP3). Not suitable if pt can’t f/u q2y.3 Considerations: voided stool/not DRE. If abnl, requires f/u colonoscopy. No bowel prep/sedation/transportation required. hs-gFOBT requires 3 samples and dietary restrictions. Can be done at home. High frequency vs. scope.3
• Flex sig q5y, per ACS2 and USPSTF,4 or flex sig q10y + FIT q1y, per USPSTF,4 or q2y, per ACP;3 per ACG,1 q5-10y but 2nd-tier. Considerations: requires bowel prep. If lesion found, may require f/u colonoscopy. Declining availability in U.S.3 - 2nd-line screens:4
• Stool DNA: mt-sDNA q3y, per ACG,1 ACS2
• CT colonography: q5y, per ACG,1 ACS,2 USPSTF4
• Colon capsule: also 2nd-tier, per ACG,1 w/ q5y interval - Not recommended:
• Per ACG: Septin 9 testing1
• Per ACP: Stool DNA, CT colonography, capsule endoscopy, urine, or serum tests3
Footnotes 1 ACG 2021. Shaukat A, et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol. 2021 Mar 1;116(3):458-479. Full-text article
2 ACS 2024. American Cancer Society Guideline for Colorectal Cancer Screening. Updated January 29, 2024. Accessed June 20, 2024
3 ACP 2023. Qaseem A, et al. Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians (Version 2). Ann Intern Med. 2023 Aug;176(8):1092-1100. Full-text article
4 USPSTF 2021. Final Recommendation Statement: Colorectal Cancer: Screening. U.S. Preventive Services Task Force. Updated May 18, 2021. Accessed May 19, 2021
5 ACG 2022. Patel SG, et al. Updates on Age to Start and Stop Colorectal Cancer Screening: Recommendations From the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2022 Jan;162(1):285-299. Full-text article
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Above-average risk: FHx CRC/advanced adenoma
A single 1st-degree relative w/ CRC/advanced adenoma diagnosed ≥60 yo Screen pts w/ a single affected1 relative w/ standard options; start earlier, per ACG,1 then resume average-risk recommendations - Start at age 40
- Stop on case-by-case basis, not based on age alone1
Factor pt preference; set frequency based on test type, per ACG1 - 1st-line screens: colonoscopy q10y or FIT q1y
- If pt unwilling/unable to do colonoscopy or annual FIT, ACG1 recommends: CT colonography q5y, mt-sDNA q3y, flex sig q5-10y, or colon capsule q5y
- ACG suggests against Septin 9 testing1
Footnotes 1 ACG 2021. Shaukat A, et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol. 2021 Mar 1;116(3):458-479. Full-text article
1st-degree relative w/ CRC/advanced adenoma diagnosed <60 yo, or multiple 1st-degree relatives any age Screen earlier w/ colonoscopy q5y, per ACG1 - Start screening: 10y prior to age youngest relative was diagnosed, or age 40 yo—whichever is earlier
- Consider genetic eval in pts w/ higher familial CRC burden (higher number and/or younger age of affected relatives)
- If pt refuses colonoscopy, ACG notes lack of RCTs supporting any screening modality aside from FIT in pts w/ FHx of CRC1
• One RCT compared single colonoscopy w/ 3 consecutive annual FITs in 1st-degree relatives of pts w/ CRC. Advanced neoplasia was detected in 4.2% and 5.6% of the FIT and colonoscopy groups, respectively (odds ratio (OR), 1.41; 95% confidence interval (CI), 0.88-2.26); no CRCs were missed w/ the FIT strategy.
• In a recent meta-analysis, FIT demonstrated sensitivity of 86% (95% CI, 31%-99%) and specificity of 91% (95% CI, 89%-93%) for CRC in pts w/ (+) FHx; for advanced neoplasia, sensitivity was 46% (95% CI, 37%-56%) and specificity was 93% (95% CI, 90%-95%)
Footnotes 1 ACG 2021. Shaukat A, et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol. 2021 Mar 1;116(3):458-479. Full-text article
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