Gastroenterology

Gastroenterology

Volume 153, Issue 1, July 2017, Pages 307-323
Gastroenterology

Consensus Guideline
Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer

https://doi.org/10.1053/j.gastro.2017.05.013Get rights and content

This document updates the colorectal cancer (CRC) screening recommendations of the U.S. Multi-Society Task Force of Colorectal Cancer (MSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy. CRC screening tests are ranked in 3 tiers based on performance features, costs, and practical considerations. The first-tier tests are colonoscopy every 10 years and annual fecal immunochemical test (FIT). Colonoscopy and FIT are recommended as the cornerstones of screening regardless of how screening is offered. Thus, in a sequential approach based on colonoscopy offered first, FIT should be offered to patients who decline colonoscopy. Colonoscopy and FIT are recommended as tests of choice when multiple options are presented as alternatives. A risk-stratified approach is also appropriate, with FIT screening in populations with an estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations. The second-tier tests include CT colonography every 5 years, the FIT–fecal DNA test every 3 years, and flexible sigmoidoscopy every 5 to 10 years. These tests are appropriate screening tests, but each has disadvantages relative to the tier 1 tests. Because of limited evidence and current obstacles to use, capsule colonoscopy every 5 years is a third-tier test. We suggest that the Septin9 serum assay (Epigenomics, Seattle, Wash) not be used for screening. Screening should begin at age 50 years in average-risk persons, except in African Americans in whom limited evidence supports screening at 45 years. CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended. Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities. Persons with a family history of CRC or a documented advanced adenoma in a first-degree relative age <60 years or 2 first-degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years.

Section snippets

Literature Review

The English language medical literature using MEDLINE (2005 to August 1, 2016), EMBASE (2005 to third quarter 2016 update), the Database of Abstracts of Reviews and Effects (2005 to third quarter 2016 update), and the Cochrane Database of Systematic Reviews (2005 to third quarter 2014 update) was searched. In MEDLINE, subject headings for colorectal cancer screening were combined with headings for fecal occult blood test, fecal immunochemical test, colonoscopy, sigmoidoscopy, CT colonoscopy,

Approaches to Screening

In the United States CRC screening usually results from an office-based interaction between a healthcare provider and patient. Screening in this setting is termed opportunistic.4

Programmatic screening (sometimes called organized screening) refers to a system-wide, organized approach to offering screening to a population or members of a healthcare plan.4 Programmatic screening has potential advantages over opportunistic screening, including systematic offers of screening, reduction of

Screening Targets

The object of screening is to reduce CRC incidence and mortality. To accomplish both aims, tests need to detect early-stage (ie, curable) CRCs and high-risk precancerous lesions.1, 21 Detection and removal of precancerous lesions prevents CRC.30, 31 The 2 main classes of precancerous lesions in the colon are conventional adenomas and serrated class lesions (Table 2). These 2 classes of precancerous lesions have distinct endoscopic features and histology and different (though overlapping)

Colonoscopy

The advantages of colonoscopy include high sensitivity for cancer and all classes of precancerous lesions, single-session diagnosis and treatment, and long intervals between examinations (10 years) in subjects with normal examinations. One or 2 negative examinations may signal lifetime protection against CRC.54 Patients who value the highest level of sensitivity in detection of precancerous lesions and are willing to undergo invasive screening should consider choosing colonoscopy. Although no

Cost Issues

A consistent finding is that CRC screening by any available modality is cost-effective compared with no screening,106, 107 and in some models screening results in cost savings. This finding relates in part to the high costs of CRC treatment. Numerous modeling studies have addressed the relative cost-effectiveness of 2 or more screening tests. The conclusions of the models frequently vary, likely depending in part on the assumptions of the respective models. For example, different models

Quality of Screening

Variable performance of screening tests affects at least colonoscopy, sigmoidoscopy, CT colonography, and FIT. Optimal results in CRC screening cannot be achieved without optimizing the technical performance and reporting of tests and ensuring that patients undergo appropriate follow-up after testing. The MSTF has made detailed recommendations regarding the technical performance of FIT86 and has previously issued quality recommendations regarding the technical performance of sigmoidoscopy117

Practical Considerations

No published randomized trials have directly compared and reported the relative effects of different tests on CRC incidence or mortality. Several trials are ongoing, but results are not yet available. When compared using simulation models that are dependent on assumptions about natural history of disease, patient acceptance of screening, and test performance, several tests appear to be similarly effective.121 Therefore, practical considerations are important for informing our recommendations.

A

Family History of CRC and Polyps

We recommend that screening in most average-risk persons be initiated at age 50 years. A family history of CRC or certain polyps can modify the recommended starting age and the frequency of screening. The MSTF has previously issued recommendations for screening in persons with Lynch syndrome,34 which is a genetically defined inherited syndrome caused by mutations in 1 or more mismatch repair genes. Patients in families that meet the clinical criteria for hereditary nonpolyposis CRC but have

Considerations Regarding Age and CRC Risk

CRC screening is recommended to begin at age 50 years in most average-risk persons, including in prior recommendations from the MSTF.1 Recent modeling supports this recommendation.121 Several issues related to age and CRC risk warrant specific discussion.

The incidence of CRC is strongly age related and continues to rise with increasing age. Partly because of widespread screening in the United States, the incidence of CRC in falling by 3% to 4% per year in persons age ≥50 years.12 The incidence

Summary

CRC screening should begin at age 50 years in asymptomatic persons. Colonoscopy every 10 years and annual FIT are currently the first considerations for screening. Colonoscopy every 10 years has advantages in the opportunistic screening setting. Annual FIT is likely to be preferred in organized screening programs. Positioning of the 2 tests can be reasonably based on a sequential offer (colonoscopy first with FIT offered to patients who decline colonoscopy, followed by second-tier tests for

Acknowledgment

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veteran Affairs.

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    Conflicts of interest The following authors disclosed financial relationships relevant to this publication: D. K. Rex: Consultant for Olympus Corp and Boston Scientific; research support recipient from Boston Scientific, Endochoice, EndoAid, Medtronic, and Colonary Solutions. T. Kaltenbach: Consultant for Olympus Corp. D. J. Robertson: Consultant for Medtronic. All other authors disclosed no financial relationships relevant to this publication.

    This article is being published jointly in Gastroenterology, American Journal of Gastroenterology, and Gastrointestinal Endoscopy.

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