Current Colorectal Cancer (CRC) Screening & Surveillance Guidelines

March is ‘Colon Cancer Awareness’ month. Colorectal cancer is the second leading cause of cancer-related deaths among women and men combined, second only to lung cancer.  We thought it was fitting to describe the current guidelines for colorectal cancer (CRC) screening and surveillance.  Screening refers to a routine screening test in an asymptomatic patient.  In the case of CRC, this most commonly takes the form of a colonoscopy for a 50-year-old patient.  Surveillance refers to a follow up examination; for example, a follow up colonoscopy for a patient who is found to have polyps at the initial colonoscopy.

There are three screening guidelines for CRC, all from 2008.  These include the U.S. Multi-Society Task Force (MSTF); the U.S. Preventive Services Task Force (USPSTF); and the American College of Gastroenterology (ACG).   As for colon polyp and/or CRC surveillance guidelines, the major GI societies have issued a joint consensus statement in a report from 2012.

The ACG guidelines offer the clearest and simplest approach to CRC screening.  The other two guidelines (MSTF & USPSTF) are similar to the ACG guidelines but are a bit more complicated and offer a ‘menu of options’ strategy.  The ACG guidelines offer a ‘preferred’ strategy that simplifies and shortens discussions with patients.  One study showed that patients were more likely to undergo CRC screening with the ‘preferred’ strategy approach compared with the more complicated ‘menu of options’ approach.  The guidelines outlined below apply only to asymptomatic patients without a family history of CRC or a personal history of inflammatory bowel disease or a polyposis syndrome.

We have included the complete articles for your reference:

• American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008
• 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
• Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer
• Screening for Colorectal Cancer: U.S. Preventive Services Task Force
  Recommendation Statement

ACG CRC screening guidelines (2008)

Preferred

• Colonoscopy every 10 yrs, beginning at age 50 for both sexes. Screening should begin at age 45 in African Americans. The 10 yr interval assumes a quality exam with no polyps or cancer identified.

Alternative

• Sigmoidoscopy every 5-10 yrs – OR –
• CT colonoscopy (formerly Virtual Colonoscopy) every 5 yrs
• If a patient declines any of the above tests, then annual FIT (fecal immunochemical test) should be offered. FIT is superior to FOBT (guaiac-based fecal occult blood test).

Stool tests (FIT or FOBT) are not necessary within 5 years of a colonoscopy

The decision to continue colonoscopy in the elderly should be individualized based on an assessment of benefit, risk and other medical conditions.

GI societies surveillance guidelines (2012)

• Colonoscopy finds no polyps or small hyperplastic polyps in the rectum or sigmoid colon:
  Next colonoscopy in 10 yrs 
• Colonoscopy finds low-risk adenomas defined as 1-2 tubular adenomas <10 mm:
  Next colonoscopy in 5-10 yrs
• Colonoscopy finds benign, but high-risk polyps including: adenoma >=10 mm, or with villous histology, high grade dysplasia; three or more adenomas; sessile serrated lesions which are dysplastic and/or >=10mm:
  Next colonoscopy in 3 yrs

It is important to note that other factors come into play when determining the appropriate interval for the patient’s next colonoscopy. Gastroenterologists take into account the quality of the preparation, confounding anatomy issues (e.g. severe diverticular disease), concomitant medical problems, and family history.