Special articleColorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer
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.
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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
Disclosure
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.
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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