Colorectal Cancer Screening Guidelines for EHHOP
CCS should update the COLONOSCOPY TRACKER with most updated results + pathology report. Never assume that a FU is in 10 years.
The following guidelines are based on those published by the United States Preventive Services Task Force (USPSTF), the American Cancer Society (ACS), the American College of Radiology (ACR), the US Multi-Society Task Force on Colorectal Cancer (USMSTF), the American College of Gastroenterology (ACG), and the American College of Physicians (ACP) [1-4].
A major issue currently facing colorectal cancer screening is the effectiveness of stool-based testing compared with colonoscopy, which is the currently accepted gold standard. While stool-based testing has a proven mortality benefit, positive tests are followed by colonoscopy with polypectomy, which confounds conclusions about the superiority of stool-based testing to colonoscopy [5]. The first randomized controlled trials directly comparing colonoscopy and a stool-based test with death from colorectal cancer at 10 years as a primary outcome are currently ongoing [6]. Colonoscopy permits direct imaging of the whole colon as well as therapeutic intervention upon pre-cancerous adenomas, and there is strong evidence that incidence of colorectal cancer is decreased after lower endoscopy [7].
There is consensus among all guidelines that a positive result on any other test must by followed by colonoscopy [8]. Additionally, endoscopic and radiologic tests have been described by several published guidelines as detecting both adenomas and cancer (also known as “cancer prevention tests”), to differentiate them from the stool-based tests, which primarily detect cancer. The ACS/USMSTF/ACR and ACG prefer tests which detect pre-cancerous as well as cancerous lesions, recommending that stool-based testing be offered only to patients who decline more sensitive endoscopic or radiologic testing. Recognizing that less-invasive stool-based testing may be more acceptable to certain patients, and that adherence to any screening regimen is better than non-adherence to an unacceptable regimen, the USPSTF and ACP recommend both stool-based and endoscopic testing equally.
At EHHOP, we are able to provide screening colonoscopies through a grant held by Dr. Steven Itzkowitz of the Division of Gastroenterology. Recognizing this financial advantage, as well as colonoscopy being a single diagnostic and therapeutic test, we recommend colonoscopy as the preferred colorectal cancer screening test for EHHOP patients. While we agree with the USPSTF and ACP that the best test is the one to which the patient will adhere, we also agree with the ACS/USMSTF/ACR and ACG that colonoscopy should be offered before other tests. Should this grant terminate, however, access to screening colonoscopy will be limited thus warranting an update to current EHHOP guidelines.
Note that these guidelines are primarily for colorectal cancer screening in asymptomatic, average-risk patients. If a patient has an adenoma or other lesion detected on colonoscopy, the surveillance recommendations of the gastroenterologist performing the procedure should be followed. In general, these should adhere to the 2012 USMSTF surveillance guidelines, which have been endorsed by ACG, ACR, ACS, the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE) [9,10].
Guidelines
Population to screen:
- All persons ≥ 45 years of age, except as noted below.
- EXCEPTIONS: Persons 45 years and older with life spans estimated at less than 10 years. These include persons of advanced age with severe frailty and debility, and all persons with ADVANCED cardiovascular, pulmonary, liver or renal disease including ALL PATIENTS ON DIALYSIS. Patients with existing cancers should be assessed for necessity of colon cancer screening on a case-by-case basis.
Screening Tests and Frequency of Screening:
- Colonoscopy
- This is the preferred colorectal cancer screening test for EHHOP. All patients should be counseled on the benefits of colonoscopy, including its role as a diagnostic and therapeutic procedure and its ability to detect and remove precancerous lesions, as well as the associated risks, including risks of bleeding requiring transfusion and colonic perforation, which occur on the order of 1 in 1000 colonoscopies [11].
- If a patient declines colonoscopy, we recommend documenting this in the chart and revisiting the issue with him on several subsequent visits before offering alternate screening options. Try to ascertain reasons for refusal and willingness to undergo colonoscopy if the patient has a positive result on alternative testing (ie stool testing).
- Frequency: every 10 years
- Fecal Immunochemical Test (FIT Test)
- This is appropriate for patients who persistently refuse colonoscopy. Patients must be counseled that a positive test requires colonoscopy for further evaluation.
- Proper stool testing only requires one stool sample, which should be returned to EHHOP within 24 hours of collection. Please see the Teaching Senior in clinic for help in assembling a kit for a patient from materials in the lab, which can be found in room 210.
- Please return directly to EHHOP, do not mail sample, otherwise EHHOP will be billed.
- Frequency: annually
- CT Colonography
- While very sensitive and specific, this test requires an identical bowel preparation as colonoscopy. It is not covered by our colonoscopy grant, and is thus more expensive for our patients and our clinic, so is, in general, not recommended.
- Frequency: every 5 years
- Flexible Sigmoidoscopy
- This test would require gastroenterology referral, and is also not covered under our grant, so is, in general, not recommended.
- Frequency: every 5 years, combined with fecal occult blood testing every 3 years1
Unacceptable Screening Tests:
- Digital rectal exam with guaiac testing
- The sensitivity and specificity of a single guaiac obtained from an in-office rectal exam are exceedingly poor for detection of cancer or adenomas. This should NOT be performed for colorectal cancer screening. Proper stool testing requires collection from three stools, as described above [8].
Special Populations:
- Persons who report a prior colonoscopy but do not have results
- All efforts should be made to obtain record of prior colonoscopy.
- If documentation is unable to be obtained, we recommend performing a colonoscopy 3 years after the reported colonoscopy. Per surveillance guidelines, most adenomas found on colonoscopy require a follow-up at 3 years, so we feel this is a safe interval at which to repeat colonoscopy and obtain a documented test [9].
- Persons with a family history of colorectal cancer or advanced adenomas (≥1 cm, high-grade dysplasia, or villous elements)3
- Single first degree relative with colorectal cancer or advanced adenoma diagnosed at age < 60 years: begin screening at age 40 or 10 years younger than the earliest diagnosis in the family, whichever comes first. Colonoscopy every 5 years is the only acceptable screening option.
- Single first degree relative with colorectal cancer or advanced adenoma diagnosed at age > 60 years: follow screening recommendations for average risk patients described above.
- Two first degree relatives with colorectal cancer or advanced adenoma diagnosed at any age: begin screening at age 40 or 10 years younger than the earliest diagnosis in the family, whichever comes first. Colonoscopy every 5 years is the only acceptable screening option.
- If the family history of an adenoma is not clearly documented as advanced, the patient should be screened as average risk. Patients lacking documentation should be encouraged to pursue such with their affected family member.
- Persons with high-risk familial syndromes (Hereditary Non-Polyposis Colorectal Cancer or Familial Adenomatous Polyposis) require more frequent screening and should be referred to gastroenterology for evaluation.
- Persons on long-term immunosuppressive agents in general should adhere to the screening guidelines above. At this time there is no clear recommendation for increased surveillance in such persons.
References
U.S. Preventive Services Task Force. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2008;149:627-637.
Levin B, et al. 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. CA Cancer J Clin 2008;58:130-160.
Rex DK, et al. American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008. Am J Gastroenterol 2009;104:739-750.
Qaseem A, et al. Screening for Colorectal Cancer: A Guidance Statement From the American College of Physicans. Ann Intern Med 2012;156:378-386.
Shaukat A, et al. Long-Term Mortality after Screening for Colorectal Cancer. N Engl J Med 2013;369:1106-1114.
Quintero E, et al. Colonoscopy versus Fectal Immunochemical Testing in Colorectal-Cancer Screening. N Engl J Med 2012;366:697-706.
Nishihara R, et al. Long-Term Colorectal-Cancer Incidence and Mortality after Lower Endoscopy. N Engl J Med 2013;369:1095-1105.
Fletcher RH. Screening for colorectal cancer: Strategies in patients at average risk. LaMont JT, Sokol HN, eds. UpToDate 15 Jan 2014. www.uptodate.com/contents/screening-for-colorectal-cancer-strategies-in-patients-at-average-risk
Liberman DA. Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844-857.
Ahnen DJ, Macrae FA. Approach to the patient with colonic polyps. Rutgeerts P, Grover S, eds. UpToDate 3 Dec 2013. www.uptodate.com/contents/approach-to-the-patient-with-colonic-polyps
Lee L, Saltzman JR. Overview of colonoscopy in adults. Howell DA, Travis AC, eds. UpToDate 29 Jan 2014.