Colorectal Cancer Screening

1. See Also
   1. Colorectal Cancer Prevention
2. Indications
   1. Colon Cancer screening in adults up to age 76-85 years
3. Diagnostics
   1. Fecal Occult Blood Testing (26% of Colon Cancer)
   2. Digital Rectal Exam (5-10% of Colon Cancer)
   3. Flexible Sigmoidoscopy (50-60% of Colon Cancer)
   4. Colonoscopy (95% of Colon Cancer)
   5. Barium Enema (32 to 53% of Colon Cancer)
4. Diagnostics: Optimal Tools
   1. Colonoscopy may be preferred for all screening (best single test efficacy)
      1. Flexible Sigmoidoscopy misses 25% of lesions (proximal)
      2. Occult blood does not increase Flexible Sigmoidoscopy sensitivity
   2. References
      1. Lieberman (2000) N Engl J Med 343:207-8
      2. Lieberman (2001) N Engl J Med 345:555-60
      3. Segnan (2007) Gastroenterology 132(7): 2304-12
5. Diagnostics: Experimental Tools
   1. Stool DNA mutation testing for colorectal neoplasia
   2. Virtual Colonoscopy (Computed Tomographic Colonography)
   3. 3D Magnetic Resonance Colonography (MRC)
      1. Approaches sensitivity and Specificity of Colonoscopy
      2. Tolerated better than Colonoscopy
6. Protocol: Average Risk (Age 50 years and older)
   1. Timing
      1. Start screening at age 50 years
      2. Stop screening at age 75 to 85 years old
         1. Depending on guidelines - USPTF recommends stopping at age 75 years
   2. First-line screening procedures
      1. Colonoscopy every 10 years (preferred)
   3. Alternative screening procedures
      1. Flexible Sigmoidoscopy every 5 years or
      2. Fecal Occult Blood testing
   4. Colorectal screening procedures that are no longer recommended
      1. Digital Rectal Exam
      2. Double contrast Barium Enema
         1. Not recommended as an alternative to endoscopy by American College of Gastroenterology
            1. Colonoscopy preferred for full colon evaluation
         2. Black women (high Incidence proximal Colon Cancer)
            1. Nelson (1997) Cancer 80:193-7
7. Protocol: Moderate Risk
   1. Single, Small Adenomatous Polyps (<1 cm)
      1. Colonoscopy at Initial polyp diagnosis
      2. Repeat Colonoscopy
         1. Within 3 years after initial polyp Diagnosis
         2. If normal, as per Average Risk Recommendations
   2. Large or multiple adenomatous polyps (>1 cm)
      1. Colonoscopy at initial polyp diagnosis
      2. Normal Colonoscopy protocol (assumes no recurrence)
         1. Repeat Colonoscopy 3 years after initial polyp
         2. Repeat Colonoscopy every 5 years
   3. History curative intent resection Colorectal Cancer
      1. Colonoscopy at Initial polyp diagnosis
      2. Normal Colonoscopy protocol (assumes no recurrence)
         1. Repeat Colonoscopy in 1 year
         2. Repeat Colonoscopy in 3 years
         3. Repeat Colonoscopy every 5 years
   4. First degree relative of Colorectal Cancer or adenoma under age 60 years (or 2 first degree relatives with onset at any age)
      1. Start: Colonoscopy at age 40 years or Colonoscopy 10 years earlier than youngest case
      2. Repeat Colonoscopy every 5 years
   5. First degree relative of Colorectal Cancer or adenoma at age over 60 years (or 2 second degree relatives with onset at any age)
      1. Start: Colonoscopy at age 40 years
      2. Repeat Colonoscopy every 10 years
   6. References
      1. Levin (2008) Gastroenterology 134: 1570-95
8. Protocol: High Risk
   1. Familial adenomatous polyposis
      1. Early surveillance
         1. Colonoscopy starting at Puberty
      2. Counseling to consider genetic testing
      3. Genetic Testing positive or polyposis confirmed
         1. Consider colectomy or
         2. Endoscopy every 1-2 years
   2. Hereditary non-polyposis Colon Cancer
      1. Early surveillance
         1. Colonoscopy starting at Age 21 years
      2. Counseling to consider genetic testing
      3. Genetic Testing positive or No genetic testing
         1. Colonoscopy every 2 yrs until age 40
         2. Colonoscopy yearly after age 40
   3. Inflammatory Bowel Disease
      1. Colonoscopy with biopsy for dysplasia
         1. Pancolitis: 8 years after the start or
         2. Left sided Colitis: 12-15 years after the start
      2. Repeat Colonoscopy every 1-2 years
9. Resources
   1. USPTF Colorectal Cancer Screening Guidelines
      1. http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm
10. References
    1. Pappalardo (2000) Gastroenterology 119:300-4
    2. Pignone (2002) Am Fam Physician 66(2):297-302
    3. Rex (2009) Am J Gastroenterol 104(3): 739-50
    4. Smith (2000) CA Cancer J Clin 50:34-49
    5. Walsh (2003) JAMA 289:1288-96
    6. Zoorob (2001) Am Fam Physician 63(6):1101-12