//fpnotebook.com/
Colorectal Cancer Screening
Aka: Colorectal Cancer Screening, Colonoscopy Intervals for Colon Cancer Screening
- See Also
- Colorectal Cancer Prevention
- Epidemiology
- In the U.S., only 62% are up-to-date with Colorectal Cancer Screening
- White (2015) MMWR Morb Mortal Wkly Rep 66(17):201-6 [PubMed]
- Indications
- Colon Cancer screening starting at age 50 years old (earlier if high risk)
- Colon Cancer screening in adults up to age 76-85 years
- Diagnostics
- Fecal Occult Blood Testing (26% of Colon Cancer)
- Tests include Guaiac-based (gFOBT), Fecal Immunochemical (FIT), and FIT-DNA
- Poor sensitivity for adenomatous polyps and serrated polyps >1 cm
- Digital Rectal Exam (5-10% of Colon Cancer)
- Flexible Sigmoidoscopy (50-60% of Colon Cancer)
- Colonoscopy (95% of Colon Cancer)
- Barium Enema (32 to 53% of Colon Cancer)
- Efficacy: Optimal Tools and Endoscopists
- Colonoscopy may be preferred for all screening (best single test efficacy)
- Flexible Sigmoidoscopy misses 25% of lesions (proximal)
- Occult blood does not increase Flexible Sigmoidoscopy sensitivity
- Lieberman (2000) N Engl J Med 343:207-8 [PubMed]
- Lieberman (2001) N Engl J Med 345:555-60 [PubMed]
- Segnan (2007) Gastroenterology 132(7): 2304-12 [PubMed]
- High quality endoscopist criteria
- Reach cecum in 95% of screening colonoscopies (cecal intubation rate)
- Detect adenomas in 15% of women, 25% of men on screening Colonoscopy age >50 years old
- Rex (2009) Am J Gastroenterol 104(3): 739-50 [PubMed]
- Diagnostics: Experimental Tools
- Stool DNA mutation testing for colorectal neoplasia
- Virtual Colonoscopy (Computed Tomographic Colonography)
- Circulating Methylated SEPT9 DNA (Epi proColon)
- Test Sensitivity 48% (not recommended for Colorectal Cancer Screening)
- Church (2014) Gut 63(2): 317-25 [PubMed]
- 3D Magnetic Resonance Colonography (MRC)
- Approaches sensitivity and Specificity of Colonoscopy
- Tolerated better than Colonoscopy
- Protocol: Screening Average Risk (Age 50 years and older)
- Timing
- Start screening at age 50 years
- American College of Gastroenterology recommends black patients start screening at 45 years old
- Stop screening at age 75 to 85 years old
- Depending on guidelines (USPTF recommends stopping at age 75 years)
- First-line screening procedures (per USPTF)
- Colonoscopy every 10 years (preferred) or
- High Sensitivity Fecal Occult Blood Testing (FOBT) every year or
- Flexible Sigmoidoscopy every 5 years AND high sensitivity FOBT every 3 years
- Colorectal screening procedures that are no longer recommended
- Digital Rectal Exam
- Double contrast Barium Enema
- Not recommended as an alternative to endoscopy by American College of Gastroenterology
- Colonoscopy preferred for full colon evaluation
- Black women (high Incidence proximal Colon Cancer)
- Nelson (1997) Cancer 80:193-7 [PubMed]
- Protocol: Screening Moderate Risk
- Higher risk Family History (RR 3-4x)
- Criteria
- One first degree relative with Colorectal Cancer or advanced adenoma before age 60 years
- Two first degree relatives with Colorectal Cancer or advanced adenoma at any age
- Protocol
- Start: Colonoscopy at age 40 years or Colonoscopy 10 years earlier than youngest case
- Repeat Colonoscopy every 5 years
- Moderate risk Family History (RR 2-3x)
- Criteria
- One first degree relative with Colorectal Cancer or advanced adenoma age 60 years or older
- Two second degree relatives with Colorectal Cancer or advanced adenoma at any age
- Protocol
- Start: Colonoscopy at age 40 years
- Repeat Colonoscopy every 10 years
- Protocol: Screening High Risk
- History curative intent resection Colorectal Cancer
- Colonoscopy at Initial polyp diagnosis
- Normal Colonoscopy protocol (assumes no recurrence)
- Repeat Colonoscopy in 1 year
- Repeat Colonoscopy in 3 years
- Repeat Colonoscopy every 5 years
- Hereditary non-polyposis Colon Cancer (HNPCC, Lynch Syndrome)
- See Hereditary non-polyposis Colon Cancer (HNPCC) for surveillance guidelines
- Adenomatous Polyposis Syndromes
- See Adenomatous Polyposis Syndrome for screening protocols
- Familial Adenomatous Polyposis (>100 synchronous advanced adenomas)
- Attenuated Familial Adenomatous Polyposis (10-99 synchronous advanced adenomas)
- MUTYH-Associated Polyposis (<100 synchronous advanced adenomas)
- Inflammatory Bowel Disease
- Background
- Ulcerative ColitisColorectal Cancer risk increases with duration since diagnosis
- Colorectal Cancer risk 2% at 10 years of disease and 18% at 30 years of disease
- Crohns Disease lifetime risk of Colorectal Cancer: 4-5%
- Protocol
- Colonoscopy with biopsy for dysplasia starting at 8-10 years from onset of symptoms
- Repeat Colonoscopy every 1-3 years (yearly if Primary Sclerosing Cholangitis)
- Peutz-Jeghers Syndrome (Hamartomatous Polyposis)
- See Peutz-Jeghers Syndrome (Hamartomatous Polyposis) for screening protocol
- Sessile Serrated Adenomatous Polyposis (5 or more proximal to sigmoid, 2 or more >1 cm)
- See Sessile Serrated Adenomatous Polyposis for screening protocol
- Protocol: Surveillance Colonoscopy after Polypectomy
- See Colon Polyp
- Precautions: Shorter follow-up interval indications
- Inadequate Bowel Preparation
- Cecum not reached
- Piecemeal or incomplete polyp resection
- Return in 10 years for repeat Colonoscopy or per normal intervals
- No polyps or normal biopsy
- Small (<10 mm) hyperplastic polyps in Rectum or sigmoid
- Return in 5-10 years for repeat Colonoscopy (then, if normal, at 10 year intervals)
- Single, small tubular adenomatous polyps (<1 cm)
- Return in 5 years for repeat Colonoscopy (then, if normal, at 10 year intervals)
- Small, sessile serrated polyps (<1 cm) without dysplasia
- Return in 3 years for repeat Colonoscopy (then, if normal, every 5 years)
- Large (>1 cm) or Multiple (3-10) tubular adenomatous polyps
- Adenoma with villous features or high grade dysplasia
- Sessile serrated polyp with cytologic dysplasia
- Traditional serrated adenoma
- Return in <3 years for repeat Colonoscopy
- More than 10 adenomatous polyps
- Return in 1 year for repeat Colonoscopy
- Serrated polyposis syndrome
- Piecemeal removal of a large (>15 mm) sessile adenoma or serrated polyp
- References
- Levin (2008) Gastroenterology 134: 1570-95 [PubMed]
- Rex (2009) Am J Gastroenterol 104(3): 739-50 [PubMed]
- Winawer (2006) Ca Cancer J Clin 56:143-59 [PubMed]
- Resources
- USPTF Colorectal Cancer Screening Guidelines
- http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm
- References
- Pappalardo (2000) Gastroenterology 119:300-4 [PubMed]
- Pignone (2002) Am Fam Physician 66(2):297-302 [PubMed]
- Rex (2009) Am J Gastroenterol 104(3): 739-50 [PubMed]
- Short (2014) Am Fam Physician 91(2): 93-100 [PubMed]
- Smith (2000) CA Cancer J Clin 50:34-49 [PubMed]
- Walsh (2003) JAMA 289:1288-96 [PubMed]
- Wilkins (2018) Am Fam Physician 97(2): 111-6 [PubMed]
- Zoorob (2001) Am Fam Physician 63(6):1101-12 [PubMed]