Colorectal Cancer Screening

1. See Also
   1. Colorectal Cancer Prevention
2. Epidemiology
   1. In the U.S., only 62% are up-to-date with Colorectal Cancer Screening
      1. White (2015) MMWR Morb Mortal Wkly Rep 66(17):201-6 [PubMed]
3. Indications
   1. Colon Cancer screening starting at age 45 years old (earlier if high risk, was age 50 prior to 2021)
   2. Colon Cancer screening in adults up to age 76-85 years
4. Diagnostics
   1. Colonoscopy (95% of Colon Cancer)
   2. Fecal Occult Blood Testing (FOBT, 26% of Colon Cancer)
      1. Poor sensitivity for adenomatous polyps and serrated polyps >1 cm
      2. Tests
         1. High Sensitivity Fecal Immunochemical (FIT, yearly, preferred FOBT)
         2. FIT-DNA (Cologuard, every 3 years, increased False Positives)
         3. Guaiac-based (gFOBT, not recommended)
   3. Digital Rectal Exam (5-10% of Colon Cancer)
   4. Flexible Sigmoidoscopy (50-60% of Colon Cancer)
   5. Barium Enema (32 to 53% of Colon Cancer)
5. Efficacy: Optimal Tools and Endoscopists
   1. Colonoscopy is 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
      3. Lieberman (2000) N Engl J Med 343:207-8 [PubMed]
      4. Lieberman (2001) N Engl J Med 345:555-60 [PubMed]
      5. Segnan (2007) Gastroenterology 132(7): 2304-12 [PubMed]
   2. High quality endoscopist criteria
      1. Reach cecum in 95% of screening colonoscopies (cecal intubation rate)
      2. Detect adenomas in 15% of women, 25% of men on screening Colonoscopy age >50 years old
      3. Rex (2009) Am J Gastroenterol 104(3): 739-50 [PubMed]
6. Diagnostics: Experimental Tools
   1. Stool DNA mutation testing for colorectal neoplasia
   2. Virtual Colonoscopy (Computed Tomographic Colonography)
   3. Circulating Methylated SEPT9 DNA (Epi proColon)
      1. Test Sensitivity 48% (not recommended for Colorectal Cancer Screening)
      2. Church (2014) Gut 63(2): 317-25 [PubMed]
   4. 3D Magnetic Resonance Colonography (MRC)
      1. Approaches sensitivity and Specificity of Colonoscopy
      2. Tolerated better than Colonoscopy
7. Protocol: Screening Average Risk (Age 45 years and older)
   1. Timing
      1. Start screening at age 45 years
         1. Prior to 2021, Colorectal Cancer Screening was recommended to start at age 50 years old
         2. Universal screening is now recommended to start at age 45 years old if no additional risk factors
         3. Of new Colon Cancer cases, 10% are found at age 50 years old
         4. (2021) JAMA 325(19):1965-77 +PMID: 34003218 [PubMed]
      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 (per USPTF)
      1. Colonoscopy every 10 years (preferred) or
      2. High Sensitivity Fecal Occult Blood Testing (FOBT) every year or
      3. Flexible Sigmoidoscopy every 5 years AND high sensitivity FOBT every 3 years
   3. 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 [PubMed]
8. Protocol: Screening Moderate Risk
   1. Higher risk Family History (RR 3-4x)
      1. Criteria
         1. One first degree relative with Colorectal Cancer or advanced adenoma before age 60 years
         2. Two first degree relatives with Colorectal Cancer or advanced adenoma at any age
      2. Protocol
         1. Start: Colonoscopy at age 40 years or Colonoscopy 10 years earlier than youngest case
         2. Repeat Colonoscopy every 5 years
   2. Moderate risk Family History (RR 2-3x)
      1. Criteria
         1. One first degree relative with Colorectal Cancer or advanced adenoma age 60 years or older
         2. Two second degree relatives with Colorectal Cancer or advanced adenoma at any age
      2. Protocol
         1. Start: Colonoscopy at age 40 years
         2. Repeat Colonoscopy every 10 years
9. Protocol: Screening High Risk
   1. 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
   2. Hereditary non-polyposis Colon Cancer (HNPCC, Lynch Syndrome)
      1. See Hereditary non-polyposis Colon Cancer (HNPCC) for surveillance guidelines
   3. Adenomatous Polyposis Syndromes
      1. See Adenomatous Polyposis Syndrome for screening protocols
      2. Familial Adenomatous Polyposis (>100 synchronous advanced adenomas)
      3. Attenuated Familial Adenomatous Polyposis (10-99 synchronous advanced adenomas)
      4. MUTYH-Associated Polyposis (<100 synchronous advanced adenomas)
   4. Inflammatory Bowel Disease
      1. Background
         1. Ulcerative ColitisColorectal Cancer risk increases with duration since diagnosis
            1. Colorectal Cancer risk 2% at 10 years of disease and 18% at 30 years of disease
         2. Crohns Disease lifetime risk of Colorectal Cancer: 4-5%
      2. Protocol
         1. Colonoscopy with biopsy for dysplasia starting at 8-10 years from onset of symptoms
         2. Repeat Colonoscopy every 1-3 years (yearly if Primary Sclerosing Cholangitis)
   5. Peutz-Jeghers Syndrome (Hamartomatous Polyposis)
      1. See Peutz-Jeghers Syndrome (Hamartomatous Polyposis) for screening protocol
   6. Sessile Serrated Adenomatous Polyposis (5 or more proximal to sigmoid, 2 or more >1 cm)
      1. See Sessile Serrated Adenomatous Polyposis for screening protocol
10. Protocol: Surveillance Colonoscopy after Polypectomy
    1. See Colon Polyp
    2. Precautions: Shorter follow-up interval indications
       1. Inadequate Bowel Preparation
       2. Cecum not reached
       3. Piecemeal or incomplete polyp resection
    3. Return in 10 years for repeat Colonoscopy or per normal intervals
       1. No polyps or normal biopsy
       2. Small (<10 mm) hyperplastic polyps in Rectum or sigmoid
    4. Return in 5-10 years for repeat Colonoscopy (then, if normal, at 10 year intervals)
       1. Single, small tubular adenomatous polyps (<1 cm)
    5. Return in 5 years for repeat Colonoscopy (then, if normal, at 10 year intervals)
       1. Small, sessile serrated polyps (<1 cm) without dysplasia
    6. Return in 3 years for repeat Colonoscopy (then, if normal, every 5 years)
       1. Large (>1 cm) or Multiple (3-10) tubular adenomatous polyps
       2. Adenoma with villous features or high grade dysplasia
       3. Sessile serrated polyp with cytologic dysplasia
       4. Traditional serrated adenoma
    7. Return in <3 years for repeat Colonoscopy
       1. More than 10 adenomatous polyps
    8. Return in 1 year for repeat Colonoscopy
       1. Serrated polyposis syndrome
       2. Piecemeal removal of a large (>15 mm) sessile adenoma or serrated polyp
    9. References
       1. Levin (2008) Gastroenterology 134: 1570-95 [PubMed]
       2. Rex (2009) Am J Gastroenterol 104(3): 739-50 [PubMed]
       3. Winawer (2006) Ca Cancer J Clin 56:143-59 [PubMed]
11. Resources
    1. USPTF Colorectal Cancer Screening Guidelines
       1. http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm
12. References
    1. Pappalardo (2000) Gastroenterology 119:300-4 [PubMed]
    2. Pignone (2002) Am Fam Physician 66(2):297-302 [PubMed]
    3. Rex (2009) Am J Gastroenterol 104(3): 739-50 [PubMed]
    4. Short (2014) Am Fam Physician 91(2): 93-100 [PubMed]
    5. Smith (2000) CA Cancer J Clin 50:34-49 [PubMed]
    6. Walsh (2003) JAMA 289:1288-96 [PubMed]
    7. Wilkins (2018) Am Fam Physician 97(2): 111-6 [PubMed]
    8. Zoorob (2001) Am Fam Physician 63(6):1101-12 [PubMed]