Guidelines

The majority of national guidelines have updated their recommendations to lower the starting screening age to 45 years in average risk individuals.1-5,a The guidelines suggest that whether to screen patients older than 75 years should be an individualized decision.1-5,a Many national guidelines recommend shared decision-making to improve screening adherence.1-4,a

Guidelines Downloads

Additional Information on CRC screening recommendations 

CRC Screening Recommendations Download

Additional Information on Average Risk and High Risk for CRC

Definition of Average Risk and High Risk Download

SUMMARY OF CURRENT GUIDELINE RECOMMENDATIONS AND CHOICE OF TEST

 Recommendations USPSTF 20211 ACS 20183 NCCN  Guidelines®
 20214,a
ACG 20212  MSTF 20215,c
 Choice of Test  Clinicians and patients may consider a variety of factors in deciding which test may be best for each person  High-sensitivity stool-  based test or a structural (visual) exam, depending on patient preference and test availability Discussion of potential harms/risks and benefits and consideration of all recommended CRC screening options  Colonoscopy and FIT as primary screening modalities, with flex sig, mt-sDNA, CTC, or colon capsule for those unable or unwilling to undergo colonoscopy or FIT

 Screening with colonoscopy every 10 years or annual FIT as first-tier options
 Colonoscopy  Every 10 years Every 10 years Every 10 years    Every 10 years  Every 10 years
(Tier 1)
 CT colonography  Every 5 years Every 5 years    Every 5 years  Every 5 years  Every 5 years
(Tier 2)
 FS  Every 5 years Every 5 years  Every 5-10 years  Every 5-10 years  Every 5 or 10 years (Tier 2)
FS with FIT   FS every 10 years with annual FIT  --  --  --  --
 Capsule Colonoscopy  -- -- -- Every 5 years Every 5 years
(Tier 3)
 
 hs-gFOBT Annual Annual Annual --  --
 FIT Annual Annual  Annual Annual  Annual (Tier 1)
   mt-sDNAb  Every 1 to 3 years Every 3 years    Every 3 years
 
 Every 3 years
 
 Every 3 years
(Tier 2)
 All Positive Results On Non-colonoscopy Screening Tests Should Be Followed Up with a Timely Colonoscopy1-5,a
 

All positive results on non-colonoscopy screening tests should be followed up with a timely colonoscopy1-5,a


  • There is a trend for increasing incidence of CRC in adults younger than age 50, and modeling suggests that starting CRC screening at age 45 may moderately increase life-years gained and decrease CRC cases and deaths compared with beginning at age 501, 9-11
  • Study data cited in the USPSTF guidelines reflect the accuracy of each method after only a single application rather than a series of repeated screenings1

NATIONAL GUIDELINES RECOMMEND SHARED DECISION MAKING TO IMPROVE SCREENING ADHERENCE

 National Guidelines Recommend Shared Decision Making to Improve Screening Adherence
US Preventive
Services Task Force
(USPSTF)
 20211
 
“Several recommended screening tests are available. Clinicians and patients may consider a variety of factors in deciding which test may be best for each person”

“Discussion with patients may help better identify screening tests that are more likely to be completed by a given individual”

American Cancer Society
(ACS)
 20183

 “The importance of offering a choice between structural or stool-based testing is included in this guideline in recognition of the role of patient values and preferences and as a practical implementation strategy to improve adherence”
 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) 20214,a
 “Because there are multiple options for screening, the choice of a particular screening modality should include a conversation with the patient concerning their preference and resource availability”

American College of Gastroenterology
(
ACG) 20212


“The ‘ideal’ screening test should be noninvasive, have high sensitivity and specificity, be safe, readily available, convenient, and inexpensive. For CRC screening, there are multiple approved tests and strategies, each with its strengths and weaknesses. In some instances, the ‘best’ screening test can be considered the one that is acceptable to the patient and gets completed.”

 
  • In shared decision making, health care providers offer options and describe their risks and benefits, and patients express their preferences and values8
  • Each screening modality has different considerations for implementation that may facilitate patient uptake of and adherence to screening or serve as a barrier1
  • Because adherence to continued screening is important, it is recommended to discuss screening considerations with each individual to determine the best screening program for them based on their preferences and availability1,4,a

Members of the Guideline Panels for National Organizations

 USPSTF12  ACS13,3  National Comprehensive Cancer Network® 
(NCCN®)4,14,15,a
 ACG2,17  MSTF16-19
  •  Independent, volunteer panel of national experts in prevention and evidence-based medicine
  • 16 nationally recognized experts in fields including behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing
  • Members are appointed by the Director of AHRQ to serve 4-year terms and screened to ensure they have no substantial conflicts of interest
  •  Community-based voluntary health organization dedicated to eliminating cancer as a major health problem
  • ACS Guideline Development Group: multidisciplinary panel of volunteers (generalist clinicians, biostatisticians, epidemiologists, economists, and patient representative)
  • CRC Screening Guidelines: 6 members with primary responsibility for reviewing evidence and drafting recommendations (entire panel reviewed and voted on update)
  • Expert advisors in areas of CRC natural history, detection, diagnosis, and decision making also involved in consultation and review
  •  Not-for-profit alliance of 30 leading cancer centers devoted to patient care, research, and education
  • Guidelines Development Group: Guidelines Steering Committee, Panels specific to each Guideline, and the headquarters Team
  • Guidelines Panels should represent all core medical specialties and clinical expertise involved in care delivered by the Guideline, including patient advocate and primary care physician where possible
  • CRC Screening Guidelines panel: members from the fields of cancer genetics, gastroenterology, internal medicine, medical oncology, pathology, patient advocacy, surgery and surgical oncology
  •  Professional association of ~15,000 GI professionals in the US and worldwide that champions the prevention, diagnosis, and treatment of digestive disorders, serving as a beacon to guide the delivery of the highest quality, compassionate, and evidence-based patient care
  • Guidelines produced in collaboration with Practice Parameters Committee of the ACG
  • Panel of expert gastroenterologists representing the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE)
  •  ACG is a professional organization that champions the prevention, diagnosis, and treatment of digestive disorders
  • AGA includes international members involved in all aspects of science, practice, and advancement

AVERAGE- VS HIGH-RISK

Tables comparing average risk and high risk

ACG: American College of Gastroenterology, ACS: American Cancer Society, CRC: colorectal cancer, CTC: computed tomography colonography, FIT: fecal immunochemical test, FS: flexible sigmoidoscopy, hs-gFOBT: high sensitivity guaiac-based fecal occult blood test, MSTF: United States Multi-Society Task Force on Colorectal Cancer. mt-sDNA: multi-target stool DNA test, NCCN: National Comprehensive Cancer Network, USPSTF: United States Preventive Services Task Force.

 

References

Davidson KW, Barry MJ, Mangione CM, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977.
Shaukat A,
Kahi CJ, Burke CA, et al. ACG clinical guidelines: colorectal cancer screening 2021. Am J Gastroenterol. 2021;116:458-479.
Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250-281.
4 
Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Colorectal Cancer Screening. V.2.2021. © National Comprehensive Cancer Network, Inc. 2022.  All rights reserved. Accessed February 23, 2022. To view the most recent and complete version of the guideline, go online to NCCN.org.
5 Patel SG, May FP, Anderson JC, et al. Updates on age to start and stop colorectal cancer screening: recommendations from the US Multi-Society Task Force on Colorectal Cancer. Gastroenterol. 2022:162(1):285-299.
6 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Genetic/familial high-risk assessment: colorectal. Version 1.2021. May 11, 2021. Accessed December 10, 2021. https://www.nccn.org/professionals/physician_gls/pdf/genetics_colon.pdf 
7 
Gupta S, Lieberman D, Anderson JC,  et al. Recommendations for follow-up after colonoscopy and polypectomy: a consensus update by the US Multi-Society Task force on Colorectal Cancer. Gastroenterol. 2020;158(4):1131-1153.e5.
8 
Barry MJ, Edgman-Levitan. Shared decision making--pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780-781.
Siegel RL, Miller KD, Goding Sauer A, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020;70(3):145-164.
10 
Knudsen AB et al. Agency for Healthcare Research and Quality; 2021. AHRQ publication 20-05271-EF-2.
11 Knudsen AB, et al. Colorectal cancer screening: an updated modeling study for the US Preventive Services Task Force.
JAMA. 2021;325(19):1998-2011.
12 United States Preventive Services Task Force. About the USPSTF. Accessed December 10, 2021
. https://www.uspreventiveservicestaskforce.org/Page/Name/about-the-uspstf 
13 
American Cancer Society. Who We Are. Accessed December 10, 2021. https://www.cancer.org/about-us/who-we-are.html 
14 
About the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Accessed December 10, 2021. https://www.nccn.org/professionals/default.aspx 
15 Development and Update of the NCCN Guidelines.
Accessed December 10, 2021. https://www.nccn.org/professionals/development.aspx 
16  Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2017:112(7):1016-1030.            
17 American College of Gastroenterology. About ACG. Accessed December 10, 2021. https://gi.org/about/ 
18 American Gastroenterological Association. About Us. Accessed December 10, 2021.
https://www.gastro.org/about-aga/about-us

19 American Society for Gastrointestinal Endoscopy. About ASGE. Accessed December 10, 2021. https://www.asge.org/home/about-asge

Footnotes

All recommendations are category 2A unless otherwise indicated. The National Comprehensive Cancer Network (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way.

b Nomenclature based on different guidelines: mt-sDNA, sDNA-FIT or FIT-FECAL DNA.

See Rex DK, et al. Am J Gastroenterol. 2017;112(7):1016-1030 for additional MSTF recommendations. 

Last Updated: 3/1/2022

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