Colorectal Cancer Screening and Prevention

 

Am Fam Physician. 2018 May 15;97(10):658-665.

  Related editorials: Should Screening Techniques for Colorectal Cancer All Have an 'A' Recommendation? Yes: All Conventional Screening Techniques Should Have an 'A' Recommendation and No: When It Comes to Colorectal Cancer Screening, Test Choice Matters.

  Patient information: See related handout on colon cancer, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Colorectal cancer is a common cause of morbidity and mortality in the United States. Most colorectal cancers arise from preexisting adenomatous or serrated polyps. The incidence and mortality of colorectal cancer can be reduced with screening of average-risk adults 50 to 75 years of age. Randomized controlled trials show evidence of reduced colorectal cancer–specific mortality with guaiac-based fecal occult blood tests and flexible sigmoidoscopy. There are no randomized controlled trials on the effectiveness of colonoscopy to reduce colorectal cancer–specific mortality; however, several randomized controlled trials comparing colonoscopy with other strategies are in progress. The best available evidence supporting colonoscopy is from prospective cohort studies that demonstrate decreased incidence of colorectal cancer and colorectal cancer–related mortality in individuals undergoing colonoscopy. Other screening options include fecal immunochemical testing, computed tomographic colonography, and multitargeted stool DNA testing combined with fecal immunochemical testing. There is good evidence that aspirin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, and hormone therapy decrease the risk of colorectal cancer and adenomatous polyps, but potential harms limit their usefulness. There is good evidence that calcium supplementation, moderate dairy consumption, reduced red meat consumption, increased physical activity, decreased body mass index, and statin use decrease the risk of colorectal cancer and adenomatous polyps. Although increased alcohol intake and tobacco use are associated with an increased risk of colorectal cancer, there is no direct evidence that reducing alcohol consumption or smoking cessation decreases the risk.

Colorectal cancer (CRC) is the third most common cancer and cause of cancer-related deaths in the United States.1 Most CRCs are caused by adenomatous or serrated polyps as a result of sporadic mutations or DNA mismatch repair.2 CRC screening reduces mortality by removing adenomatous and serrated polyps or by early detection of CRC; however, only 62% of eligible persons were up-to-date on CRC screening, according to the 2015 National Health Interview Survey.3,4

Screening Guidelines

The U.S. Preventive Services Task Force (USPSTF) recommends CRC screening for average-risk adults 50 to 75 years of age.3 The decision to screen adults 76 to 85 years of age should be individualized based on overall health, previous screening, willingness to undergo treatment for CRC if found, and comorbid conditions.3  Other guidelines are generally consistent (Table 1).3,59

The U.S. Food and Drug Administration recently approved a new serology test to detect circulating methylated SEPT9 DNA (Epi proColon), which is found in some CRCs.3 A prospective study of 7,941 individuals found poor sensitivity (48%) with this test,10 and it is not recommended by any U.S. cancer screening guidelines.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Colorectal cancer screening is recommended in average-risk adults 50 to 75 years of age.

A

3

Randomized controlled trials show evidence of reduced colorectal cancer–specific mortality with guaiac-based fecal occult blood testing (number needed to screen = 1,000) and flexible sigmoidoscopy screening (number needed to screen = 850).

A

11, 25

Aspirin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, and hormone therapy decrease the risk of colorectal cancer and adenomatous polyps; however, increased risks of adverse effects outweigh potential benefits for most patients.

B

28, 3032, 52, 54

Calcium supplementation, increased dairy consumption, reduced red meat consumption, increased physical activity, decreased body mass index, and statin use are associated with a lower risk of colorectal cancer and adenomatous polyps, although most of the evidence is from observational studies.

C

37, 40, 44, 47, 48, 5052, 55, 56

There is no evidence that antioxidants, fiber, or folic acid decreases the risk of colorectal cancer or adenomatous polyps.

B

45, 46, 49, 53


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Colorectal cancer screening is recommended in average-risk adults 50 to 75 years of age.

A

3

Randomized controlled trials show evidence of reduced c

The Authors

show all author info

THAD WILKINS, MD, MBA, FAAFP, is director of academic development and a professor in the Department of Family Medicine at the Medical College of Georgia at Augusta University....

DANIELLE McMECHAN, MD, is in private practice in Augusta. At the time the article was submitted, Dr. McMechan was a third-year resident in the Department of Family Medicine at the Medical College of Georgia at Augusta University.

ASIF TALUKDER, MD, is a third-year resident in the Department of Surgery at the Medical College of Georgia at Augusta University.

Address correspondence to Thad Wilkins, MD, MBA, FAAFP, Medical College of Georgia at Augusta University, 1120 15th St., Augusta, GA 30912 (e-mail: jwilkins@augusta.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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