Practice Guidelines

Colorectal Cancer Screening: ACP Guidance Statements

 

Am Fam Physician. 2020 Aug 15;102(4):250-252.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Screening reduces CRC mortality in patients 50 to 75 years of age, with greatest benefit in patients older than 60 years.

• The ACP recommends screening average-risk patients with one of the following: colonoscopy every 10 years, flexible sigmoidoscopy every 10 years with biennial FIT, biennial guaiac FOBT, or biennial FIT.

• Because of limited evidence of benefit and increased harms, neither FIT with stool DNA testing nor CT colonography is a recommended screening method.

From the AFP Editors

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Up to 80% of CRC develops from colonic adenomas over five to 20 years, illustrating the potential benefit of early detection. Only 10% of adenomas progress to CRC over 10 years; the rest stabilize or regress. The American College of Physicians (ACP) developed a consensus statement for CRC screening of average-risk adults based on their review of six independent guidelines and supporting evidence. People at elevated risk are subject to other screening recommendations and are not addressed here.

Overall Recommendations

The ACP recommends routine screening of average-risk adults between 50 and 75 years of age to reduce CRC mortality. Screening is not recommended after 75 years of age or when life expectancy is less than 10 years. Several screening methods are recommended (Table 1), with decisions based on patient preferences.

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TABLE 1.

ACP Recommended Colorectal Cancer Screening Methods for Average-Risk Adults

Screening methodRecommended screening intervalNumber needed to screen to prevent one death from colorectal cancerPatient benefitsImportant harms

Recommended

Colonoscopy

Every 10 years

Unknown

Definitive study

Requires colon preparation and anesthesia Risk of colon perforation (NNH = 384 to 2,500) Risk of major bleeding (NNH = 294 to 1,250)

Flexible sigmoidoscopy and FIT

Flexible sigmoidoscopy every 10 years and FIT every two years

850 over 11 years (flexible sigmoidoscopy alone); 2,000 for < 60 years; 345 for ≥ 60 years

Proven mortality benefit

Requires colon preparation Often requires anesthesia Risk of major bleeding (NNH = 5,000) Will miss proximal disease; recommended with biennial FIT

FIT

Every two years

Unknown

No colon preparation Single stool sample No dietary restrictions False-negative test results are less than one in 1,000

One false positive in every 11 tests requires unnecessary colonoscopy

Guaiac fecal occult blood testing

Every two years

377 over 18 years

Proven mortality benefit No colon preparation

Dietary restrictions Multiple stool samples One in 182 tests will be a false negative, missing cancer One in 82 tests will be a false positive that requires unnecessary colonoscopy

Not recommended

FIT with stool DNA

Every three years

Unknown

No colon preparation Single stool sample No dietary restrictions Predicts fewer false-negative test results than FIT

Specificity lower than FIT, increasing false positives that require unnecessary colonoscopy Positive stool DNA result may lead to overly aggressive testing

Computed tomography colonography

Every five years

Unknown

Accuracy similar to colonoscopy

Requires colon preparation Radiation exposure Positive test results require colonoscopy Incidental extracolonic findings in up to 69% of tests


Note: The NNHs were calculated by the author based on data provided in the original ACP guideline.

ACP = American College of Physicians; FIT = fecal immunochemical testing; NNH = number needed to harm.

TABLE 1.

ACP Recommended Colorectal Cancer Screening Methods for Average-Risk Adults

Screening methodRecommended screening intervalNumber needed to screen to prevent one death from colorectal cancerPatient benefitsImportant harms

Recommended

Colonoscopy

Every 10 years

Unknown

Definitive study

Requires colon preparation and anesthesia Risk of colon perforation (NNH = 384 to 2,500) Risk of major bleeding (NNH = 294 to 1,250)

Flexible sigmoidoscopy and FIT

Flexible sigmoidoscopy every 10 years and FIT every two years

850 over 11 years (flexible sigmoidoscopy alone); 2,000 for < 60 years; 345 for ≥ 60 years

Proven mortality benefit

Requires colon preparation Often requires anesthesia Risk of major bleeding (NNH = 5,000) Will miss proximal disease; recommended with biennial FIT

FIT

Every two years

Unknown

No colon preparation Single stool sample No dietary restrictions False-negative test results are less than one in 1,000

One false positive in every 11 tests requires unnecessary colonoscopy

Guaiac fecal occult blood testing

Every two years

377 over 18 years

Proven mortality benefit No colon preparation

Dietary restrictions Multiple stool samples One in 182 tests will be a false negative, missing cancer One in 82 tests will be a false positive that requires unnecessary colonoscopy

Not recommended

FIT with stool DNA

Every three years

Unknown

No colon preparation Single stool sample No dietary restrictions Predicts fewer

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

 

 

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