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Am Fam Physician. 2012;86(12):1153-1154

Guideline source: American College of Physicians

Evidence rating system used? Yes

Literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? Yes

Published source: Annals of Internal Medicine, March 6, 2012

Although the incidence of colorectal cancer in the United States has been declining by 2 to 3 percent per year over the past 15 years, it is the second leading cause of cancer-related death in the country. The disease is rare before 40 years of age, with 90 percent of cases occurring in those older than 50 years. Appropriate screening is important because detection and removal of premalignant adenomas or localized cancer can prevent the development of cancer.

The American College of Physicians (ACP) recently reviewed available guidelines from the American Cancer Society/U.S. Multi-Society Task Force on Colorectal Cancer/American College of Radiology, Institute for Clinical Systems Improvement, U.S. Preventive Services Task Force, and the American College of Radiology. Based on the evidence from these guidelines, the ACP has published best practice advice, which is summarized in Table 1.

Indications for screening
Average-risk adults starting at 50 years of age
High-risk adults starting at 40 years of age, or at 10 years younger than the age at which colorectal cancer was diagnosed in the youngest affected relative
Black adults starting at 40 years of age
See Table 2 for screening intervals of the different testing options
Harms of unnecessary screening
Endoscopic and radiologic tests
Optical colonoscopy: costly and limited availability (facilities and clinicians), postpolypectomy bleeding, perforation/bleeding, cardiopulmonary complications, diverticulitis, severe abdominal pain, death, false-negative results
Flexible sigmoidoscopy: perforation/bleeding, false-negative results
Double-contrast barium enema: perforation/bleeding (low risk), false-positive results, false-negative results
Computed tomography colonography: low-dose radiation exposure, additional diagnostic testing and procedures for lesions that might not be clinically significant, false- negative results
Stool-based tests: few known harms other than false-positive results, false-negative results
High-value, cost-conscious care
Clinicians should not screen adults who are older than 75 years or who have a life expectancy of less than 10 years (e.g., those with significant comorbid conditions such as diabetes mellitus, cardiopulmonary diseases, or stroke); harms of screening seem to outweigh the benefits in most of these patients
10 years is usually regarded as a safe interval for optical colonoscopy screening

Guidance Statements

Clinicians should perform individualized assessment of risk for colorectal cancer in adults.

This assessment can help determine when screening should begin. Risks include age, race, and family history (e.g., history of colorectal cancer, especially in a first-degree relative diagnosed before 50 years of age; hereditary nonpolyposis; or familial adenomatous polyposis). Blacks have the highest incidence of cancer compared with other races.

Clinicians should screen for colorectal cancer in average-risk adults starting at 50 years of age, and in high-risk adults at 40 years of age or at 10 years younger than the age at which colorectal cancer was diagnosed in the youngest affected relative.

Evidence shows that screening identifies premalignant lesions, allowing for early treatment and reduced mortality. The benefits of screening outweigh the risks in these adults.

Stool-based tests, flexible sigmoidoscopy, or optical colonoscopy should be used for screening average-risk adults. Test selection should be based on benefits versus harms, availability, and patient preference.

Because colorectal cancer screening tests have similar effectiveness, the patient should be counseled about the benefits, harms, effectiveness data, and costs of the different options (Table 2). Optical colonoscopy is generally considered the preferred screening test; however, it has a false-negative rate of 10 to 20 percent, and evidence on the optimal frequency of the screening is unclear. Although colonoscopy screening every 10 years is regarded as safe in average-risk persons, high-risk persons should be screened every five years. If a noncolonoscopic test is used, patients with a positive result should receive follow-up colonoscopy screening. Although computed tomography colonography is an option for average-risk patients older than 50 years, the U.S. Preventive Services Task Force found insufficient evidence to determine the benefits and harms of the test.

Computed tomography colonographyMediumMediumHigh5 yearsComplete bowel preparation
Double-contrast barium enemaLowLowLow5 yearsComplete bowel preparation
Flexible sigmoidoscopy*MediumMediumHigh5 yearsComplete bowel preparation
Guaiac-based fecal occult blood test*VariableVariableLowAnnualTwo samples from three consecutive stools at home
Immunochemical-based fecal occult blood test*VariableVariableMediumAnnualStool sample
Optical colonoscopyHighHighHigh10 yearsComplete bowel preparation
Stool DNA panel*VariableHighHighUncertainAdequate stool sample (30-g minimum)

Screening should end after 75 years of age or if the patient's life expectancy is less than 10 years.

The harms of screening seem to outweigh the benefits in these patients.

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

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at

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