New guidance from the American College of Physicians advises doctors to evaluate each patient’s individual risk and base colorectal cancer screening on that assessment.
The four point guidance statement says:
- Clinicians should perform an individual colorectal cancer risk assessment for all adults.
- Average risk adults should be screened at age 50. Individuals at high risk should begin screening at age 40 or 10 years before the youngest relative was diagnosed with colorectal cancer.
- Average risk individuals should be screened with a stool-based test, flexible sigmoidoscopy, or optical colonoscopy. Colonoscopy should be used to screen patients who are at high risk.
- Clinicians should stop screening for patients over 75 or adults with less than 10 years of life expectancy.
Rather than develop a brand-new set of colorectal cancer screening guidelines for healthcare providers, the Clinical Guidelines Committee of American College of Physicians (ACP) reviewed and evaluated existing guidelines in the National Guidelines Clearinghouse including:
- A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology
- American College of Radiology Appropriateness Criteria on Colorectal Cancer Screening
- Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement
- Institute for Clinical Systems Improvement Healthcare Guideline: Colorectal Cancer Screening
After reviewing the published guidelines and rating them using the Agree II standards, the committee, agreed on the four Guidance Statements:
- Guidance Statement 1: ACP recommends that clinicians perform individualized assessment of risk for colorectal cancer in all adults.
- Guidance Statement 2: ACP recommends that clinicians screen for colorectal cancer in average-risk adults starting at the age of 50 years and in high-risk adults starting at the age of 40 years or 10 years younger than the age at which the youngest affected relative was diagnosed with colorectal cancer.
- Guidance Statement 3: ACP recommends using a stool-based test,flexible sigmoidoscopy, or optical colonoscopy as a screening test in patients who are at average risk. ACP recommends using optical colonoscopy as a screening test in patients who are at high risk. Clinicians should select the test based on the benefits and harms of the screening test, availability of the screening test, and patient preferences.
- Guidance Statement 4: ACP recommends that clinicians stop screening for colorectal cancer in adults over the age of 75 years or in adults with a life expectancy of less than 10 years.
Note that the definition of high risk in Guidance Statement 2 is not clear. While age, race, and family history are considered, personal medical history is not. No specific guidance is provided for people with inherited colorectal cancer syndromes. The authors write:
Clinicians should perform individualized assessment of colorectal cancer risk in all adults to help in deciding when to begin screening. Risks for colorectal cancer include age, race, and family history (for example, diagnosis of colorectal cancer, hereditary nonpolyposis, or familial adenomatous polyposis). Diagnosis of colorectal cancer in a first degree relative, especially before age 50 years, increases the probability of colorectal cancer in all adults; a thorough family history, including the age of diagnosis of colorectal cancer for primary and secondary relatives, is important for assessing this risk. African Americans have the highest incidence of colorectal cancer compared with other races.
A simple set of screening questions is available online for health professionals to use to identify Lynch syndrome (hereditary non-polyposis colon cancer) in patients as young as 25.
What Does This Mean for Patients
The ACP guidelines are nothing new. They review existing colorectal cancer screening guidelines and provide a simple four point guide for deciding on when and how to screen for colorectal cancer.
Perhaps the strongest take-away message is that the first step in deciding what is the right screening test and the right time to begin screening is to assess individual risk for colorectal cancer.
- Patients with average risk should begin screening at age 50. The best test is for people of average risk is based on risks and benefits for the patient, is available, and is preferred by the patient.
- Patients at higher risk need to begin screening at age 40 with colonoscopy. According to the ACP this includes African Americans and people with a family history of colorectal cancer.
- Be aware some patients with a strong family history of colorectal or uterine cancer may have inherited a mutation for Lynch syndrome and need to begin screening much earlier than age 40. Be sure that your doctor’s assessment includes that assessment.
The ACP has a Summary for Patients that reviews the guidance statement.
Fight Colorectal Cancer has more help in assessing your risk for colorectal cancer.