Colorectal Cancer Screening Guidelines

Reaffirmed: October 2, 2018 by Michael Puff, MD, Matt Moeller, MD, Terri Osborne, MD, Nicole Aldrich, Quality Improvement Specialist

Originally Approved by SHMG Clinical Excellence Council, February 8, 2017   
CRC Task Force: Michael Puff, MD, Gastroenterology, Sponsor; Sandeep Walia, MD, Martin Luchtefeld, MD, Michael Harrison, MD, Matt Moeller, MD, Terri Osborne, MD, Judy Smith, MD

SUMMARY OF RECOMMENDATIONS

Colonoscopy is the preferred modality for screening. It has been clearly shown to reduce mortality and has the highest life years gained compared to other methods of colon cancer screening.

  • Colonoscopy is effective because it not only detects early cancers, but removes pre-cancerous lesions that turn into cancer. It is the only modality that has both diagnostic and therapeutic modality. 

If patients are unwilling or cannot undergo colonoscopy, we recommend yearly FIT (Hemosure) testing.

  • This recommendation is based on cost effectiveness data and the performance characteristics of the stool based tests discussed below. This approach is also recommended due to the high miss rates , high false positive rates, lack of  long term data, and unclear testing intervals with fecal DNA testing (Cologuard) and SEPT9 (Epi proColon). 

Other proven options for screening include CT colonography every five years and sigmoidoscopy every five years combined with yearly FIT testing. 

Providers also need to be aware that digital rectal exam is not recommended for colorectal cancer screening.

These recommendations apply only to average risk individuals based on personal and family history.

DISCUSSION

Screening for colorectal cancer has been proven to save lives. Every patient who meets age criteria should be screened for colorectal cancer. There are several screening options that have been studied, including colonoscopy, CT colonography, flexible sigmoidoscopy, FIT testing (iFOBT—immunochemical fecal occult blood testing --Hemosure), FIT-DNA (Cologuard), and blood tests such as Epi proColon (SEPT9).

The USPSTF continues to recommend colorectal cancer screenings begin at age 50 and continue until age 75. The decision to screen for colorectal cancer between age 75 and 85 years of age is an individual one taking into account the patient's overall health, life expectancy, and prior screening history.

Based on published evidence, Spectrum Health Medical Group Clinical Excellence Council has defined the optimal test for colorectal cancer screening as colonoscopy. Colonoscopy has the ability to detect pre-cancerous polyps and remove them, thus preventing cancer. It also has the highest sensitivity, averts the most cancer deaths, and has the most life-years gained per 1,000 individuals screened. Colonoscopy should be performed every 10 years for average risk patients when a high quality normal exam is reported. High risk patients, as defined by personal or family history, have different recommendations. Persons with a family history of colorectal cancer or a documented advanced adenoma in a first degree relative age <60 or two first degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every five years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, which is earlier. Persons with a single first degree relative diagnosed at ≥60 years with colorectal or an advanced adenoma can be offered average risk screening options beginning at age 40.

If patients are unwilling or cannot undergo sedation for colonoscopy, alternative prevention tests include CT colonography every five years OR sigmoidoscopy every five years in tandem with a yearly FIT test. CT colonography is inferior to colonoscopy in terms of its sensitivity of polyp detection, the need for colonoscopy if polyps are detected, and the unnecessary diagnostic testing if there are extra-colonic findings. Flexible sigmoidoscopy is inferior to colonoscopy due to missing right sided colon lesions and the availability of high quality colonoscopy in our region. 

Stool based testing is suggested for patients unwilling to have a colonoscopy but who will submit to a colonoscopy if a positive test result is found. There are many stool-based test options that include guaiac based fecal occult blood (gFOBT, Hemoccult), fecal immunochemical test (FIT), and multi-target stool DNA test (Cologuard). These tests require specific collection methods and are obtained at home, not in the office. Of these three stool based tests, FIT (Hemosure) testing is more sensitive than gFOBT (Hemoccult). FIT testing done yearly will significantly increase sensitivity. Routine digital rectal exams are not sufficient for colorectal cancer screening.

The fecal DNA test (Cologuard) detects more advanced adenomas than FIT, but misses 58 percent of advanced adenomas compared with colonoscopy and has a significant number of false positives. In addition, it only detects 42 percent of sessile serrated flat polyps that are greater than one centimeter. Lastly, it has a lower specificity (more false positive results) compared to FIT testing (86.6 percent versus 94.9 percent) and is less cost effective than FIT testing. (Gastroenterology 2016; 151:427–439). Fecal DNA testing (Cologuard) is currently recommended by the manufacturer every one to three years, but no long term data has been established for fecal DNA testing intervals. 

Septin9 DNA test (Epi proColon) is a blood test that has recently become available. The SEPT9 DNA test has lower sensitivity and specificity than the other tests. It only has a sensitivity of 48 percent for detecting colorectal cancer per the USPFT guidelines and even lower for advanced adenomas. In addition, its specificity is 16 points lower than the FIT test and at a higher cost. This blood test is recommended annually but there is no long term data on this test. The significance of a positive SEPT9 DNA test with a negative colonoscopy is unknown at this time. For reporting purposes, SEPT9 does not meet HEDIS criteria for colorectal cancer screening and thus will not improve our quality performance measures for Medicare and other payers.

The full guidelines for colorectal cancer screening are found here;
JAMA vol.316:20 p2135-2145.  Lieberman et al Nov 2016