Large Intestine: Colon Cancer Screening

Colonoscopy Screening

General Colonoscopy Recommendations

  • Start: Age 50
    • *Some Societies are Moving to Age 45
  • Repeat: Every 10 Years
  • Stop: Age 76-85
  • If First-Degree Relative Has Colon Cancer:
    • Start: Age 40 or 10-Years Before the Age of Diagnosis
    • Repeat: Every 5 Years

American Cancer Society (ACS)

  • Start: Age 45
    • *Previously Recommended Age 50
  • Repeat: Every 10 Years
  • Stop: Age 76-85

US Preventative Services Task Force (USPSTF)

  • Start: Age 50
    • *Draft Recommendation as of January 2021 will Change Starting Age to 45
  • Stop: Age 76-85

World Gastroenterology Organization (WGO)

  • Average Risk:
    • Start: Age 50
    • Repeat: Every 10 Years
  • First-Degree Relative:
    • Start at 40 or 10 Years Before Earliest Relative
    • Relative < 60 or 2 First Degree Relatives: Every 5 Years
    • Relative > 60: Every 10 Years

National Comprehensive Cancer Network (NCCN)

  • Start: Age 50
  • Repeat: Every 10 Years
  • First-Degree Relative:
    • Start: Age 40 or 10 Years Before Earliest Relative
    • Repeat: Every 5 Years

Colonoscopy Contraindications

  • Recent MI
  • Pregnancy
  • Splenomegaly

Colonoscope 1

Novel Screening Methods

General

  • Contraindicated in High-Risk Patients
  • Follow Up Any Positives with a Colonoscopy (The Gold Standard)

Fecal Testing

  • Guaiac-Based Fecal Occult Blood Test (FOBT)
    • Repeat: Every Year
    • Procedure: Guaiac Test of Stool Sample Reacts to Peroxidase Activity of Heme (Detects Blood)
      • Three Stool Samples Collected at Home – DRE Samples are Not Sensitive
    • Considerations: High False-Negative & False-Positive Rates
      • Sensitivity (One Time Use): 50-60%
        • Higher Sensitivity if Repeated Every 1-2 Years
      • Majority of Positive Tests are False Causing Unnecessary Interventions
    • False Positive: Beef, Vitamin C, Iron, Cimetidine
  • Fecal Immunochemical Test (FIT/IFOBT)
    • Repeat: Every Year
    • Procedure: Tests Feces for Hgb Using Highly-Sensitive Techniques
  • Multi-Targeted Stool DNA Test (Cologuard)
    • Repeat: Every 3 Years
    • Procedure: Tests Stool Samples for Molecular Markers
    • Considerations: Optimal Set of Molecular Markers Not Yet Determined & Low Sensitivity but Higher than FIT
      • Sensitivity: 52-80%
      • Specificity: 87%

CT Colonography (Virtual Colonoscopy)

  • Repeat: Every 5 Years
  • Procedure: CT Done with Air Insufflation for Colonic Distention & Oral Contrast to Allow Digital Subtraction of Fecal Material
  • Considerations: Satisfactory for Large Polyps but Not for Small-Medium Polyps
    • Large Polyps (≥ 10 mm):
      • Sensitivity: 93%
      • Specificity: 97%
    • Medium & Large Polyps:
      • Sensitivity: 86%
      • Specificity: 86%
    • All Polyps:
      • Sensitivity: 45-97%
      • Specificity: 26-97%

Flexible Sigmoidoscopy

  • Repeat: Every 5 Years
  • Considerations: Unable to View Right Colon

FIT Testing 2

CT Colonography 3

Pathology Considerations

Adenoma Repeat Testing – United States Multi-Society Task Force on Colorectal Cancer (2019)

  • Hyperplastic Polyps (HP):
    • < 10 mm: Normal Schedule
    • ≥ 10 mm: 3-5 Years
  • Tubular Adenomas:
    • 1-2: 7-10 Years
    • 3-4: 3-5 Years Mn
    • 5-10: 3 Years
    • > 10: 1 Year
    • Advanced Adenoma: Repeat 3 Years
      • Advanced Characteristics:
        • Size ≥ 10 mm
        • Tubulovillous or Villous Histology
        • High-Grade Dysplasia
  • Sessile Serrated Polyp (SSP):
    • 1-2: 5-10 Years
    • 3-4: 3-5 Years
    • 5-10: 3 Years
    • Advanced Characteristics: Repeat 3 Years
      • Size ≥ 10 mm
      • Any Dysplasia
      • Traditional Serrated Adenoma (TSA)
  • Resection in Piecemeal Fashion (≥ 20 mm): 6 Months to Ensure Complete Excision

Inflammatory Bowel Disease (IBD)

Hereditary Nonpolyposis Colon Cancer (HNPCC/Lynch Syndrome)

Familial Adenomatous Polyposis (FAP)

Colon CA Post-Resection

  • Initial:
    • If Entire Colon Was Seen at Prior Colonoscopy: 1 Year
    • If Entire Colon Was Not Seen at Prior Colonoscopy: 6 Months
  • Repeat: At 3 Years
  • Other Measures:
    • CEA Every 3-6 Months for 3-5 Years
    • CT Chest/Abdomen/Pelvis Every Year for 3 Years

Mnemonics

Repeat Colonoscopy for Adenomas

  • “3 at 3”
  • *2012 Guidelines Recommended 3 Year Follow Up for 3-10 Adenomas but New Recommendations were Expanded

References

  1. Gilo 1969. Wikimedia Commons. (License: CC BY-SA-3.0)
  2. Schreuders EH, Grobbee EJ, Spaander MC, Kuipers EJ. Advances in Fecal Tests for Colorectal Cancer Screening. Curr Treat Options Gastroenterol. 2016 Mar;14(1):152-62. (License: CC BY-4.0)
  3. Yun JY, Ro HJ, Park JB, Choi JB, Chung JE, Kim YJ, Suh WH, Lee JK. Diagnostic performance of CT colonography for the detection of colorectal polyps. Korean J Radiol. 2007 Nov-Dec;8(6):484-91. (License: CC BY-NC-3.0)