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TABLE OF CONTENTS:
A direct comparison of American Gastroenterological Association/American Society for Gastrointestinal Endoscopy/American College of Physicians/American College of Gastroenterology (AGA/ASGE/ACP/ACG), Finnish Medical Society Duodecim (FMS), and University of Michigan Health System (UMHS) recommendations for colorectal cancer screening, among individuals of varying risk for developing colorectal cancer, is provided in the five tables below. This synthesis purposefully excludes recommendations for symptomatic individuals and the management of positive screening results.
Table 1 presents the guidelines' scope, comparing the objectives, target population, intended users, and screening interventions discussed in each guideline. Table 2 focuses on screening recommendations for asymptomatic individuals who are at average risk for colorectal cancer. Various screening interventions are presented along with recommendations regarding frequency and administration of screening tests where applicable. Table 3 considers screening and surveillance recommendations for individuals at increased risk for colorectal cancer. Table 4 compares the potential benefits and possible harms associated with screening. Table 5 provides a comparison of the various evidence and recommendation rating schemes used by FMS and UMHS. It also includes citations for the references supporting recommendations, where applicable.
Following the content comparison, areas of agreement and differences among the guidelines are discussed. In general, the timing of the guideline with respect to available data is an important factor to consider when evaluating areas of differences among guidelines.
Abbreviations used in the text and table:
TABLE 1: SCOPE | |
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Objective | |
AGA/ASGE/ACP/ACG (2003) |
|
FMS (2005) |
Evidence-Based Medicine Guidelines collect, summarize, and update the core clinical knowledge essential in general practice. The guidelines also describe the scientific evidence underlying the given recommendations. |
UMHS (2004) |
To implement an evidenced-based strategy for cancer screening in adults |
Target Population | |
AGA/ASGE/ACP/ACG (2003) |
Note: People with symptoms or signs that suggest the presence of CRC or polyps fall outside the domain of screening and should be offered an appropriate diagnostic evaluation (see Table 2 in the original guideline document). |
FMS (2005) |
|
UMHS (2004) |
|
Intended Users | |
AGA/ASGE/ACP/ACG (2003) |
Physicians |
FMS (2005) |
Health Care Providers |
UMHS (2004) |
Physicians |
Screening Interventions Considered | |
AGA/ASGE/ACP/ACG (2003) |
|
FMS (2005) |
|
UMHS (2004) |
Screening options considered but not recommended:
Note: This guideline also addresses interventions regarding breast cancer screening, prostate cancer screening and cervical cancer screening. |
TABLE 3: COMPARISON OF RECOMMENDATIONS FOR SCREENING FOR COLORECTAL CANCER: PEOPLE AT INCREASED RISK FOR COLORECTAL CANCER | |
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People with Family History of Colorectal Cancer | |
AGA/ASGE/ACP/ACG (2003) |
People with a first-degree relative (parent, sibling, or child) with colon cancer or adenomatous polyps diagnosed at age <60 years or 2 first-degree relatives diagnosed with colorectal cancer at any age should be advised to have screening colonoscopy starting at age 40 years or 10 years younger than the earliest diagnosis in their family, whichever comes first, and repeated every 5 years (see Table 3 in the original guideline document). People with a first-degree relative with colon cancer or adenomatous polyp diagnosed at age >60 years or 2 second-degree relatives with colorectal cancer should be advised to be screened as average risk persons, but beginning at age 40 years. People with 1 second-degree relative (grandparent, aunt, or uncle) or third-degree relative (great-grandparent or cousin) with colorectal cancer should be advised to be screened as average risk persons. |
FMS (2005) |
The use of colonoscopy for screening of asymptomatic individuals is indicated only in cases with marked familial susceptibility to cancer, or if an adenoma has earlier been removed endoscopically. |
UMHS (2004) |
*From the American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American College of Physicians, American College of Gastroenterology (AGA/ASGE/ACP/ACG). Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60. |
People with a Family History of Familial Adenomatous Polyposis | |
AGA/ASGE/ACP/ACG (2003) |
People who have a genetic diagnosis of familial adenomatous polyposis (FAP), or are at risk of having FAP but genetic testing has not been performed or is not feasible, should have annual sigmoidoscopy, beginning at age 10 to 12 years, to determine if they are expressing the genetic abnormality. Genetic testing should be considered in patients with FAP who have relatives at risk. Genetic counseling should guide genetic testing and considerations of colectomy. |
FMS (2005) |
The use of colonoscopy for screening of asymptomatic individuals is indicated only in cases with marked familial susceptibility to cancer or if an adenoma has earlier been removed endoscopically. |
UMHS (2004) |
*From the American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American College of Physicians, American College of Gastroenterology (AGA/ASGE/ACP/ACG). Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60. |
People with a Family History of Hereditary Nonpolyposis Colorectal Cancer (HNPCC) | |
AGA/ASGE/ACP/ACG (2003) |
People with a genetic or clinical diagnosis of HNPCC or who are at increased risk for HNPCC should have colonoscopy every 1 to 2 years beginning at age 20 to 25 years, or 10 years earlier than the youngest age of colon cancer diagnosis in the family--whichever comes first. Genetic testing for HNPCC should be offered to first-degree relatives of persons with a known inherited mismatch repair (MMR) gene mutation. It should also be offered when the family mutation is not already known, but 1 of the first 3 of the modified Bethesda Criteria is met (see Table 5 in the original guideline document). |
FMS (2005) |
The use of colonoscopy for screening of asymptomatic individuals is indicated only in cases with marked familial susceptibility to cancer or if an adenoma has earlier been removed endoscopically. |
UMHS (2004) |
Persons who are gene carriers or pancolitis at risk for HNPCC should be screened with a colonoscopy every 1 to 2 years, beginning at age 20 to 25 years or 10 years younger than the earliest case in the family, whichever comes first.* *From the American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American College of Physicians, American College of Gastroenterology (AGA/ASGE/ACP/ACG). Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60. |
People with a History of Adenomatous Polyps | |
AGA/ASGE/ACP/ACG (2003) |
Patients who have had 1 or more adenomatous polyps removed at colonoscopy should be managed according to the findings on that colonoscopy. Patients who have had numerous adenomas, a malignant adenoma (with invasive cancer), a large sessile adenoma, or an incomplete colonoscopy should have a short interval follow-up colonoscopy based on clinical judgment. Patients who have advanced or multiple adenomas (>3) should have their first follow-up colonoscopy in 3 years. Patients who have 1 or 2 small (<1 cm) tubular adenomas should have their first follow-up colonoscopy at 5 years. It is not unreasonable, given available evidence, to choose even longer intervals. However, the evidence is still evolving. Future evidence may clarify the intervals more precisely. The timing of the subsequent colonoscopy should depend on the pathology and number of adenomas detected at follow-up colonoscopy. For example, if the first follow-up colonoscopy is normal or only 1 or 2 small (<1 cm) tubular adenomas are found, the next colonoscopy can be in 5 years. |
FMS (2005) |
|
UMHS (2004) |
Persons who have a history of adenomatous polyps, for example:
Manage according to the findings and clinical judgment, for example:
Timing of subsequent colonoscopy depends on findings at follow-up.* *From the American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American College of Physicians, American College of Gastroenterology (AGA/ASGE/ACP/ACG). Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60. |
People with a History of Colorectal Cancer | |
AGA/ASGE/ACP/ACG (2003) |
Patients with a colon cancer that has been resected with curative intent should have a colonoscopy around the time of initial diagnosis to rule out synchronous neoplasms. If the colon is obstructed preoperatively, colonoscopy can be performed approximately 6 months after surgery. If this or a complete preoperative examination is normal, subsequent colonoscopy should be offered after 3 years, and then, if normal, every 5 years. |
FMS (2005) |
No recommendations offered. |
UMHS (2004) |
History of CRC: After colonoscopy to rule out synchronous neoplasms and resection with curative intent, first follow-up colonoscopy after 3 years, and then, if normal, every 5 years. *From the American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American College of Physicians, American College of Gastroenterology (AGA/ASGE/ACP/ACG). Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60. |
People with Inflammatory Bowel Disease | |
AGA/ASGE/ACP/ACG (2003) |
In patients with long-standing, extensive inflammatory bowel disease, surveillance colonoscopy with systematic biopsies should be considered. This applies to both ulcerative colitis and Crohn's colitis because the cancer risk is similar in both diseases. |
FMS (2005) |
No recommendations offered. |
UMHS (2004) |
Inflammatory bowel disease (ulcerative colitis, Crohn's colitis): In patients with long-standing, extensive inflammatory bowel disease (ulcerative colitis, Crohn's colitis), surveillance colonoscopy with systematic biopsies should be considered.* *From the American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American College of Physicians, American College of Gastroenterology (AGA/ASGE/ACP/ACG). Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60. |
TABLE 5: EVIDENCE AND RECOMMENDATION RATING SCHEMES; REFERENCES SUPPORTING THE RECOMMENDATIONS | |
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Rating Scheme | |
FMS (2005) |
Levels of Evidence
References Supporting the Recommendations
|
UMHS (2004) |
Levels of evidence reflect the best available literature in support of an intervention or test:
References Supporting the Recommendations American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, American College of Physicians, American College of Gastroenterology (AGA/ASGE/ACP/ACG). Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003 Feb;124(2):544-60. |
The American Gastroenterological Association in collaboration with the American Society for Gastrointestinal Endoscopy, American College of Physicians, and American College of Gastroenterology (AGA/ASGE/ACP/ACG), the Finnish Medical Society Duodecim (FMS), and the University of Michigan Health System (UMHS) present recommendations for CRC screening in people at average risk (asymptomatic, age >50 years, no other risk factors) and provide explicit reasoning behind their judgments. Also, AGA/ASGE/ACP/ACG, and FMS present recommendations for asymptomatic adults with some degree of increased risk of developing CRC. UMHS refers to expert guidelines from medical specialty organizations (AGA/ASGE/ACP/ACG, for example) for individuals at risk.
All guideline developer organizations represented in this synthesis recommend screening for colorectal cancer in average risk, asymptomatic adults. The two guideline developers located in North America, AGA/ASGE/ACP/ACG and UMHS provide an age at which screening should begin (>50 years); FMS does not designate a starting age. The two guideline developers located in North America also recommend screening, utilizing one of several acceptable screening tests such as fecal occult blood testing (FOBT) or flexible sigmoidoscopy. These two groups present two or more acceptable screening options and do not explicitly recommend one screening test over another citing a lack of solid evidence to do so. FMS only considers FOBT for population-based screening in its recommendations (although it makes no clear recommendations for it); In discussing the rationale for FOBT, UMHS acknowledges that clear evidence for reduced CRC mortality exists with a mass FOBT screening program, but further notes that this screening modality has come under criticism due to its low sensitivity and specificity, low patient compliance, and the possibility that it does little more than randomly assign subjects to receive colonoscopy.
The two guideline developer organizations presenting recommendations for how to choose a screening test, AGA/ASGE/ACP/ACG and UMHS, agree that patients should be involved, to some degree, in selecting a screening intervention. Each of these organizations agrees the advantages and disadvantages of the various screening options should be shared with the patient. AGA/ASGE/ACP/ACG recommends candidates should then have the opportunity to select how they will be screened. UMHS states what should be considered when making the choice, one item being patient preference.
DRE
All guideline developer organizations represented in this synthesis directly or indirectly acknowledge that the DRE is not an acceptable screening intervention.
FOBT, Sigmoidoscopy, FOBT + Sigmoidoscopy, Colonoscopy, Barium Enema
Two guideline developer organizations, AGA/ASGE/ACP/ACG and UMHS recognize FOBT, sigmoidoscopy, combination of FOBT and sigmoidoscopy, and colonoscopy as acceptable screening interventions for use in asymptomatic adults of average risk. These organizations acknowledge that the option of total colon examination (TCE) by colonoscopy or barium enema has not been supported by randomized controlled trials and that support for its use comes from indirect evidence of benefit and efficacy. UMHS notes that air or double-contrast barium enema is an acceptable modality, but does not recommend it. FMS only considered FOBT for screening asymptomatic adults of average risk (and colonoscopy for screening asymptomatic adults at increased risk). All organizations recognize that a positive FOBT result requires diagnostic follow-up.
Surveillance with Colonoscopy
There is general agreement among the guideline developers who provide screening recommendations for individuals at risk for developing CRC that colonoscopy is the most appropriate screening intervention for people with a history of adenomatous polyps, CRC, or inflammatory bowel disease.
Genetic Counseling and Genetic Testing
AGA/ASGE/ACP/ACG recommends genetic counseling followed by genetic testing for individuals with FAP and HNPCC. Genetic counseling and genetic testing are not interventions considered by FMS or UMHS.
Familial Susceptibility
The guidelines are in general agreement regarding screening recommendations for people with a family history of CRC. AGA/ASGE/ACP/ACG and UMHS recommend increased surveillance or earlier screening for these individuals. FMS recommends colonoscopy for persons with marked familial susceptibility but does not state the age at which to begin or how frequently.
FOBT: Dietary Restrictions, Newer Technology
AGA/ASGE/ACP/ACG recommends use of dietary restrictions when the newer, more sensitive, guaiac-based FOBTs are used but not when the new immunochemical FOBTs are performed. AGA/ASGE/ACP/ACG cited a systematic review of 3 trials which found no improvement in positivity rates or change in compliance rates noting that the older, less sensitive guaiac-based tests were used in the trials. They further note that dietary restriction does affect the performance of the more sensitive guaiac-based FOBTs recently introduced into clinical practice. Dietary restrictions in relationship to FOBTs are not discussed by UMHS and FMS.
AGA/ASGE/ACP/ACG is the only guideline developer to specifically recommend use of immunochemical FOBTs in practice.
DCBE -- Screening Frequency
Differences are also noted in recommendations for screening frequency for double-contrast barium enema (DCBE) and colonoscopy. AGA/ASGE/ACP/ACG recommends DCBE every 5 years. UMHS refers to the AGA/ASGE/ACPA/ACG recommendation for DCBE screening every 5 years, but does not recommend, only stating the need for more observational studies of barium enema in literature.
This Synthesis was originally prepared by ECRI on June 7, 1998, and has been updated and revised on a number of occasions since that time. It has been reviewed by each of the guideline developers that are represented. It was updated in December 2006, to withdraw CTHPHC guidelines following their removal from the NGC Web site. This Synthesis was updated again on May 15, 2007 to withdraw ACS guidelines following their removal from the NGC Web site. This Synthesis was revised on November 28, 2007 following the removal of the USPSTF recommendations.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Screening for colorectal cancer. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 1998 Jun 7 (updated 2007 Dec). [cited YYYY Mon DD]. Available: http://www.guideline.gov.