ACP Issues Guidance Statement on CRC Screening of Average-risk Adults

The American College of Physicians today issued a guidance statement for routine colorectal cancer screening for average-risk adults.

The guidance, which is the result of rigorous review by ACP of current leading screening guidelines with conflicting recommendations, recommends that physicians screen all adults aged 50-75 years with an average risk for the disease and who have no symptoms (Guidance Statement 1). The full statement was published in the Annals of Internal Medicine.

“Not enough people in the United States get screened for colorectal cancer,” stated ACP President Robert M. McLean, MD, MACP in an ACP press release. Echoing the new Guidance Statement 2, McLean said, “Physicians should perform an individualized risk assessment for colorectal cancer in all adults. Doctors and patients should select the screening test based on a discussion of the benefits, harms, costs, availability, frequency, and patient preferences.”

The frequency of screening depends upon the screening approach selected. ACP suggests any one of the 3 following screening strategies:
• Fecal immunochemical test (FIT) or high sensitivity guaiac-based fecal occult blood test (gFOBT) every 2 years
•Colonoscopy every 10 years
• Flexible sigmoidoscopy every 10 years plus FIT every 2 years

The guidance targets adults at average risk for CRC and does not apply to anyone with a family or personal history of CRC, with a long-standing history of inflammatory bowel disease, with  genetic syndromes such as familial cancerous polyps, or a personal history of benign polyps, or other risk factors.

Research demonstrates that the median age for a diagnosis of colorectal cancer is 67 years and that persons aged 65 to 75 years derive the greatest benefit from CRC screening. The ACP, in its review, found that screening in adults aged 50 to 75 years also is beneficial. The new Guidance Statement 3 recommends that physicians should stop screening for CRC in average risk adults older than age 75 years or with a life expectance of fewer than 10 years. The 3 ACP Guidance Statements in full are below.

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ACP searched the National Guideline Clearinghouse and the Guidelines International Network library for CRC screening guidelines.

Criteria: developed by national-level organizations and published in English between June 1, 2014 and May 28, 2018.

Guidelines found: American College of Radiology, Canadian Task Force on Preventive Health Care, US Preventive Services Task Force.

Three addtional guidelines were included that are commonly used in the US clinical practice but were not identified in either database: American Cancer Society, Scottish Intercollegiate Guidelines Network, US Multi-Society Task Force on Colorectal Cancer.

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ACP Talking Point for Patients: What are the benefits of screening?

"Screening for CRC can reduce the development of and deaths from CRC."

Benefits and harms of the recommended screening tests were evaluated based on review of results of randomized controlled trials reported by the clinical guidelines reviewed.

Three methods are associated with a reduction in CRC-related mortality. None of the screening methods has demonstrated a redution in all-cause mortality.

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ACP Talking Point for Patients:  What are the harms of screening?

"All screening tests have harms and burdens, although most are infrequent and well tolerated. The harms and burdens vary by person and screening strategy."

The potential harms of CRC screening tests should be inlcuded in discussions with patients when considering the choice to undergo screening and individual preferences. While the potential harms of CRC screening may vary by person and the specific strategy, they include the discomfort and inconvenience of bowel preparation, emotional harm associated with false positive and negative results, radiation exposure, and bleeding and perforation.  

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ACP clinical considerations for clinicians.

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ACP clinical considerations for clinicians.

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