II. Indications

  1. Colon Cancer screening in adults up to age 76-85 years

IV. Efficacy: Optimal Tools and Endoscopists

  1. Colonoscopy may be preferred for all screening (best single test efficacy)
    1. Flexible Sigmoidoscopy misses 25% of lesions (proximal)
    2. Occult blood does not increase Flexible Sigmoidoscopy sensitivity
    3. Lieberman (2000) N Engl J Med 343:207-8 [PubMed]
    4. Lieberman (2001) N Engl J Med 345:555-60 [PubMed]
    5. Segnan (2007) Gastroenterology 132(7): 2304-12 [PubMed]
  2. High quality endoscopist criteria
    1. Reach cecum in 95% of screening colonoscopies (cecal intubation rate)
    2. Detect adenomas in 15% of women, 25% of men on screening Colonoscopy age >50 years old
    3. Rex (2009) Am J Gastroenterol 104(3): 739-50 [PubMed]

V. Diagnostics: Experimental Tools

  1. Stool DNA mutation testing for colorectal neoplasia
  2. Virtual Colonoscopy (Computed Tomographic Colonography)
  3. 3D Magnetic Resonance Colonography (MRC)
    1. Approaches sensitivity and Specificity of Colonoscopy
    2. Tolerated better than Colonoscopy

VI. Protocol: Screening Average Risk (Age 50 years and older)

  1. Timing
    1. Start screening at age 50 years
      1. American College of Gastroenterology recommends black patients start screening at 45 years old
    2. Stop screening at age 75 to 85 years old
      1. Depending on guidelines - USPTF recommends stopping at age 75 years
  2. First-line screening procedures (per USPTF)
    1. Colonoscopy every 10 years (preferred) or
    2. High Sensitivity Fecal Occult Blood Testing (FOBT) every year or
    3. Flexible Sigmoidoscopy every 5 years AND high sensitivity FOBT every 3 years
  3. Colorectal screening procedures that are no longer recommended
    1. Digital Rectal Exam
    2. Double contrast Barium Enema
      1. Not recommended as an alternative to endoscopy by American College of Gastroenterology
        1. Colonoscopy preferred for full colon evaluation
      2. Black women (high Incidence proximal Colon Cancer)
        1. Nelson (1997) Cancer 80:193-7 [PubMed]

VII. Protocol: Screening Moderate Risk

  1. First degree relative of Colorectal Cancer or adenoma under age 60 years (or 2 first degree relatives with onset at any age)
    1. Start: Colonoscopy at age 40 years or Colonoscopy 10 years earlier than youngest case
    2. Repeat Colonoscopy every 5 years
  2. First degree relative of Colorectal Cancer or adenoma at age over 60 years
    1. Start: Colonoscopy at age 50 years (consider starting age 45 years old in black patients)
    2. Repeat Colonoscopy every 10 years

VIII. Protocol: Screening High Risk

  1. History curative intent resection Colorectal Cancer
    1. Colonoscopy at Initial polyp diagnosis
    2. Normal Colonoscopy protocol (assumes no recurrence)
      1. Repeat Colonoscopy in 1 year
      2. Repeat Colonoscopy in 3 years
      3. Repeat Colonoscopy every 5 years
  2. Familial adenomatous polyposis
    1. Early surveillance
      1. Colonoscopy starting at Puberty
    2. Counseling to consider genetic testing
    3. Genetic Testing positive or polyposis confirmed
      1. Consider colectomy or
      2. Endoscopy every 1-2 years
  3. Hereditary non-polyposis Colon Cancer
    1. Early surveillance
      1. Colonoscopy starting at Age 21 years
    2. Counseling to consider genetic testing
    3. Genetic Testing positive or No genetic testing
      1. Colonoscopy every 2 years until age 40
      2. Colonoscopy yearly after age 40
  4. Inflammatory Bowel Disease
    1. Colonoscopy with biopsy for dysplasia
      1. Pancolitis: 8 years after the start or
      2. Left sided Colitis: 12-15 years after the start
    2. Repeat Colonoscopy every 1-2 years

IX. Protocol: Surveillance Colonoscopy after Polypectomy

  1. See Colon Polyp
  2. Precautions: Shorter follow-up interval indications
    1. Inadequate Bowel Preparation
    2. Cecum not reached
    3. Piecemeal or incomplete polyp resection
  3. Return in 10 years for repeat Colonoscopy or per normal intervals
    1. No polyps or normal biopsy
    2. Small (<10 mm) hyperplastic polyps in Rectum or sigmoid
  4. Return in 5-10 years for repeat Colonoscopy (then, if normal, at 10 year intervals)
    1. Single, small tubular adenomatous polyps (<1 cm)
  5. Return in 5 years for repeat Colonoscopy (then, if normal, at 10 year intervals)
    1. Small, sessile serrated polyps (<1 cm) without dysplasia
  6. Return in 3 years for repeat Colonoscopy (then, if normal, every 5 years)
    1. Large (>1 cm) or Multiple (3-10) tubular adenomatous polyps
    2. Adenoma with villous features or high grade dysplasia
    3. Sessile serrated polyp with cytologic dysplasia
    4. Traditional serrated adenoma
  7. Return in <3 years for repeat Colonoscopy
    1. More than 10 adenomatous polyps
  8. Return in 1 year for repeat Colonoscopy
    1. Serrated polyposis syndrome
    2. Piecemeal removal of a large (>15 mm) sessile adenoma or serrated polyp
  9. References
    1. Levin (2008) Gastroenterology 134: 1570-95 [PubMed]
    2. Rex (2009) Am J Gastroenterol 104(3): 739-50 [PubMed]
    3. Winawer (2006) Ca Cancer J Clin 56:143-59 [PubMed]

X. Resources

  1. USPTF Colorectal Cancer Screening Guidelines
    1. http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm

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