COLORECTAL CANCER PREVENTION 2000Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology1
Introduction
Colorectal cancer is the second leading cause of cancer death in the United States (1). Physicians and lay persons are becoming increasingly aware that most colorectal cancers and most deaths from colorectal cancer are preventable through screening. Screening is the search for cancer and precancerous polyps (adenomas) in asymptomatic persons. Colorectal cancer has several features that make it ideal for screening. First, it is both common and serious (fatal if not identified early or left untreated). Second, it has a readily identifiable and slow growing precursor lesion, the adenoma, removal of which prevents progression to cancer 2, 3, 4. Third, colorectal cancer, once developed, is believed to advance relatively slowly from stages that are readily curable by surgery (Dukes A and B) to stages that are not (Dukes C and D). Fourth, currently recommended prevention tests are widely available.
The American College of Gastroenterology (ACG) is an organization of over 7,300 gastroenterologists and other health care professionals with special interest in GI medicine. The interests of the ACG are education and research in clinical gastroenterology and supporting clinical gastroenterologists in the care of their patients. The ACG has previously endorsed the 1997 colorectal cancer screening guideline of the Agency for Healthcare Policy and Research (AHCPR) (5). The AHCPR’s recommendations presented a menu of options (Table 1)for screening average-risk persons. These options have similar cost-effectiveness ratios 5, 6. However, there are substantial differences between the various options regarding their effectiveness, initial costs, and to a lesser degree, risk. The ACG continues to endorse the AHCPR guideline.
This paper outlines the preferred colorectal cancer screening recommendations of the ACG and represents an update of the ACG position on screening represented in the AHCPR guideline. The ACG undertook the development of updated screening recommendations for the following reasons. First, continual expansion in the use of lower bowel endoscopy, and improved understanding of the effectiveness of colonoscopy and polypectomy, combined with decline in the use of barium enema, have established clinical gastroenterologists at the forefront of colorectal cancer prevention. This updated recommendation is meant to reflect trends in the rapidly changing perceptions of colorectal cancer prevention strategies among clinical gastroenterologists in both academic and private practice. Second, scientific publications concerning colorectal cancer screening appear regularly. Therefore, regular updates in colorectal cancer screening recommendations are needed to reflect new data.
These recommendations were developed by a panel of ACG members with expertise in colorectal cancer screening. The panel was appointed by the executive committee of the ACG, and these recommendations were reviewed and approved by the Board of Trustees and the Publications Committee of the ACG.
Section snippets
Average-risk screening
Definition: Persons age 50 and older are at average risk if they have no risk factors for colorectal cancer other than age.
Barium enema
SCBE is generally considered inferior to DCBE for detection of colorectal polyps (112), which is a major goal of screening. In the only cross-sectional study using SCBE for screening, SCBE led to the detection of adenomas in only 2% of screenees (34). In another report, a series of patients presented with cancer shortly after one or more negative SCBE examinations (113). A number of these cancers were fatal. Thus, SCBE is not recommended for colorectal cancer screening.
DCBE is the least
High-risk screening
High-risk colon cancer screening refers to screening for and within families with the rare syndromes of familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (HNPCC), and screening persons with positive family histories that do not meet clinical criteria of the well-defined syndromes. The syndromes are important because of the extreme risk of colon cancer, but together account for only 1–2% of colon cancer cases in the U.S. Cancer risk in the less well-defined
References (142)
- et al.
Colorectal cancer screeningClinical guidelines and rationale
Gastroenterology
(1997) - et al.
Prevalence of proximal colonic polyps in average-risk asymptomatic patients with negative fecal occult blood tests and flexible sigmoidoscopy
Gastrointest Endosc
(1996) - et al.
Short (35-cm) versus long (60-cm) flexible sigmoidoscopyA comparison of findings and tolerance in asymptomatic screening for colorectal neoplasia
Gastrointest Endosc
(1985) - et al.
Performing screening flexible sigmoidoscopy using colonoscopesExperience in 500 subjects
Gastrointest Endosc
(1990) - et al.
Neoplasia distal to the splenic flexure in patients with proximal colon cancer
Gastrointest Endosc
(1996) - et al.
Sensitivity of screening sigmoidoscopy for proximal colorectal tumors
Lancet
(1995) - et al.
Colon cancer in the very old (>80 years) is predominantly proximal, without sentinel left colon polyp
Gastrointest Endosc
(1997) - et al.
Occurrence of distal neoplasia in patients with proximal colon cancer
Gastrointest Endosc
(1997) - et al.
Prospective determination of distal colon findings in average-risk patients with proximal colon cancer
Gastrointest Endosc
(1999) - et al.
Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice
Gastroenterology
(1997)
Five-year incidence of adenomas after negative colonoscopy in asymptomatic average-risk persons
Gastroenterology
Prevention of colorectal cancer by once-only sigmoidoscopy
Lancet
Failure of colonoscopy to detect colorectal cancerEvaluation of 47 cases in 20 hospitals
Gastrointest Endosc
Initial management and follow-up surveillance of patients with colorectal adenomas
Gastroenterol Clin North Am
Cost-effectiveness model for colon cancer screening
Gastroenterology
Rates of colonoscopic perforation in current practice
Gastroenterology
Prospecive analysis of complications 30 days after outpatient colonoscopy
Gastrointest Endosc
Appropriate intervals for surveillance
Gastrointest Endosc
The yield of a second screening flexible sigmoidoscopy in average-risk persons after one negative examination
Gastroenterology
Randomized study of screening for colorectal cancer with faecal-occult-blood test
Lancet
Randomized control trial of faecal-occult-blood screening for colorectal cancer
Lancet
Cancer statistics, 1999
CA Cancer J Clin
Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup
N Engl J Med
The Funen adenoma follow-up studyIncidence and death from colorectal carcinoma in an adenoma surveillance program
Scand J Gastroenterol
Population-based surveillance by colonoscopyEffect on the incidence of colorectal cancer. Telemark Polyp Study I
Scand J Gastroenterol
Cost-effectiveness of colorectal cancer screening in average-risk adults
Colonic neoplasia in asymptomatic persons with negative fecal occult blood testsInfluence of age, gender, and family history
Am J Gastroenterol
A prospective study of the prevalence of colonic neoplasms in asymptomatic patients with an age-related risk
Am J Gastroenterol
Flexible sigmoidoscopy may be ineffective for secondary prevention of colorectal cancer in asymptomatic, average-risk men
Dig Dis Sci
Screening for colon malignancy with colonoscopy
Am J Gastroenterol
Low cost, office-based, screening colonoscopy
Am J Gastroenterol
Prevalence of colonic adenomas in average risk asymptomatic patients on daily aspirin
Gastrointest Endosc
Population-based colonoscopy screening for colorectal cancer is feasible, and safe. Preliminary results from the VA colonoscopy screening trial
Gastrointest Endosc
Risk of advanced proximal neoplasia based on distal colorectal findingsAn analysis from the Lilly colorectal cancer (CRC) prevention program
Am J Gastroenterol
A case control study of screening sigmoidoscopy and mortality from colorectal cancer
N Engl J Med
Screening sigmoidoscopy and colorectal cancer mortality
J Natl Cancer Inst
Left-sided colonoscopy as screening procedure for colorectal neoplasia in asymptomatic volunteers ≥45 years
Gut
Fiberoptic sigmoidoscopy in an asymptomatic population
Gastrointest Endosc
Epidemiology of polyps in the rectum and sigmoid colon. Design of a population screening study
Scan J Gastroenterol
Flexible sigmoidoscopy as a screening procedure for neoplasia of the colon
Surg Gynecol Obstet
Sigmoidoscopic examinations with rigid and flexible fiberoptic sigmoidoscope in the surgeon’s officeA comparative prospective study of effectiveness in 1,012 cases
Dis Colon Rectum
Clinical experience with flexible sigmoidoscopy in asymptomatic and symptomatic patients
J Biol Med
Establishing a flexible sigmoidoscopy/colonoscopy program for surgical residents
Am Surg
Flexible fiberoptic sigmoidoscopyAn office procedure
Can J Surg
Screening for colorectal cancer in an Hungarian county
Endoscopy
Free flexible sigmoidoscopy on Kauai
Hawaii Med J
Screening for colorectal neoplasia in asymptomatic patients using flexible fiberoptic sigmoidoscopy
Dis Colon Rectum
The benefits of systematic fiberoptic flexible sigmoidoscopy
Arch Intern Med
Uptake, yield of neoplasia, and adverse effects of flexible sigmoidoscopy screening
Gut
Population based randomized study of uptake and yield of screening by flexible sigmoidoscopy compared with screening by faecal occult blood testing
BMJ
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In conjunction with ACG Consumer Brochure: “ACG Recommendations on Colorectal Cancer Screening for Average and Higher Risk Patients in Clinical Practice”.