COLORECTAL CANCER PREVENTION 2000
Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology1

https://doi.org/10.1016/S0002-9270(00)00851-0Get rights and content

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

First page preview

First page preview
Click to open first page preview

References (142)

  • D.K. Rex et al.

    Five-year incidence of adenomas after negative colonoscopy in asymptomatic average-risk persons

    Gastroenterology

    (1996)
  • W.S. Atkin et al.

    Prevention of colorectal cancer by once-only sigmoidoscopy

    Lancet

    (1993)
  • J.H. Haseman et al.

    Failure of colonoscopy to detect colorectal cancerEvaluation of 47 cases in 20 hospitals

    Gastrointest Endosc

    (1997)
  • A.G. Zauber et al.

    Initial management and follow-up surveillance of patients with colorectal adenomas

    Gastroenterol Clin North Am

    (1997)
  • D.A. Lieberman

    Cost-effectiveness model for colon cancer screening

    Gastroenterology

    (1995)
  • M.D. Basson et al.

    Rates of colonoscopic perforation in current practice

    Gastroenterology

    (1998)
  • R. Zubarik et al.

    Prospecive analysis of complications 30 days after outpatient colonoscopy

    Gastrointest Endosc

    (1999)
  • S.J. Winawer

    Appropriate intervals for surveillance

    Gastrointest Endosc

    (1999)
  • D.K. Rex et al.

    The yield of a second screening flexible sigmoidoscopy in average-risk persons after one negative examination

    Gastroenterology

    (1994)
  • O. Kronborg et al.

    Randomized study of screening for colorectal cancer with faecal-occult-blood test

    Lancet

    (1996)
  • J.D. Hardcastle et al.

    Randomized control trial of faecal-occult-blood screening for colorectal cancer

    Lancet

    (1996)
  • S.H. Landis et al.

    Cancer statistics, 1999

    CA Cancer J Clin

    (1999)
  • S.J. Winawer et al.

    Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup

    N Engl J Med

    (1993)
  • O.D. Jorgensen et al.

    The Funen adenoma follow-up studyIncidence and death from colorectal carcinoma in an adenoma surveillance program

    Scand J Gastroenterol

    (1993)
  • E. Thiss-Evensen et al.

    Population-based surveillance by colonoscopyEffect on the incidence of colorectal cancer. Telemark Polyp Study I

    Scand J Gastroenterol

    (1999)
  • Cost-effectiveness of colorectal cancer screening in average-risk adults

    (1995)
  • D.K. Rex et al.

    Colonic neoplasia in asymptomatic persons with negative fecal occult blood testsInfluence of age, gender, and family history

    Am J Gastroenterol

    (1993)
  • D.A. Johnson et al.

    A prospective study of the prevalence of colonic neoplasms in asymptomatic patients with an age-related risk

    Am J Gastroenterol

    (1990)
  • P.G. Foutch et al.

    Flexible sigmoidoscopy may be ineffective for secondary prevention of colorectal cancer in asymptomatic, average-risk men

    Dig Dis Sci

    (1991)
  • D.A. Lieberman et al.

    Screening for colon malignancy with colonoscopy

    Am J Gastroenterol

    (1991)
  • J.D. Rogge et al.

    Low cost, office-based, screening colonoscopy

    Am J Gastroenterol

    (1994)
  • E.J. Lawitz et al.

    Prevalence of colonic adenomas in average risk asymptomatic patients on daily aspirin

    Gastrointest Endosc

    (1999)
  • D.B. Nelson et al.

    Population-based colonoscopy screening for colorectal cancer is feasible, and safe. Preliminary results from the VA colonoscopy screening trial

    Gastrointest Endosc

    (1999)
  • T.F. Imperiale et al.

    Risk of advanced proximal neoplasia based on distal colorectal findingsAn analysis from the Lilly colorectal cancer (CRC) prevention program

    Am J Gastroenterol

    (1998)
  • J.V. Selby et al.

    A case control study of screening sigmoidoscopy and mortality from colorectal cancer

    N Engl J Med

    (1992)
  • P.A. Newcomb et al.

    Screening sigmoidoscopy and colorectal cancer mortality

    J Natl Cancer Inst

    (1992)
  • D.P. Foley et al.

    Left-sided colonoscopy as screening procedure for colorectal neoplasia in asymptomatic volunteers ≥45 years

    Gut

    (1987)
  • O. Goldsmith et al.

    Fiberoptic sigmoidoscopy in an asymptomatic population

    Gastrointest Endosc

    (1978)
  • G. Hoff et al.

    Epidemiology of polyps in the rectum and sigmoid colon. Design of a population screening study

    Scan J Gastroenterol

    (1985)
  • G.R. Lipshutz et al.

    Flexible sigmoidoscopy as a screening procedure for neoplasia of the colon

    Surg Gynecol Obstet

    (1979)
  • G. Marks et al.

    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

    (1979)
  • C.T. Meyer et al.

    Clinical experience with flexible sigmoidoscopy in asymptomatic and symptomatic patients

    J Biol Med

    (1980)
  • R.K. Pearl et al.

    Establishing a flexible sigmoidoscopy/colonoscopy program for surgical residents

    Am Surg

    (1986)
  • L.E. Smith

    Flexible fiberoptic sigmoidoscopyAn office procedure

    Can J Surg

    (1985)
  • L. Ujszaszy et al.

    Screening for colorectal cancer in an Hungarian county

    Endoscopy

    (1985)
  • R.S. Weiner

    Free flexible sigmoidoscopy on Kauai

    Hawaii Med J

    (1986)
  • D.C. Wherry

    Screening for colorectal neoplasia in asymptomatic patients using flexible fiberoptic sigmoidoscopy

    Dis Colon Rectum

    (1981)
  • G.W. Yarborough et al.

    The benefits of systematic fiberoptic flexible sigmoidoscopy

    Arch Intern Med

    (1985)
  • W.S. Atkin et al.

    Uptake, yield of neoplasia, and adverse effects of flexible sigmoidoscopy screening

    Gut

    (1998)
  • J.E. Verne et al.

    Population based randomized study of uptake and yield of screening by flexible sigmoidoscopy compared with screening by faecal occult blood testing

    BMJ

    (1998)
  • Cited by (549)

    • Epidemiology and risk factors of colorectal polyps

      2017, Best Practice and Research: Clinical Gastroenterology
    View all citing articles on Scopus
    1

    In conjunction with ACG Consumer Brochure: “ACG Recommendations on Colorectal Cancer Screening for Average and Higher Risk Patients in Clinical Practice”.

    View full text