What are the recommendations for colon cancer screening in individuals with a first-degree relative history of colorectal cancer (CRC)?

From the Guidelines

Individuals with a first-degree relative who has had colon cancer should begin screening at age 40 or 10 years before the age at which their relative was diagnosed, whichever comes first, with a preferred screening method of colonoscopy every 5 years 1. This recommendation is based on the most recent guidelines from the American Gastroenterological Association, which suggest that individuals with a family history of colorectal cancer (CRC) are at increased risk of developing the disease and should undergo more aggressive screening. The increased risk is due to potential shared genetic factors and environmental exposures within families, and having a first-degree relative with colon cancer approximately doubles the risk of developing the disease. Alternative screening options include:

• Annual fecal immunochemical testing (FIT)
• Multi-target stool DNA testing every 3 years
• CT colonography every 5 years However, colonoscopy remains the gold standard for high-risk patients. It is also important to note that if multiple first-degree relatives have had colon cancer or if a relative was diagnosed before age 50, genetic counseling should be considered to evaluate for hereditary syndromes like Lynch syndrome or familial adenomatous polyposis. Additionally, maintaining a healthy lifestyle with regular physical activity, a diet high in fruits and vegetables, limited red meat consumption, and avoiding tobacco and excessive alcohol can further reduce the risk of developing colon cancer 1.

From the Research

Recommendations for Colon Cancer Screening

• Individuals with a first-degree relative history of colorectal cancer (CRC) should undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier 2
• For those with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma, average-risk screening options can be offered beginning at age 40 years 2
• The U.S. Multi-Society Task Force on Colorectal Cancer recommends a risk-stratified approach, with colonoscopy screening in high prevalence populations, such as those with a family history of CRC 2

Screening Guidelines

• The American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy recommend screening for individuals with a family history of CRC or advanced adenoma in a first-degree relative 2
• Individuals with a first-degree relative with hereditary nonpolyposis colorectal cancer should begin colonoscopy at 25 years of age and repeat colonoscopy every one to two years 3
• Those with a family history of adenomatous polyposis syndromes should begin screening at 10 years of age or in a person's mid-20s, depending on the syndrome, and repeat colonoscopy typically every one to two years 3

Barriers to Screening

• Lack of insurance coverage is a common barrier to screening, noted in 12.5% of patients 4
• Racial and socioeconomic disparities exist among high-risk patients who should pursue screening, with patients of Black race and those with Medicare/Medicaid insurance being more likely to have family members with unknown or no screening 4

Detection Rates

• A multicentric study found a high detection rate of precancerous lesions and colorectal cancer in first-degree relatives of colorectal cancer patients, with 19.4% of total subjects having adenomatous polyps and 2.1% having colorectal cancer 5
• The study suggests that guidelines should continue to recommend earlier and more frequent screening in first-degree relatives of patients with colorectal cancer, and maintain the use of colonoscopy as the main screening option 5