What are the next steps after a positive Cologuard (Colon Cancer Screening Test) result?

Next Steps After a Positive Cologuard Test

A positive Cologuard test requires prompt follow-up with a diagnostic colonoscopy, ideally within 3 months but no later than 6 months after the positive result. 1

Understanding the Significance of a Positive Cologuard Result

A positive Cologuard test indicates the potential presence of colorectal cancer or precancerous lesions. Cologuard has a sensitivity of 92.3% for colorectal cancer and 42.4% for advanced precancerous lesions, with a specificity of 86.6% 1. This means:

• The test detects most cancers but may miss some precancerous lesions
• Some positive results will be false positives
• Any positive result requires follow-up regardless of the possibility of a false positive

Recommended Follow-up Timeline

The timeline for follow-up is critical:

• Optimal timing: Within 3 months of a positive result 1
• Maximum acceptable delay: No more than 6 months 1
• Risk of delay: Delaying beyond 6 months increases:
  • Overall risk of colorectal cancer by 58%
  • Risk of advanced-stage disease by 116% 1

Follow-up Procedure

1. Diagnostic colonoscopy

   • Complete bowel preparation is required
   • Sedation is typically used; patients will need a day off work and transportation home
   • The entire colon must be examined 2, 1

2. During colonoscopy

   • Any polyps found will be removed and sent for pathology
   • Biopsies will be taken of suspicious areas
   • The procedure allows both detection and treatment in one session 3

Why Colonoscopy Is Necessary After Positive Cologuard

All major guidelines emphasize that any positive stool-based test requires follow-up with colonoscopy:

• The National Comprehensive Cancer Network (NCCN) 1
• The American Cancer Society 1
• The U.S. Multi-Society Task Force on Colorectal Cancer 1
• The American Gastroenterological Association 1

Colonoscopy is the only appropriate follow-up test because:

1. It allows direct visualization of the entire colon
2. It permits immediate removal of polyps
3. It enables biopsy of suspicious lesions
4. It can prevent cancer through removal of precancerous lesions 2, 3

Common Barriers to Follow-up and How to Address Them

Research shows that many patients with positive stool tests do not complete follow-up colonoscopy 4. Common barriers include:

• Lack of understanding: Many patients don't comprehend the significance of a positive result 4
• Fear of the procedure: Concerns about discomfort, preparation, or findings
• Logistical challenges: Transportation, time off work, etc.

To address these barriers:

• Ensure clear communication about the importance of follow-up
• Address fears and concerns directly
• Provide educational materials about the colonoscopy procedure
• Assist with scheduling and logistics when possible 1, 4

What to Expect from Follow-up Colonoscopy

Based on research of patients with positive fecal tests who underwent colonoscopy 5:

• Normal findings: ~6%
• Benign conditions (hemorrhoids, diverticulosis): ~32%
• Polyps or adenocarcinoma: ~62%
  • Benign polyps: ~16%
  • Adenomatous (precancerous) polyps: ~36%
  • Adenocarcinoma (cancer): ~10%

Future Screening Recommendations

After colonoscopy, future screening recommendations will depend on findings:

• If colonoscopy is normal: Return to average-risk screening in 10 years 2
• If polyps are found: Follow polyp surveillance guidelines based on number, size, and pathology of polyps
• If cancer is found: Treatment and surveillance will follow cancer management protocols

Key Points to Remember

• A positive Cologuard test is not a diagnosis of cancer but requires prompt follow-up
• Colonoscopy is the only appropriate next step after a positive result
• Delays beyond 6 months significantly increase cancer risk
• The majority of patients with positive tests will have findings on colonoscopy that require intervention or surveillance

The follow-up colonoscopy is not just another screening test but a diagnostic procedure that can both detect and prevent colorectal cancer through polyp removal.