Guidelines for Colorectal Cancer Detection Within the Last 5 Years
The American Gastroenterological Association, American College of Physicians, and American Cancer Society recommend that average-risk individuals begin colorectal cancer screening at age 45, with colonoscopy every 10 years or annual Fecal Immunochemical Test (FIT) as the preferred first-tier screening options. 1
Recommended Screening Age and Intervals
Average-Risk Individuals:
- Starting age: 45 years (qualified recommendation) 2, 1
- Continue screening through: Age 75 for those in good health with life expectancy >10 years 2, 1
- Ages 76-85: Individualize decisions based on prior screening history, health status, and patient preferences 2, 1
- Age >85: Discourage screening (risks outweigh benefits) 2, 1
High-Risk Individuals:
- Family history of CRC or advanced adenoma in first-degree relative <60 years or 2 first-degree relatives at any age: Begin screening at age 40 or 10 years before youngest affected relative's diagnosis, whichever is earlier; repeat every 5 years 1
- One first-degree relative diagnosed with CRC before age 45: Begin screening at age 30 1
- Two affected first-degree relatives before age 50: Begin screening at age 20 1
Recommended Screening Tests and Intervals
Tier 1 (Preferred Options):
- Colonoscopy: Every 10 years
- FIT (Fecal Immunochemical Test): Annually
Tier 2 (Alternative Options):
- FIT-fecal DNA (Cologuard): Every 3 years
- CT colonography: Every 5 years
- Flexible sigmoidoscopy: Every 5 years
- High-sensitivity guaiac-based fecal occult blood test: Annually
Test Performance Comparison
| Test | Sensitivity for CRC | Sensitivity for Advanced Precancerous Lesions | Specificity |
|---|---|---|---|
| Cologuard | 92.3% | 42.4% | 86.6% |
| FIT | 73.8% | 23.8% | 94.9% |
Follow-up Recommendations
- All positive results on non-colonoscopy screening tests must be followed up with timely colonoscopy 2, 1
- Adenomatous polyps found and removed should be followed up with colonoscopy in 3-5 years, depending on size and number 1
- Personal history of CRC: Surveillance colonoscopy within 1 year of resection, then every 3-5 years if normal 1
Quality Metrics for Screening
- Colonoscopy quality metrics: Adenoma detection rate, cecal intubation rates, withdrawal time 1
- FIT quality metrics: Participation rates, inadequate tests, follow-up colonoscopy completion for positive results 1
Important Considerations and Potential Pitfalls
- African Americans may need to start screening at age 45, even if general population screening begins at 50 1
- Avoid screening too frequently as there is no evidence it improves outcomes but increases costs 1
- Consider patient preferences when selecting screening tests to improve adherence 1
- Avoid continuing screening beyond appropriate age, particularly after age 75 in individuals with negative prior screening 1
- Be aware of potential harms:
The updated guidelines reflect the concerning trend of increasing CRC incidence among adults younger than 55 years, with a 51% increase from 1994 to 2014 and an 11% increase in mortality from 2005 to 2015 2. This has led to the qualified recommendation to begin screening at age 45 for average-risk individuals, while maintaining the strong recommendation for screening at age 50 and older.