Colorectal Cancer Screening Guidelines
Average-risk adults should begin colorectal cancer screening at age 45 with either a high-sensitivity stool-based test or a structural examination, continuing through age 75 if in good health with a life expectancy of more than 10 years. 1
Screening Age Recommendations
- Average-risk adults should begin screening at age 45 1
- Screening should continue through age 75 for those in good health with life expectancy >10 years 1
- For adults aged 76-85, screening decisions should be individualized based on patient preferences, life expectancy, health status, and prior screening history 1
- Screening is generally not recommended for individuals over age 85 1
- High-risk individuals (those with a first-degree relative with colorectal cancer or advanced adenoma diagnosed before age 60) should begin screening at age 40 or 10 years before the youngest affected relative's diagnosis, whichever comes first 1, 2
- African Americans should begin screening at age 45 due to higher disease burden 1, 2
Recommended Screening Tests and Intervals
Tier 1 (Preferred) Tests
Tier 2 Tests
- High-sensitivity guaiac-based fecal occult blood test (HSgFOBT) annually 1, 3
- Multitarget stool DNA test (mt-sDNA/FIT-DNA) every 3 years 1, 3
- CT colonography every 5 years 1, 4, 3
- Flexible sigmoidoscopy every 5 years 1, 4, 3
Risk Stratification Approach
- For average-risk individuals, either colonoscopy every 10 years or annual FIT are recommended as first-line options 1, 3
- A risk-stratified approach is appropriate, with FIT screening in populations with estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations 3
- High-risk individuals should undergo colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier 3
- Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years 3
Implementation Considerations
- All positive results from non-colonoscopy screening tests must be followed up with timely colonoscopy 1
- Patient preference is an important consideration when selecting a screening method 1, 5
- The quality of colonoscopy is critical for effective screening and should be monitored using quality indicators such as cecal intubation rates, withdrawal time, adenoma detection rates, appropriate follow-up intervals, and complication rates 1
- Health systems should implement programmatic approaches to CRC screening, including patient education, provider education, mailed screening outreach, and/or patient navigation to maximize screening participation 5
When to Stop Screening
- Screening can be discontinued in adults aged 75+ who are up-to-date with prior negative screening results 1, 2
- For adults aged 76-85, screening should be based on overall health status, prior screening history, and life expectancy 1
- Screening is not recommended for adults over age 85 1
- Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy 3
Common Pitfalls and Caveats
- Failure to follow up positive stool-based tests with colonoscopy negates the benefit of screening 1
- Inadequate bowel preparation can reduce colonoscopy effectiveness 1
- Discontinuing screening too early in healthy individuals or continuing too long in those with limited life expectancy can lead to unnecessary risks 1
- Variability in colonoscopy quality can significantly impact screening effectiveness 1
- CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended 3