What are the key recommendations for colon cancer screening and prevention?

Key Elements for Colon Cancer Screening Reporting

Starting Age for Screening

Begin screening at age 45 years for average-risk adults, with colonoscopy every 10 years or annual FIT as first-tier options. 1

• The recommendation to start at age 45 is based on rising colorectal cancer incidence in younger adults and similar rates of advanced neoplasia in 45-49 year-olds compared to historical 50-year-old screening cohorts 2, 3
• African American patients should begin screening at age 45 due to higher incidence rates 2, 4
• For patients with a first-degree relative diagnosed with colorectal cancer or advanced adenoma before age 60, or two first-degree relatives at any age, begin colonoscopy at age 40 or 10 years before the youngest affected relative's diagnosis, whichever comes first 1, 3, 4
• Repeat colonoscopy every 5 years in these higher-risk family history patients 1, 4

Stopping Age for Screening

Discontinue screening at age 75 for patients who are up-to-date with prior negative screening tests, particularly colonoscopy. 2, 3

• For ages 76-85 without prior screening history, screen only after assessing comorbidities, overall health status, and life expectancy greater than 10 years 1, 2
• Discourage screening beyond age 85 as harms outweigh benefits 1, 2
• Stop screening earlier when life expectancy falls below 10 years regardless of age 2, 3

Screening Test Options and Intervals

Tier 1 Tests (Preferred)

• Colonoscopy every 10 years 1, 3
• Annual fecal immunochemical test (FIT) 1, 3

Tier 2 Tests (For patients declining Tier 1)

• CT colonography every 5 years 1, 3
• Multitarget stool DNA test (FIT-DNA) every 3 years 1, 3
• Flexible sigmoidoscopy every 5 years 1, 3
• High-sensitivity guaiac-based fecal occult blood test annually 1

Critical Follow-Up Requirements

All positive non-colonoscopy screening tests must be followed by timely diagnostic colonoscopy. 1, 3

• This is non-negotiable—failure to complete colonoscopy after positive stool-based tests negates the screening benefit 3

Quality Metrics for Colonoscopy

Physicians performing screening colonoscopy must measure and report quality indicators: 1, 3

• Cecal intubation rates (should exceed 90% in screening populations) 1, 3
• Withdrawal time (minimum 6 minutes) 1
• Adenoma detection rates (varies by age and sex, but generally ≥25% in men, ≥15% in women over 50) 1
• Complication rates (both minor and major) 1, 3
• Appropriate intervals between studies based on findings 1, 3

Risk Stratification Questions

Ask these three questions to determine screening approach: 1

1. Has the patient had colorectal cancer or an adenomatous polyp? 1
2. Does the patient have inflammatory bowel disease? 1
3. Has a family member had colorectal cancer or adenomatous polyp—if so, how many relatives, were they first-degree, and at what age? 1

High-Risk Conditions Requiring Modified Screening

Family History Categories 1

• First-degree relative with colorectal cancer <50 years: Colonoscopy at age 40 or 10 years before diagnosis, repeat every 3-5 years 1
• First-degree relative with colorectal cancer at age 50-59: Colonoscopy at age 40, repeat every 5 years 1
• First-degree relative with colorectal cancer ≥60 years: Average-risk screening starting at age 40 1
• Two related first-degree relatives at any age: Colonoscopy at age 40 or 10 years before earliest diagnosis, repeat every 3-5 years 1

Inflammatory Bowel Disease

• Begin colonoscopy 8-10 years after symptom onset 5
• Repeat every 1-3 years depending on disease extent and other risk factors 5

Hereditary Syndromes

• Lynch syndrome (HNPCC): Colonoscopy starting at age 25, repeat every 1-2 years 5
• Familial adenomatous polyposis: Screening at age 10-12 years, repeat every 1-2 years 5
• Peutz-Jeghers syndrome: Colonoscopy at age 8, then at 18, then every 3 years 5

Common Pitfalls to Avoid

• Never continue screening beyond age 85—evidence consistently shows harms exceed benefits 2, 3
• Never fail to follow up positive stool tests with colonoscopy—this is the most critical breakdown in the screening cascade 3
• Never use inadequate bowel preparation—this significantly reduces colonoscopy effectiveness 3
• Never ignore family history—patients with affected first-degree relatives <60 years need earlier and more frequent screening 1, 4
• Never stop screening too early in healthy, never-screened individuals—they lack the protective effect of prior negative tests and may benefit up to age 85 2