Colonoscopy Screening Recommendations
Average-Risk Adults
Average-risk adults should begin colorectal cancer screening at age 45 years, with colonoscopy every 10 years or annual fecal immunochemical testing (FIT) as first-line options. 1, 2
The definition of average-risk requires no personal history of colorectal cancer, inflammatory bowel disease, hereditary CRC syndromes, adenomatous polyps, or family history of colorectal cancer in any first-degree relative. 3
The age threshold was lowered from 50 to 45 years due to rising early-onset colorectal cancer incidence, which will account for 10% of colon cancers and 25% of rectal cancers over the next decade. 1
Colonoscopy and FIT are designated as tier-1 screening tests and should be offered first, with colonoscopy providing the advantage of simultaneous detection and removal of precancerous lesions at 10-year intervals. 2, 4
Second-tier options include CT colonography every 5 years, multitarget stool DNA test (FIT-DNA) every 3 years, and flexible sigmoidoscopy every 5-10 years, reserved for patients who decline colonoscopy and FIT. 2, 4
All positive non-colonoscopy screening tests must be followed by timely diagnostic colonoscopy—failure to do so negates the entire benefit of screening. 2
African Americans
African Americans should begin screening at age 45 years due to higher disease burden and earlier onset of disease. 1, 2, 5
Family History and Increased-Risk Individuals
For individuals with one 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, 2
Repeat colonoscopy every 5 years in these higher-risk family history patients. 1, 2
For a single first-degree relative diagnosed at age 60 or older with colorectal cancer or advanced adenoma, begin screening at age 40 with any average-risk screening test. 1, 4
Two or more first-degree relatives with colorectal cancer at any age requires colonoscopy every 5 years starting at age 40 or 10 years before the earliest diagnosis. 1
Advanced adenoma in a first-degree relative requires colonoscopy every 5-10 years beginning at age 40 or at the age of onset of adenoma in the relative, whichever is first. 1
When to Stop Screening
Discontinue screening at age 75 in patients who are up-to-date with prior negative screening tests, particularly colonoscopy. 2, 4
Stop screening when life expectancy falls below 10 years regardless of age. 2, 5, 6
Discourage screening beyond age 85 as harms outweigh benefits. 2
For patients aged 76-85 years who have never been screened, screening decisions should consider life expectancy exceeding 10 years, as never-screened individuals are more likely to benefit than those with prior negative screening. 5
Quality Metrics for Colonoscopy
Cecal intubation rates should exceed 90% in screening populations, with withdrawal time of at least 6 minutes. 2
Adenoma detection rates should be at least 25% in men and 15% in women over 50. 2, 7
High-quality bowel preparation is paramount for accurate diagnosis, with split-dose regimens superior to single-dose regimens. 7
Critical Pitfalls to Avoid
Patients under age 50 with colorectal bleeding symptoms require diagnostic colonoscopy, not screening. 2
Inadequate bowel preparation reduces colonoscopy effectiveness and should trigger repeat examination. 2, 7
Continuing screening in patients over 75 who are up-to-date with negative tests exposes them to unnecessary procedural risks. 2
Family history must be systematically collected and documented, including age at diagnosis of affected relatives, as this information is often inaccurately reported or missing. 1
Do not use Septin9 serum assay, stool DNA alone, computed tomography colonography, capsule endoscopy, urine, or serum screening tests as first-line screening options. 4, 6