What is the preferred screening method, Cologuard (Multitarget Stool DNA test) versus Fecal Immunochemical Test (FIT), for a patient who refuses colonoscopy and has a history of Cologuard (Multitarget Stool DNA test) 3 years ago?

From the Guidelines

For a patient who refuses colonoscopy and had Cologuard 3 years ago, I would recommend offering FIT testing now. According to the most recent guidelines from the US Preventive Services Task Force 1, annual FIT testing is a recommended screening option for average-risk patients. Since it has been 3 years since her last Cologuard, either option would be appropriate for continued screening. FIT testing is less expensive and may be more accessible, but has lower sensitivity for detecting precancerous polyps compared to Cologuard. Cologuard combines FIT with DNA testing, making it more sensitive but also more expensive. The decision between these options should consider patient preference, insurance coverage, and risk factors.

Some key points to consider:

• The US Multi-Society Task Force on Colorectal Cancer recommends colonoscopy every 10 years or annual FIT as first-tier options for screening average-risk persons for colorectal neoplasia 1.
• The FIT–fecal DNA test, such as Cologuard, has a higher sensitivity for cancer but lower specificity and higher cost compared to FIT alone 1.
• Annual FIT testing is estimated to provide a greater life-years gained than annual high-sensitivity gFOBT or sDNA-FIT every 3 years 1.
• For average-risk patients (age 45-75 without family history or other risk factors), either FIT or Cologuard is acceptable as an alternative to colonoscopy. However, if the patient has increased risk factors such as family history of colorectal cancer or personal history of polyps, colonoscopy should be strongly encouraged as the preferred screening method despite her reluctance.

It is essential to document her refusal of colonoscopy and the alternative screening plan in her medical record. Given the patient's history and current guidelines, FIT testing is a reasonable and recommended option for continued screening.

From the Research

Patient Eligibility for Colo-Gard vs FIT Testing

• The patient had a colo-gard 3 years ago and is now refusing colonoscopy, which is a common screening method for colorectal cancer 2.
• According to the US Preventive Services Task Force, screening for colorectal cancer should begin at age 45 for average-risk individuals, and several screening strategies are recommended, including high-sensitivity guaiac fecal occult blood test (HSgFOBT), fecal immunochemical test (FIT), and multi-target stool DNA (mt-sDNA) test 2.
• For patients who refuse colonoscopy, alternative screening methods such as CT colonography or colon capsule endoscopy may be considered 3, 4.
• The choice of screening test depends on various factors, including the invasiveness of the test, test performance, screening interval, accessibility, and cost 2.

Comparison of Colo-Gard and FIT Testing

• Colo-Gard, also known as colon capsule endoscopy, is a minimally invasive screening method that has excellent sensitivity for polyp detection and a high negative predictive value 4.
• FIT testing, on the other hand, is a non-invasive screening method that detects blood in the stool, which can be an indication of colorectal cancer 2, 5.
• A study comparing colon capsule endoscopy and CT colonography in FIT-positive colorectal cancer screening subjects found that colon capsule endoscopy was more sensitive for the detection of any neoplastic lesion 5.

Recommendations for the Patient

• Given the patient's history of colo-gard 3 years ago and refusal of colonoscopy, alternative screening methods such as FIT testing or colon capsule endoscopy may be considered 2, 3, 4.
• The patient's healthcare provider should engage in informed decision-making with the patient to determine the most appropriate screening test, taking into account the patient's individual risk factors, preferences, and values 2.