Colorectal Cancer Screening Guidelines Toolkit

Publication Date: February 26, 2024

Last Updated: March 13, 2024

Background:

Colorectal cancer (CRC) is a type of cancer that starts in the colon or rectum. The colon and rectum are parts of the large intestine. The rectum is the final part of the large intestine just before the anus.
CRC is very common. In the United States, it is:
- the fourth most common cancer diagnosed among adults
- the second leading cause of death from cancer
- most common in adults aged 65 to 74.
This patient guide will help you better understand CRC screening, including your options, and how to decide which, if any, is right for you.

How CRC develops:

CRC typically starts as a polyp (a small protruding growth) that slowly increases in size and becomes cancer. Some of these polyps are adenomas (benign glandular tumors that may develop into cancer.)
Progression from polyp to invasive cancer varies from 5 years or less to more than 20 years. Some adenomas stabilize and others regress.

CRC Prevention Starts with Screening:

CRC screening is the process of detecting early-stage CRCs and even precancerous lesions (abnormal growths that can turn into cancer over time if not removed) in people with no symptoms and no history of cancer or precancerous lesions.
CRC is the most preventable, yet least prevented, cancer. This means that CRC is the most avoidable, but unfortunately, it is not prevented as much as it could be because many people do not get screened. Prevention of CRC starts with screening.
CRC can save lives by early detection and management of the lesions.
CRC can be a part of a screening program or campaign.

CRC Screening Clinical Practice Guidelines:

Multiple clinical practice guidelines have been published in the United States regarding colorectal cancer (CRC) screening. This toolkit highlights both similarities and differences.
- Similarities:
  - Patients younger than 45 should be screened if they are at higher risk for CRC.
  - Screening can stop at 75 for most patients, and 85 for nearly all patients.
  - Screening intervals are fairly consistent across all guidelines.
- Differences:
  - New guidelines recommend starting screening at 45, not 50 as before.
  - Some guidelines pick specific tests while others recommend that be decided by the healthcare provider.

Basics of Screening (Timing Based on Age):

Average Risk Patients	High-Risk Patients¹	Older Adults
Some guidelines recommend screening from age 45 to75 years Others recommend screening from age 50 to 75 years.	Most guidelines do not provide this information. Some guidelines recommend screening at an earlier age such as 40 or 10 years before youngest average risk age for each individual risk.	Most guidelines suggest screening from age 75 to 85 years although this may vary based on individual preferences and other considerations.

¹ High-risk patients include a family history of colorectal cancer or polyps, a family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC), a family personal history of colorectal cancer, personal history of chronic inflammatory bowel disease (ulcerative colitis or Crohn's disease), persons with certain medical conditions such as cystic fibrosis.

Screening Methods:

Screening Options & Methods	Frequency	What to Know
Stool Tests (Not all are covered by insurance.)
Fecal Immunochemical Test (FIT)	Once a Year	It checks for blood in stool using antibodies It is done at home by collecting a single sample and sending it to the lab or doctor’s office No diet or medication restrictions It is less effective than visual tests in detecting advanced adenoma (a benign glandular tumor that may develop into cancer) It is relatively inexpensive Follow-up colonoscopy for positive test results may be subject to out-of-pocket costs
Guaiac-based Fecal Occult Blood Test (gFOBT)	Once a Year	It checks for blood in stool using a special chemical known as ‘guaiac’ It is done at home by collecting multiple samples and sending them to the lab or the doctor’s office It requires dietary and medication restrictions It is less effective than visual tests in detecting advanced adenoma (a benign glandular tumor that may develop into cancer) It is inexpensive compared to other methods, with higher false-positive rates than FIT, leading to more colonoscopies Follow-up colonoscopy for positive test results may be subject to out-of-pocket costs
Stool DNA (sDNA)/ FIT-DNA	Every 1 to 3 Years	It combines the FIT method with a test that detects altered DNA in the stool It is a relatively new test with limited data on the outcomes It is done at home by collecting a single sample and sending it to the lab or doctor’s office It is more expensive than other stool-based tests, with uncertainties about what to do if the test shows a positive result but a colonoscopy later comes back negative Follow-up colonoscopy for positive test results may be subject to out-of-pocket costs
Visual Tests
Colonoscopy	Every 10 Years	It checks the entire colon using a flexible tube with a tiny light and a camera It is done at a medical facility, usually under sedation Polyps can be removed during the screening visit Risk of some complications from the test or the anesthesia Lower sensitivity in the proximal (upper) colon Bowl preparation is required An accompanied member and time off work is needed It is the most expensive but covered or reimbursable by insurance Polyp removal and anesthesia may be subject to out-of-pocket costs
CT Colonography (Virtual Colonoscopy)	Every 5 years	It scans the colon using X-Ray It is done at a medical facility Bowl preparation is required It is relatively expensive and may not be covered by insurance Follow-up colonoscopy for positive test results may be subject to out-of-pocket costs
Flexible Sigmoidoscopy	Every 5 to 10 Years	It scans the lower colon and rectum using a flexible tube with a tiny light and a camera It is done at a medical facility It does not examine the proximal (upper) colon It may be less available It requires an enema before the procedure It can be uncomfortable, even painful There are concerns about the lack of quality standards Follow-up colonoscopy for positive test results may be subject to out-of-pocket costs

Shared Decision-Making (How to Make the Right Choice):

Overview:

The choice of colorectal cancer (CRC) screening method should be a shared decision made between you and your healthcare provider.
This process of working with your healthcare provider to determine what works best for you is called “shared decision-making.”
The goal of the shared decision-making process is to make sure that patients and healthcare providers are on the same page throughout the care process and that the care process is designed for each patient’s individual needs and preferences.
In the context of CRC, SDM helps you to choose a CRC screening option you will likely adhere to.
Your preference toward a certain test is important; it is a key to adherence, but it must align with high-quality screening options, test accessibility, and colonoscopy accessibility if needed.
There is no universal preference for adults toward a specific screening test. It is not “one size fits all.”
What to expect from your care team if you need to be tested:
- They will explain to you why the screening is needed
- They will communicate with you the screening options
- They will make recommendations on which test is better for you

Things to Discuss with Your Healthcare Provider:
You can talk to your healthcare provider about the following to determine which screening method Is right for you.

Family history
- Based on your family history of CRC or polyps, some screening methods may be more appropriate than others.
Convenience
- Some tests can be done in your home, while others are done in your healthcare provider’s office or a specialized imaging facility.
Potential need for follow-up screening
- Some screening methods, while more convenient initially, may require follow-ups with other tests depending on the results.
Cost
- Some screening methods cost more than others. What your health insurance will cover can also play a part in determining which screening method is right for you. Some tests are accompanied by other procedures that may or may not be covered by your insurance such as anesthesia.
Accuracy
- Some tests are more accurate than others. That means how well the test can correctly identify the disease if present and rule it out if absent.
Risks
- While all screening methods are relatively low risk, some do come with higher risks than others. Some risks may arise from the test while others may arise from the anesthesia.
Access and support system
- Some procedures may require you to visit a specific location, and have someone who can help bring you to and from your appointment.
Availability
- Not all methods may be available in all locations, so talk to your healthcare provider to determine what your options are.

Adherence (The Importance of Following Through):

Colorectal cancer (CRC) is a very preventable disease, but prevention starts with screening.
You may benefit from an organized screening campaign or program if you find one near you. Organized screening programs help more people get screened for CRC. This is better than just leaving it up to each doctor's office.
Reminders by mail, email, phone calls, or texts help the follow-through process.
Some screening tests may require more patient preparation than others. This is especially true with a colonoscopy and other visual tests. It is important to consider this when choosing a screening test.
Regardless of which method you choose, following the direction of your healthcare provider is a very important part of the care process. If you are having a colonoscopy, this includes following all instructions before the screening, including any required bowel preparation.
Failure to follow your healthcare provider’s directions may result in needing to have the test rescheduled, or potentially needing to have it redone.
Some of the most common reasons that patients may not test include:
- Fear of the procedure
- Financial issues
- Lack of support from friends and family, including not being able to secure a ride to or from the procedure
- Discomfort from the preparation methods
- The feeling that the procedure is “not needed”

Talk to your healthcare provider if you are experiencing any of these concerns or conditions that may affect your decision to test and the outcome of your screening procedure. Support services may be offered, or you may even be offered a different screening method that better suits your individual needs.

Additional resources:

ASCO colorectal cancer screening patient resource: https://www.cancer.net/cancer-types/colorectal-cancer/screening
National Cancer Institute Colorectal Cancer Screening Physician Data Query (PDQ)—Patient Version: https://www.cancer.gov/types/colorectal
Colorectal cancer screening patient guide: https://www.guidelinecentral.com/guideline/325065/patient-summary/1803500/
CDC Colorectal Cancer Screening Tests: https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm

Abbreviations

CRC: Colorectal Cancer
FIT: Fecal Immunochemical Test
SDM: Shared Decision-making
gFOBT: Guaiac-based Fecal Occult Blood Test

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.