Early Detection of Colorectal Cancer

Publication Date: February 25, 2019
Last Updated: November 5, 2024

Treatment

Table 3. Screening: Asymptomatic, Average-Risk Population, High-Incidence Areas, Age 50 - 75

1.1 gFOBT

Basic
People should receive highly sensitive gFOBT every 1 (preferred) – 2 years if resources are available (based on resources and patient adherence).

Limited, Enhanced, Maximal
People should receive highly sensitive gFOBT annually. (, H , S )
614

1.2  FIT

Basic
People may receive FIT, if available, every 1 (preferred) – 2 years (based on resources and patient adherence).

Limited, Enhanced, Maximal
People may receive FIT annually. (, I , M )
614

1.3 Flexible Sigmoidoscopy

Basic
N/A

Limited, Enhanced, Maximal
People should receive Flexible Sigmoidoscopy every 5 years. (, H , S )
614

1.4 Flexible Sigmoidoscopy plus (FIT or FOBT)

Basic
N/A

Limited, Enhanced, Maximal
People may receive Flexible Sigmoidoscopy every 10 yrs plus FIT (or if FIT not available, then FOBT) every year. (, I , S )
614

1.5 Colonoscopy

Basic/ Limited
N/A

Enhanced, Maximal
People may receive colonoscopy every 10 years. (, L , W )
614

1.6 CT colonography

Basic/ Limited/ Enhanced
N/A

Maximal
People may receive CT colonography. (, L , W )
614

1.7 FIT-DNA

Basic/ Limited/ Enhanced
N/A

Maximal
People may receive FIT-DNA.

(, L , W )
614

Table 4. Reflex Testing: If Patients Have a Positive Result From CRC Screening

2. 

Basic
If patients have a positive result from CRC screening, then clinicians should refer patients to colonoscopy (first choice) or sigmoidoscopy (second choice) if available. However, because endoscopy is not available in most Basic settings, clinicians should perform or refer patients to reflex testing with double contrast barium enema.

After reflex testing:
if a patient’s barium enema results are positive refer to colonoscopy, if available, otherwise refer the patient to surgery.

Limited
If patients have a positive result from CRC screening, then clinicians should perform or refer patients to a colonoscopy, if available. If clinicians cannot refer patients to a colonoscopy, then clinicians should administer a double contrast barium enema.

After reflex testing:
If a patient’s barium enema results are positive refer to colonoscopy, if available, otherwise refer the patient to surgery.
Note: If person in Limited Setting received positive results from Flexible Sigmoidoscopy screening (± stool screening) and there is low availability of colonoscopy, a completion colonoscopy is not mandatory. The colonoscopy or DCBE as reflex testing is more warranted for positive gFOBT, FIT, stool DNA, DCBE, or CT colonography.

Enhanced, Maximal
If patients have a positive result from a non-colonoscopy CRC screening, then clinicians should perform or refer patients to a colonoscopy. ( IC , Ins, S )
614

Table 5. People With Positive Pre-Malignant Polyps or Other Abnormal Screening Results

Pedunculated

3.1 Colonoscopy

Basic/ Limited
N/A


Enhanced, Maximal
Colonoscopy should be performed always with therapeutic intent.

(, Ins, S )
614
Basic/ Limited
N/A

Enhanced, Maximal
Performed by endoscopist with training in polypectomy. (, L , S )
614

3.2 Polypectomy 

Basic/ Limited
N/A

Enhanced, Maximal
Lesions should be removed with polypectomy. (, I , S )
Refer to guidelines for special considerations including anti-coagulants and coronary stents.
614

3.3 Evaluation of morphology 

Basic/ Limited
N/A


Enhanced, Maximal
Large pre-malignant lesions not suitable for endoscopic resection should be referred for surgical resection.

(, Ins, S )
614

3.4 Mucosal tattooing 

Basic/ Limited
N/A

Enhanced, Maximal
If lesion cannot be removed (in BSG guidelines); if large lesion has a high likelihood of malignancy (informal consensus) may be performed. (, Ins, W )
614

3.5 Histology/ pathology 

Basic/ Limited
N/A

Enhanced, Maximal
Removed lesions should be retrieved for histologic exam; confirm negative borders of resection. (, Ins, S )
614

3.6 Referral to surgery 

Basic/ Limited
N/A


Enhanced, Maximal
Only patients with lesions that cannot be removed endoscopically should be referred to surgery.

(, Ins, S )
614

Non-Pedunculated

3.7 Colonoscopy 

Basic/ Limited
N/A

Enhanced, Maximal
Yes always with therapeutic intent;

(, Ins, S )
614

Basic/Limited
N/A

Enhanced, Maximal
endoscopic resection first line therapy for LNPCP with no suspicion of malignancy.

614

Basic/Limited
N/A

Enhanced, Maximal
Should be performed by endoscopists with training in large complex polyps.

(, L , W )
614
Basic/ Limited
N/A

Enhanced, Maximal
Multidisciplinary team may perform colonoscopies. (, Ins, W )
614
3.8 Polypectomy 

Basic/ Limited
N/A

Enhanced, Maximal
Lesions should be removed with polypectomy; removal of lesions is dependent on the low likelihood of malignancy.

(, I , S )
614

Basic/ Limited
N/A

Enhanced, Maximal
Possibility of complete resection, refer to BSG/ACGB guidelines.

(, L , S )
614
Refer to guidelines for special considerations including anti-coagulants and coronary stents.
3.9 Evaluation of morphology 
Basic/ Limited
N/A

Enhanced, Maximal
Endoscopic assessment of lesion using enhanced endoscopy methods (if available may include chromoendoscopy); clinicians should follow the BSG guideline. (, Ins, S )
614

3.10 Mucosal tattooing 

Basic/ Limited
N/A


Enhanced, Maximal
If lesion cannot be removed (in BSG guidelines); if large lesion has a high likelihood of malignancy should be performed. For patients with polyps that are completely removed, clinicians may perform tattooing for surveillance purposes.

(, Ins, W )
614
3.11 Histology/ pathology 
Basic/ Limited
N/A

Enhanced, Maximal
Removed lesions should be retrieved for histologic exam; confirm negative borders of resection. (, Ins, S )
614

3.12 Referral to surgery 

Basic/ Limited
N/A


Enhanced, Maximal
Only patients with lesions that cannot be removed endoscopically should be referred to surgery.

(, Ins, S )
614
1 BSG = British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps.
Source: Rutter MD, et al. Gut 2015;0:1–27. doi:10.1136/gutjnl-2015-309576 Availabe at: https://www.bsg.org.uk/asset/14074495-3BF4-4EA8-BED8E740BA1E6177.

Table 6. Optimal Strategy For Workup/Diagnosis for Those With Symptoms

4.1 DRE

Basic, Limited
DRE may be performed (standard part of physical).

Enhanced, Maximal
N/A physical exam (IC, Ins, )
614

4.2 Double contrast barium enema 

Basic, Limited
Double contrast barium enema may be performed.

Enhanced, Maximal
N/A ( IC , Ins, )
614

4.3 For those without contraindications to colonoscopy

Basic, Limited
Colonoscopy with biopsy for those without contraindications should be performed, if colonoscopy is available, including by referral.


Enhanced, Maximal
Colonoscopy with biopsy for those without contraindications should be performed. (, , )
614

4.4 For those with contraindications to colonoscopy (or colonoscopy not available) but no contraindications to flexible sigmoidoscopy – if the patient can't tolerate colonoscopy then full visualization.

Basic, Limited
Flexible sigmoidoscopy with biopsy, if no contraindication, may be performed with barium enema.

Enhanced, Maximal
Flexible sigmoidoscopy with biopsy, if no contraindication, may be performed with full visualization of the colon (either barium enema or CT colonography). (, L , W )
614

4.5 Patients with contraindications to colonoscopy and to flexible sigmoidoscopy.

Basic Limited
N/A – refer to 4.2

Enhanced
CT colonography if suspicious findings and if other two tests contraindicated may be performed.
Or if 2nd tier DCBE is not possible.

Maximal
CT colonography if suspicious findings and if other two tests contraindicated may be performed.
2nd tier DCBE if CT colonography not possible. (, H , M )
614

4.6 Patients who have had an incomplete colonoscopy

Basic
N/A (patient would not have received colonoscopy in basic) (, , )
614
Limited
Barium enema (Note: colonoscopy may not have been available, therefore incomplete colonoscopy would not apply) ( IC , Ins, S )
614
Enhanced
If a patient in the Enhanced setting had an incomplete colonoscopy, then patients may receive an double contrast enhanced-barium enema or CT colonography (for CT colonography, if the local radiology service can demonstrate competency in this technique). (, I , S )
614
Maximal
Repeat colonoscopy or, if not feasible, the next tier would be one of the two following:
CT colonography, if the local radiology service can demonstrate competency in this technique OR
Barium enema may be offered (if nothing else is possible). (, , )
614

Recommendation Grading

Overview

Title

Early Detection of Colorectal Cancer

Authoring Organization

American Society of Clinical Oncology

Publication Month/Year

February 25, 2019

Last Updated Month/Year

October 2, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To provide resource-stratified, evidence-based recommendations on the early detection of colorectal cancer in four tiers to clinicians, patients, and caregivers.

Target Patient Population

For people who are asymptomatic, are ages 50 to 75 years, with no family history of colorectal cancer, are at average risk

Target Provider Population

Gastroenterologists, surgeons, medical oncologists, radiation oncologists, primary care providers, health planners, policy makers

PICO Questions

  1. What are the optimal strategies for population-level early detection of colorectal cancer in high-incidence and resource-constrained settings?

  2. What is the optimal reflex testing strategy for people with positive screening results?

  3. What is the optimal strategy for people with premalignant polyps or other abnormal screening results?

  4. What are the optimal methods of diagnosis for patients with signs and symptoms of early colorectal cancer?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Prevention

Diseases/Conditions (MeSH)

D003108 - Colonic Diseases, D003113 - Colonoscopy, D015179 - Colorectal Neoplasms

Keywords

colon cancer, colorectal cancer, CRC, Early Detection

Source Citation

DOI: 10.1200/JGO.18.00213 Journal of Global Oncology , no. 5 (December 01, 2019) 1-22.

Supplemental Methodology Resources

Data Supplement, Methodology Supplement

Methodology

Number of Source Documents
28
Literature Search Start Date
January 1, 2007
Literature Search End Date
December 31, 2017
Description of External Review Process
ASCO has a rigorous review process for guidelines. After the draft has been approved by the Expert Panel, the guideline is independently reviewed and approved by the Clinical Practice Guideline Oversight Committee (CPGC). Select members of the CPGC are asked to critically review the guideline prior to the next scheduled CPGC meeting. The CPGC members then present the results of their reviews to the full committee, discuss the review with the full committee, and the CPGC votes on whether to approve the guideline (with recusals from members who have relationships with affected companies). Approved ASCO Guidelines are then submitted to the Society’s journal for consideration of publication.
Description of Public Comment Process
ASCO Guidelines are available for open comment for a 2 to 3‐week period. Guideline recommendations available for open comment are posted on asco.org/open‐comment‐guidelines. Prospective reviewers must contact ASCO to request to review the draft guideline recommendations and are required to sign a non‐disclosure and confidentiality agreement before receiving the draft guideline recommendations. Reviewers must identify themselves by name and affiliation; anonymous comments will not be accepted. Guidelines staff review and summarize comments and bring relevant comments to the Expert Panel Co‐ chairs, and to the entire panel if necessary. Any changes made from the open comment process will be reviewed by the entire panel prior to CPGC approval. Comments are advisory only and ASCO is not bound to make any changes based on feedback from open comment. ASCO does not respond to reviewers or post responses to comments; however, major edits to the draft will be reflected in the open comment discussion.
Specialties Involved
Colon And Rectal Surgery, Family Medicine, Gastroenterology, Internal Medicine General, Oncology, Surgery General, Radiation Oncology, Oncology
Description of Systematic Review
The Protocol specifies the purpose of the guideline product, target patient population, clinical outcomes of interest, key features of the systematic literature review, and a proposed timeline for completion. ASCO staff, the Expert Panel Co‐Chairs, and possibly other panel members selected by the Co‐Chairs (the Expert Panel Steering Committee), will typically draft the protocol for full panel review. A standard protocol worksheet is used for consistency. Once the Co‐Chairs have approved a first draft of the Protocol, the Protocol will be shared with the full Expert Panel. At the discretion of the Guidelines Director, the CPGC leadership and/or the CPGC Methodology Subcommittee may review the Protocol to make suggestions for revision intended to clarify aspects of the plan for developing the guideline. These suggestions are sent to the Expert Panel Co‐Chairs. Work on the systematic literature review can proceed upon the sign‐off of the Protocol by the Expert Panel.
List of Questions
See Full Text
Description of Study Criteria
See Supplement
Description of Search Strategy
Upon approval of the Protocol, a systematic review of the medical literature is conducted. ASCO staff use the information entered into the Protocol, including the clinical questions, inclusion/exclusion criteria for qualified studies, search terms/phrases, and range of study dates, to perform the systematic review. Literature searches of selected databases, including The Cochrane Library and Medline (via PubMed) are performed. Working with the Expert Panel, ASCO staff complete screening of the abstracts and full text articles to determine eligibility for inclusion in the systematic review of the evidence. Unpublished data from meeting abstracts are not generally used as part of normal ASCO guideline development (“Meeting Data”). However, abstract data from reputable scientific meetings and congresses may be included on a case‐by‐case basis after review by the CPGC leadership. Expert Panels should present a rationale to support integration of abstract data into a guideline. The CPGC leadership will consider the following inclusion criteria for the unpublished scientific meeting data: 1) whether the data were independently peer reviewed in connection with a reputable scientific meeting or congress; 2) the potential clinical impact of the unpublished data; 3) the methodological quality and validity of the associated study; 3) the potential harms of not including the data; and 4) the availability of other published data to inform the guideline recommendations.
Description of Study Selection
Literature search results were reviewed and deemed appropriate for full text review by two ASCO staff reviewers in consultation with the Expert Panel Co-Chairs. Data were extracted by two staff reviewers and subsequently checked for accuracy through an audit of the data by another ASCO staff member. Disagreements were resolved through discussion and consultation with the Co-Chairs if necessary. Evidence tables are provided in the manuscript and/or in Data Supplement.
Description of Evidence Analysis Methods
ASCO guideline recommendations are crafted, in part, using the GuideLines Into DEcision Support (GLIDES) methodology. ASCO adopted a five‐step approach to carry out quality appraisal, strength of evidence ratings and strength of recommendations ratings. The ASCO approach was primarily adapted from those developed by the AHRQ,, USPSTF, and GRADE, however with the validation of the GRADE methodology, the sole use of GRADE is being evaluated by the Clinical Practice Guidelines Committee.
Description of Evidence Grading
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect. Intermediate: Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect. Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect. Insufficient: Evidence is insufficient to discern the true magnitude and direction of the net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.
Description of Recommendation Grading
ASCO uses a formal consensus methodology based on the modified Delphi technique in clinically important areas where there is limited evidence or a lack of high‐quality evidence to inform clinical guidance recommendations. Evidence Based: There was sufficient evidence from published studies to inform a recommendation to guide clinical practice. Formal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. Therefore, the Expert Panel used a formal consensus process to reach this recommendation, which is considered the best current guidance for practice. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). The results of the formal consensus process are summarized in the guideline and reported in the Data Supplement (see the Supporting Documents" field). Informal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. The recommendation is considered the best current guidance for practice, based on informal consensus of the Expert Panel. The Panel agreed that a formal consensus process was not necessary for reasons described in the literature review and discussion. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). No recommendation: There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.
Description of Funding Source
ASCO provides funding for Guideline Development.
Company/Author Disclosures
ASCO Conflict of Interest Policy complies with the CMSS Code for Interactions with Companies. ASCO requires disclosure by individuals involved in drafting, reviewing, and approving guideline recommendations.
Percentage of Authors Reporting COI
100