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Guideline Summary
Guideline Title
American College of Gastroenterology guidelines for colorectal cancer screening 2008.
Bibliographic Source(s)
Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM, American College of Gastroenterology. American College of Gastroenterology guidelines for colorectal cancer screening 2008. Am J Gastroenterol. 2009 Mar;104(3):739-50. [133 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Colorectal cancer (CRC)

Guideline Category
Evaluation
Prevention
Risk Assessment
Screening
Clinical Specialty
Family Practice
Gastroenterology
Internal Medicine
Oncology
Preventive Medicine
Radiology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To update the American College of Gastroenterology (ACG) colorectal cancer (CRC) screening recommendations

Target Population
  • Average-risk persons age 50 and older (African Americans age 45 and older)
  • Patients at increased risk for colorectal cancer
    • Persons with single first-degree relative with colorectal cancer (CRC) or advanced adenoma diagnosed at age <60 years or two first-degree relatives with CRC or advanced adenomas (age 40 years and older)
    • Persons with familial adenomatous polyposis (FAP) or at risk of FAP
    • Patients who meet the Bethesda criteria for hereditary nonpolyposis colorectal cancer
Interventions and Practices Considered
  1. Colonoscopy
  2. Flexible sigmoidoscopy
  3. Computed tomography (CT) colonography
  4. Fecal immunochemical test for blood (FIT)
  5. Hemoccult Sensa
  6. Fecal deoxyribonucleic acid (DNA) testing
  7. Screening initiation and intervals based on risk and family history
Major Outcomes Considered
  • Sensitivity and specificity of screening tests
  • Incidence of colorectal cancer (CRC)
  • Effectiveness of screening in reducing mortality from CRC
  • Cost-effectiveness of screening tests

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A systematic literature review was carried out by the writing committee. Ovid Medline and PubMed (from 1966 to 2008), EMBASE (from 1980 to 2008), and CINAHL (from 1982 to 2008) were searched. Only peer-reviewed English language articles were included.

The following specific search terms were used: colorectal cancer, colorectal polyps, colorectal adenomas, colorectal adenomatous polyps, colorectal polyp risk, colorectal cancer risk, colorectal cancer epidemiology, colorectal cancer screening, colonoscopy, flexible sigmoidoscopy, barium enema, CT colonography, virtual colonoscopy, fecal occult blood test, fecal immunochemical test.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Category of Evidence and Strength of Recommendation

Grade of Recommendation/Description Benefit vs. Risk and Burdens Methodological Quality of Supporting Evidence Implications
1A/Strong recommendation, high-quality evidence Benefits clearly outweigh risk and burdens, or vice versa Randomized controlled trials (RCTs) without important limitations or overwhelming evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation
1B/Strong recommendation, moderate quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation
1C/Strong recommendation, low-quality or very low-quality evidence Benefits clearly outweigh risk and burdens, or vice versa Observational studies or case series Strong recommendation but may change when higher quality evidence becomes available
2A/Weak recommendation, high-quality evidence Benefits closely balanced with risks and burden RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients' or societal values
2B/Weak recommendation, moderate quality evidence Benefits closely balanced with risks and burden RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients' or societal values
2C/Weak recommendation, low-quality or very low-quality evidence Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced Observational studies or case series Very weak recommendations; other alternatives may be equally reasonable
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Not stated
Description of Methods Used to Formulate the Recommendations

Not applicable

Rating Scheme for the Strength of the Recommendations

See the "Rating Scheme for the Strength of the Evidence" field.

Cost Analysis
  • Cost analyses of colonoscopy as a screening test for colorectal cancer (CRC) have found cost-effectiveness at equal or greater levels than other screening strategies with a 10-year interval.
  • The inability of computed tomography (CT) colonography to detect polyps 5 mm and smaller, which constitutes 80% of colorectal neoplasms, necessitates performance of the test at 5-year, rather than 10-year intervals. This is likely to increase overall costs, if CT colonography is used as a primary strategy.
  • False positive results of CT colonography diminish cost-effectiveness by increasing follow-up colonoscopies and repeat CT colonographies to verify false positive status.
  • Initiation of CRC screening at a younger age (as early as 45 years) may be shown to be beneficial and cost-effective in persons with more than 20 pack-years of smoking as well as in the obese population. These recommendations, however, may be tempered by the presence of medical complications of smoking and obesity that reduce the impact of CRC screening on overall life expectancy.

Refer to Table 4 in Appendix B of the original guideline document for key measures for improving the quality and cost-effectiveness of colonoscopy as a CRC screening test.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This guideline has been reviewed and approved by the Practice Parameters Committee of the American College of Gastroenterology (ACG) and by the ACG Board of Trustees.

Recommendations

Major Recommendations

The category of evidence and strength of recommendation definitions are provided at the end of the "Major Recommendations" field.

Rationale for a Preferred Strategy

As in 2000, the American College of gastroenterology (ACG) recommends that clinicians have access to a "preferred" strategy for making colorectal cancer (CRC) screening recommendations, as an alternative to the "menu of options" approach, if warranted by the performance characteristics of one of the tests. The ACG recommends colonoscopy every 10 years based on the evidence of colonoscopy effectiveness, cost-effectiveness, and acceptance by patients. A "preferred" strategy simplifies and shortens discussions with patients and could also increase the likelihood that screening is offered to patients. One randomized trial showed that patients were more likely to undergo screening with the "preferred" strategy approach compared with the "menu of options." Another study found no improvement in screening rates when multiple options were presented. Maintaining simplicity in guidelines may have value, in that recent evidence has suggested that practitioners often do not follow recommended intervals for postpolypectomy surveillance, which may in part be because of their complexity. The ACG acknowledges that listing quality colonoscopy as a "preferred" CRC prevention strategy places greater emphasis on the effectiveness than on risk. Current trends in procedure use in the United States reflect and are consistent with the ACG's recommendation of colonoscopy as the preferred strategy for CRC screening, in that colonoscopy procedure volumes have risen dramatically, whereas flexible sigmoidoscopy and double-contrast barium enema (DCBE) procedure volumes have decreased precipitously, and fecal occult blood test (FOBT) has decreased modestly.

Cancer Prevention Tests versus Cancer Detection Tests

The recent joint guideline (the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology) groups CRC screening tests into cancer prevention and cancer detection tests. Cancer prevention tests have the potential to image both cancer and polyps, whereas cancer detection tests have low sensitivity for polyps and typically lower sensitivity for cancer compared with that in cancer prevention tests (imaging tests). The ACG supports the division of screening tests into cancer prevention and cancer detection tests, but recommends a preferred cancer prevention test — colonoscopy every 10 years (Grade 1 B) and a preferred cancer detection test — annual fecal immunochemical test (FIT) to detect occult bleeding (Grade 1 B). All recommendations in this guideline are provided below.

CRC Screening Recommendations

Preferred CRC Screening Recommendations

  • Cancer prevention tests should be offered first. The preferred CRC prevention test is colonoscopy every 10 years, beginning at age 50 (Grade 1 B). Screening should begin at age 45 years in African Americans (Grade 2 C).
  • Cancer detection test. This test should be offered to patients who decline colonoscopy or another cancer prevention test. The preferred cancer detection test is annual FIT for blood (Grade 1 B).

Alternative CRC Prevention Tests

  • Flexible sigmoidoscopy every 5–10 years (Grade 2 B)
  • Computed tomography (CT) colonography every 5 years (Grade 1 C)

Alternative Cancer Detection Tests

  • Annual Hemoccult Sensa (Grade 1 B)
  • Fecal deoxyribonucleic acid (DNA) testing every 3 years (Grade 2 B)

Recommendations for Screening When Family History is Positive but Evaluation for Hereditary Non-polyposis Colorectal Cancer (HNPCC) Considered Not Indicated

  • Single first-degree relative with CRC or advanced adenoma diagnosed at age ≥60 years

    Recommended screening: same as average risk (Grade 2 B)

  • Single first-degree with CRC or advanced adenoma diagnosed at age <60 years or two first-degree relatives with CRC or advanced adenomas

    Recommended screening: colonoscopy every 5 years beginning at age 40 years or 10 years younger than age at diagnosis of the youngest affected relative (Grade 2 B)

Familial Adenomatous Polyposis (FAP)

  • Patients with classic FAP (>100 adenomas) should be advised to pursue genetic counseling and genetic testing, if they have siblings or children who could potentially benefit from this testing (Grade 2 B).
  • Patients with known FAP or who are at risk of FAP based on family history (and genetic testing has not been performed) should undergo annual flexible sigmoidoscopy or colonoscopy, as appropriate, until such time as colectomy is deemed by physician and patient as the best treatment (Grade 2 B).
  • Patients with retained rectum after subtotal colectomy should undergo flexible sigmoidoscopy every 6–12 months (Grade 2 B).
  • Patients with classic FAP, in whom genetic testing is negative, should undergo genetic testing for bi-allelic MYH mutations. Patients with 10–100 adenomas can be considered for genetic testing for attenuated FAP and if negative, MYH associated polyposis (Grade 2 C).

HNPCC

  • Patients who meet the Bethesda criteria should undergo microsatellite instability testing of their tumor or a family member's tumor and/or tumor immunohistochemical staining for mismatch repair proteins (Grade 2 B).
  • Patients with positive tests can be offered genetic testing. Those with positive genetic testing, or those at risk when genetic testing is unsuccessful in an affected proband, should undergo colonoscopy every 2 years beginning at age 20–25 years, until age 40 years, then annually thereafter (Grade 2 B).

Definitions:

Category of Evidence and Strength of Recommendation

Grade of Recommendation/Description Benefit vs. Risk and Burdens Methodological Quality of Supporting Evidence Implications
1A/Strong recommendation, high-quality evidence Benefits clearly outweigh risk and burdens, or vice versa Randomized controlled trials (RCTs) without important limitations or overwhelming evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation
1B/Strong recommendation, moderate quality evidence Benefits clearly outweigh risk and burdens, or vice versa RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation
1C/Strong recommendation, low-quality or very low-quality evidence Benefits clearly outweigh risk and burdens, or vice versa Observational studies or case series Strong recommendation but may change when higher quality evidence becomes available
2A/Weak recommendation, high-quality evidence Benefits closely balanced with risks and burden RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients' or societal values
2B/Weak recommendation, moderate quality evidence Benefits closely balanced with risks and burden RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients' or societal values
2C/Weak recommendation, low-quality or very low-quality evidence Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced Observational studies or case series Very weak recommendations; other alternatives may be equally reasonable
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Prevention of colorectal cancer

Potential Harms
  • Screening colonoscopy can be associated with significant harm, particularly colonic perforation. Many perforations are related to polypectomy and because small polyps are so numerous, small polyp polypectomy perforations contribute substantially to the overall perforation risk. Perforations associated with removal of small polyps are unfortunate, because the overwhelming majority of these polyps will not harm patients. The perforation risk and the requirement for thorough bowel preparation are the major downsides of colonoscopy.
  • False positives are common with computed tomography (CT) colonography, and the specificity for polyps ≥1 cm in size in the National CT Colonography Trial was only 86%, with a positive predictive value of 23%. Thus, colonoscopy for polyps detected on CT colonography will often require long procedures, in order to verify absence of other polyps. False positives diminish cost-effectiveness by increasing follow-up colonoscopies and repeat CT colonographies to verify false positive status. The American College of Gastroenterology (ACG) recommends that asymptomatic patients be informed of the possibility of radiation risk associated with one or repeated CT colonography studies, though the exact risk associated with radiation is unclear.

Qualifying Statements

Qualifying Statements

The "menu-of-options" approach was first formalized by the "GI consortium" in May 1997, endorsed by the American Cancer Society in 1997, revised by the US Multisociety Task Force in 2003, and revised by a joint committee of the US Multisociety Task Force, the American Cancer Society, and the American College of Radiology in 2008. The ACG participated in and endorsed the menu-of-options approach in 1997, 2003, and 2008. The ACG continues to endorse the menu-of-options approach as appropriate to CRC screening. Publication of this guideline does not rescind the ACG's endorsement of the joint guideline.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Foreign Language Translations
Patient Resources
Slide Presentation
Tool Kits
Wall Poster
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM, American College of Gastroenterology. American College of Gastroenterology guidelines for colorectal cancer screening 2008. Am J Gastroenterol. 2009 Mar;104(3):739-50. [133 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Mar
Guideline Developer(s)
American College of Gastroenterology - Medical Specialty Society
Source(s) of Funding

American College of Gastroenterology

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Authors: Douglas K. Rex, MD, FACG; David A. Johnson, MD, FACG; Joseph C. Anderson, MD; Phillip S. Schoenfeld, MD, MSEd, MSc (Epi), FACG; Carol A. Burke, MD, FACG; John M. Inadomi, MD, FACG

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American College of Gastroenterology (ACG) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Colon cancer. You can prevent it. Poster. Bethesda (MD): American College of Gastroenterology; 1 p. Electronic copies: Available from the American College of Gastroenterology (ACG) Web site External Web Site Policy.
  • 2009 colon cancer screening. New guidelines...and insights. Slide set. Bethesda (MD): American College of Gastroenterology; 2009. 86 p. Electronic copies: Available from the ACG Web site External Web Site Policy.
  • 2012 CRC community education toolkit. Available from the ACG Web site External Web Site Policy.
Patient Resources

A variety of patient education resources about colorectal cancer, including podcasts, frequently asked questions, and a brochure, are available from the American College of Gastroenterology (ACG) Web site External Web Site Policy. Resources are also available in Spanish from the ACG Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on May 30, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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