Practice Guidelines

ACG Guidelines for Colorectal Cancer Screening

MARA LAMBERT

Guideline source: American College of Gastroenterology Literature search described? Yes Evidence rating system used? Yes Published source: American Journal of Gastroenterology, March 2009 Available at: http://www.nature.com/ajg/journal/v104/n3/full/ ajg2009104a.html (subscription required)

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

In 2000, the American College of Gastroenterology (ACG) became the first organization to recommend colonoscopy as the preferred screening method for colorectal cancer. The ACG updated its screening recommendations in 2008, and continues to support colonoscopy in average-risk patients every 10 years based on the evidence of effectiveness, cost-effectiveness, and patient acceptance. Recommendations from the 2008 guidelines that differ from the previous guidelines are presented in Table 1.

Cancer Prevention Tests vs. Cancer Detection Tests In 2008, a joint committee of the U.S. Multisociety Task Force, the American Cancer Society, and the American College of Radiology released a guideline that divided colorectal cancer screening tests into two groups: cancer prevention tests and cancer detection tests. Prevention tests are capable of imaging cancer and polyps, whereas detection tests have low sensitivity for polyps and lower sensitivity for cancer compared with prevention tests. The ACG supports this division of tests and specifies that the preferred prevention test should be colonoscopy every 10 years, and the preferred detection test should be annual fecal immunochemical test (FIT) for occult bleeding (Table 2). Patients should be offered colonoscopy beginning at 50 years of age. If patients have economic issues that preclude primary screening with colonoscopy, or if patients

Table 1. Updates to the 2000 American College of Gastroenterology Recommendations on Screening for Colorectal Cancer
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Adapted with permission from Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM, for the American College of Gastroenterology. American College of Gastroenterology guidelines for colorectal cancer screening 2008. Am J Gastroenterol. 2009;104(3):740.

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Table 2. Colorectal Cancer Screening Recommendations

The rights holder did not grant the American Academy of Family Physicians the right to sublicense this material to a third party. For the missing item, see the original print version of this publication.

Grade 1 A = strong recommendation, high-quality evidence; Grade 1 B = strong recommendation, moderate-quality evidence; Grade 1 C = strong recommendation, low- or very low-quality evidence; Grade 2 A = weak recommendation, high-quality evidence; Grade 2 B = weak recommendation, moderate-quality evidence; Grade 2 C = weak recommendation, low- or very low-quality evidence. Adapted with permission from Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM, for the American College of Gastroenterology. American College of Gastroenterology guidelines for colorectal cancer screening 2008. Am J Gastroenterol. 2009;104(3):741.

decline colonoscopy, the physician should offer an alternative prevention test or the preferred detection test (i.e., occult blood detection through FIT). The ACG supports annual FIT as a preferred cancer detection test in place of guaiac-based fecal occult blood testing. Although the guaiac-based Hemoccult Sensa and the fecal DNA test are possible alternative detection tests, FIT is less expensive than fecal DNA testing and has produced more extensive data than the Hemoccult Sensa. Age to Begin Screening in Persons at Average Risk The ACG recommends that colorectal cancer screening begin at 50 years of age in men and women at average risk 648 American Family Physician

(i.e., those without a family history of colorectal neoplasia). However, screening should begin at 45 years of age in black men and women. Evidence supports screening for colorectal cancer before 50 years of age in persons with an extreme smoking history or obesity, although a formal recommendation has not been issued. Family History Screening The ACG no longer recommends an increased level of screening for a simple family history of adenomas in a first-degree relative. Patients with one first-degree relative with colorectal cancer or advanced adenoma (i.e., adenoma greater than 1 cm, or with high-grade
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Practice Guidelines
dysplasia or villous elements) diagnosed at 60 years or older should receive the same screening as average-risk patients. Patients with one first-degree relative diagnosed before 60 years of age, or with two first-degree relatives diagnosed at any age, should have a screening colonoscopy every five years beginning at 40 years of age or 10 years younger than the age of the youngest affected relative at the time of diagnosis. Table 2 summarizes the ACG recommendations for modification of the screening approach when a family history of colorectal polyps and cancer are not suggestive of hereditary nonpolyposis colorectal cancer (HNPCC). Familial Adenomatous Polyposis Patients with features of an inherited colorectal cancer syndrome should be encouraged to seek genetic counseling and, if appropriate, genetic testing (Table 2). Patients with familial adenomatous polyposis (FAP) should undergo APC mutation testing. If this test is negative, MYH mutation testing is recommended. Patients with FAP and those at risk of FAP should be screened annually with flexible sigmoidoscopy or colonoscopy until the patient and physician determine that a colectomy is the best treatment. Endoscopic assessment every six to 12 months after surgery is recommended for patients with a retained rectum after subtotal colectomy. Genetic counseling, APC and MYH mutation testing, and individualized colonoscopy surveillance should be considered in patients who have fewer than 100 colorectal polyps. Upper endoscopic surveillance is recommended for patients with FAP or MYH-associated polyposis. Hereditary Nonpolyposis Colorectal Cancer Patients who meet the Bethesda criteria for HNPCC should undergo microsatellite instability testing of their tumor or an affected family members tumor (Table 2). This may be combined with tumor immunohistochemical staining for mismatch repair proteins. Patients with positive tests may be offered genetic counseling and should undergo colonoscopy every two years beginning at 20 to 25 years of age until 40 years of age, and annually thereafter. Answers to This Issues CME Quiz Q1. Q2. Q3. Q4. Q5. B C C, D D A, C, D Q6. Q7. Q8. Q9. Q10. A B A, C A B Q11. Q12. Q13. Q14. B, C, D A A, B, D C

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