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Recommended В» Page 13 of 18 В» FAP NATION

This assessment of net benefit applies to stool-based tests with high sensitivity, colonoscopy, computed tomography (CT) colonography, and flexible sigmoidoscopy. See Table 1 for characteristics of recommended screening strategies. The USPSTF recommendation for screening for colorectal cancer does not include serum tests, urine tests, or capsule endoscopy for colorectal cancer screening because of the limited available evidence on these tests and because other effective tests (ie, the recommended screening strategies) are available.

The risks and benefits of different screening tests vary. See Table 1 for characteristics of recommended screening strategies, which may include combinations of screening tests. Because of limited available evidence,9,10 the USPSTF recommendation does not include serum tests, urine tests, or capsule endoscopy for colorectal cancer screening. Recommended stool-based and direct visualization screening tests are described below.

The USPSTF recognizes the higher colorectal cancer incidence and mortality in Black adults and strongly encourages clinicians to ensure their Black patients receive recommended colorectal cancer screening, follow-up, and treatment. The USPSTF encourages the development of systems of care to ensure adults receive high-quality care across the continuum of screening and treatment, with special attention to Black communities, which historically experience worse colorectal cancer health outcomes.

Maintaining comparable benefits and harms of screening with the various strategies requires that patients, clinicians, and health care organizations adhere to currently recommended protocols for screening intervals, follow-up colonoscopy, and treatment. Each screening test has different considerations for implementation that may facilitate patient uptake of and adherence to screening or serve as a barrier to screening (see Table 1 for additional details). Implementation considerations include where the screening test is performed, who performs the screening procedure, the need for preprocedure bowel preparation, the need for anesthesia or sedation during the test, and follow-up procedures for abnormal findings on a screening test. These considerations have implications for how feasible and preferable a given screening test is for an individual. Discussion of implementation considerations with patients may help better identify screening tests that are more likely to be completed by a given individual.

Evidence on accuracy of high-sensitivity gFOBT to detect colorectal cancer and advanced adenomas compared with a colonoscopy reference standard was reported in 2 studies (n?=?3503).9,10 Reported sensitivity to detect colorectal cancer ranged from 0.50 to 0.75 (95% CI, 0.09-1.0) and reported specificity ranged from 0.96 to 0.98 (95% CI, 0.95-0.99). Sensitivity for detecting advanced adenomas was lower, ranging from 0.06 to 0.17 (95% CI, 0.02-0.23), while specificity was similar (0.96 to 0.99 [95% CI, 0.96-0.99]).9,10 A larger evidence base was available on the accuracy of FIT, with the most evidence available on the OC-Sensor family of FITs (13 studies; n?=?44,887).9,10 Using the threshold recommended by the manufacturer (20 μg hemoglobin per gram of stool), the pooled sensitivity for detection of colorectal cancer was 0.74 (95% CI, 0.64-0.83; 9 studies; n?=?34,352) and pooled specificity was 0.94 (95% CI, 0.93-0.96; 9 studies; n?=?34,352). Similar to high-sensitivity gFOBT, sensitivity for detecting advanced adenomas was lower while specificity was similar; pooled sensitivity was 0.23 (95% CI, 0.20-0.25) and pooled specificity was 0.96 (95% CI, 0.95-0.97).9,10 Accuracy estimates of 9 other types of FIT were similar but were generally reported only in single studies. In 4 studies (n?=?12,424) reporting the accuracy of sDNA-FIT,9,10 pooled sensitivity for colorectal cancer detection was 0.93 (95% CI, 0.87-1.0) and pooled specificity was 0.84 (95% CI, 0.84-0.86), with a lower pooled sensitivity for detecting advanced adenomas (0.43 [95% CI, 0.40-0.46]) but higher pooled specificity (0.89 [95% CI, 0.86-0.92]).9,10 Ten of the accuracy studies on FIT also reported results by age strata and generally found no significant difference; 2 reported stratified analyses for individuals younger than 50 years. Two studies suggested lower specificity for colorectal cancer detection in adults 70 years or older; a single study on sDNA-FIT suggested decreasing specificity with increasing age.9,10

Two prospective cohort studies (n?=?436,927) in US-based populations reported on colorectal cancer outcomes after colonoscopy screening.9,10 One study among health professionals found that after 22 years of follow-up, colorectal mortality was lower in persons who reported receiving at least 1 colonoscopy (adjusted hazard ratio, 0.32 [95% CI, 0.24-0.45]),39 although findings were no longer significant after 5 years for adults with a first-degree relative with colorectal cancer. This study included persons younger than 50 years, although results for this age group were not reported separately. Another cohort study among Medicare beneficiaries reported that the risk of colorectal cancer was significantly lower in adults aged 70 to 74 years (but not aged 75 to 79 years) 8 years after receiving a screening colonoscopy (standardized risk, 0.42% [95% CI, 0.24%-0.63%]).40 One large, prospective cohort study (n?=?5,417,699) from Taiwan reported on colorectal cancer mortality after introduction of a nationwide screening program with FIT in adults aged 50 to 69 years.41 After 1 to 3 rounds of biennial FIT screening, lower colorectal cancer mortality was found at 6 years of follow-up (adjusted relative risk, 0.90 [95% CI, 0.84-0.95]).

Based on averaging estimates across the 3 CISNET models, if screening were performed from ages 45 to 75 years with one of the USPSTF recommended strategies, an estimated 286 to 337 life-years would be gained, an estimated 42 to 61 cases of colorectal cancer would be averted, and an estimated 24 to 28 colorectal cancer deaths would be averted, per 1000 adults screened, depending on the specific strategy used (Figure 1).12 This finding translates to an estimated 104 to 123 days of life gained per person screened. Lowering the starting age of screening from age 50 years to age 45 years results in an estimated additional 2 to 3 cases of colorectal cancer being averted, an estimated 1 additional colorectal cancer death averted, and an estimated 22 to 27 additional life-years gained per 1000 adults (ie, 8 to 10 additional days of life gained per person screened)12 (Figure 1).

Harms from CT colonography are uncommon (19 studies; n?=?90,133), and the reported radiation dose for CT colonography ranges from 0.8 to 5.3 mSv (compared with an average annual background radiation dose of 3.0 mSv per person in the US).9,10 Accurate estimates of rates of serious harms from colonoscopy following abnormal CT colonography results are not available. Extracolonic findings on CT colonography are common. Based on 27 studies that included 48,235 participants, 1.3% to 11.4% of examinations identified extracolonic findings that required workup.9,10 Three percent or less of individuals with extracolonic findings required definitive medical or surgical treatment for an incidental finding. A few studies suggest that extracolonic findings may be more common in older age groups. Long-term clinical follow-up of extracolonic findings was reported in few studies, making it difficult to know whether it represents a benefit or harm of CT colonography.

Based on the available empirical evidence,9,10 harms from colonoscopy (either a screening colonoscopy, follow-up colonoscopy after a positive screening result from other methods, or surveillance colonoscopy in persons in whom adenomas have previously been detected) were considered to be the main source of colorectal cancer screening harms in the CISNET modeling study.12,13 Thus, harms were quantified as the lifetime number of colonoscopy complications associated with screening, and the lifetime number of colonoscopies was used as a proxy for the burden of screening. Based on averaging estimates across the 3 models, if screening were performed from ages 45 to 75 years with 1 of the USPSTF recommended strategies, an estimated 1535 to 4248 colonoscopy procedures and 10 to 16 colonoscopy complications would be expected over the lifetime of 1000 screened adults (ie, 1.5 to 4.2 colonoscopies per person over the lifetime and complications estimated as occurring in 1 in every 63 to 102 adults screened from ages 45 to 75 years).12,13

Role of the Funder/Sponsor: AHRQ staff assisted in the following: development and review of the research plan, commission of the systematic evidence review from an Evidence-based Practice Center, coordination of expert review and public comment of the draft evidence report and draft recommendation statement, and the writing and preparation of the final recommendation statement and its submission for publication. AHRQ staff had no role in the approval of the final recommendation statement or the decision to submit for publication.

This work may not be reproduced, reprinted, or redistributed for a fee, nor may the work be sold for profit or incorporated into a profit-making venture without the express written permission of AHRQ. This work is subject to the restrictions of Section 1140 of the Social Security Act, 42 U.S.C. 320b-10. When parts of a recommendation statement are used or quoted, the USPSTF Web page should be cited as the source.

On this site, the term "country" does not in all cases refer to a territorial entity that is a state as understood by international law and practice. As used here, the term also covers some territorial entities that are not states. Dependent territories of member countries are listed alphabetically followed by a description of the constitutional relationships with their member countries. 041b061a72


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