ACG revises CRC screening guidelines, supports starting screening at 45 for average-risk patients, doesn't recommend blood-based screening test

The American College of Gastroenterology updated its 2009 guidelines around colorectal cancer screening, making 21 total recommendations. 

ACG posed several key questions and developed practical recommendations for practice providers. The recommendations were crafted through a focused literature search and supplemented by existing guidelines and technical reviews of CRC screening by key organizations. The guidelines were then modified using a Grading of Recommendations, Assessment, Development and Evaluation methodology. 

The recommendations are: 

1. We recommend CRC screening in average-risk individuals between ages 50 and 75 years to reduce incidence of advanced adenoma, CRC and mortality from CRC. Strong recommendation; moderate-quality evidence

2. We suggest CRC screening in average-risk individuals between ages 45 and 49 years to reduce incidence of advanced adenoma, CRC and mortality from CRC. Conditional recommendation; very low-quality evidence

3. We suggest that a decision to continue screening beyond age 75 years be individualized. Conditional recommendation; very low-quality evidence

4. We recommend colonoscopy and [fecal immunochemical testing] as the primary screening modalities for CRC screening. Strong recommendation; low-quality evidence

5. We suggest consideration of the following screening tests for individuals unable or unwilling to undergo colonoscopy or FIT: flexible sigmoidoscopy, multitarget stool DNA test, CT colonography or colon capsule. Conditional recommendation; very low-quality evidence

6. We suggest against Septin 9 for CRC screening. Conditional recommendation, very low-quality evidence

7. We recommend that the following intervals should be followed for screening modalities: FIT every one year, colonoscopy every 10 years. Strong recommendation; low-quality evidence

8. We suggest that the following intervals should be followed for screening modalities:

Multitarget stool DNA test every three years, flexible sigmoidoscopy every five to 10 years, CTC every five years, CC every five years. Conditional recommendation; very low-quality evidence

9. We suggest initiating CRC screening with a colonoscopy at age 40 or 10 years before the youngest affected relative, whichever is earlier, for individuals with CRC or advanced polyp in one first-degree relative (FDR) at age <60 years or CRC or advanced polyp in ≥2 FDR at any age. We suggest interval colonoscopy every five years. Conditional recommendation; very low-quality evidence

10. We suggest consideration of genetic evaluation with higher familial CRC burden (higher number and/or younger age of affected relatives). Conditional recommendation; very low-quality evidence

11. We suggest initiating CRC screening at age 40 or 10 years before the youngest affected relative and then resuming average-risk screening recommendations for individuals with CRC or advanced polyp in one first-degree relative at age ≥60 years. Conditional recommendation; very low-quality evidence

12. In individuals with one second-degree relative (SDR) with CRC or advanced polyp, we suggest following average-risk CRC screening recommendations. Conditional recommendation; low-quality evidence

13. We recommend that all endoscopists performing screening colonoscopy should measure their individual cecal intubation rates (CIRs), adenoma detection rates (ADRs), and withdrawal times (WTs). Strong recommendation, moderate-quality evidence for ADR, low-quality evidence for WT and CIR.

14. We suggest that colonoscopists with ADRs below the recommended minimum thresholds (<25 percent) should undertake remedial training. Conditional recommendation, very low-quality evidence

15. We recommend that colonoscopists spend at least six minutes inspecting the mucosa during withdrawal. Strong recommendation, low-quality evidence

16. We recommend that colonoscopists achieve CIRs of at least 95 percent in screening subjects. Strong recommendation, low-quality evidence

17. We suggest low-dose aspirin in individuals between the ages of 50 and 69 years with a cardiovascular disease risk of ≥10 percent over the next 10 years, who are not an increased risk for bleeding and willing to take aspirin for at least 10 years to reduce the risk of CRC. Conditional recommendation; low-quality evidence

18. We recommend against the use of aspirin as a substitute for CRC screening. Strong recommendation, low-quality evidence

19. We recommend organized screening programs to improve adherence to CRC screening compared with opportunistic screening. Strong recommendation; low-quality evidence

20. We suggest the following strategies to improve adherence to screening: patient navigation, patient reminders, clinician interventions, provider recommendations and clinical decision support tools. Conditional recommendation; very low-quality evidence

21. We suggest the following strategies to improve adherence to follow-up of a positive screening test: mail and phone reminders, patient navigation and provider interventions. Conditional recommendation; very low-quality evidence

View the entire guideline here

Note: Recommendations were copied entirely and presented above. Acronyms were expanded when appropriate.  

Some notable takeaways: 

1. Despite having several options available for testing, about 33 percent of the U.S. is unscreened. ACG emphasized the importance of reaching a screening rate above 80 percent. 

2. To reach this goal, ACG recognizes that providers should adopt cost-effective, accurate and noninvasive methodologies associated with reducing complications to avoid the hurdles some more invasive methods place. To this end, the ACG specifically recognized FIT is "optimal for programmatic screening when systems are in place to navigate patients into colonoscopy." 

3. Colonoscopy is still the gold standard for most patients. Colonoscopy alternatives should be used when patients are hesitant to undergo the procedure. 

4. ACG followed in CMS' footsteps and didn't recommend Epigenomics AG's Epi proColon, a blood-based CRC screening test. ACG conducted a systematic review of 39 studies that had a pooled CRC sensitivity of 62 percent for the test and a specificity of 90 percent. ACG concluded, "Given the low sensitivity and the lack of longitudinal and comparative data on test performance, this test is not considered an optimal screening modality of this time." 

5. ACG also followed in The U.S. Preventive Services Task Force's footsteps and made a conditional recommendation that average-risk patients begin screening at 45. The organization also recommended that patients with a first-degree relative begin screening at age 40 or 10 years before the youngest affected relative. These individuals can then begin following average-risk guidelines barring the discovery of a polyp. 

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