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{{Colon cancer}}
{{Colon cancer}}
To view the screening of familial adenomatous polyposis (FAP), click [[Familial adenomatous polyposis differential screening|'''here''']]<br>
To view the screening of hereditary nonpolyposis colorectal cancer (HNPCC), click [[Hereditary nonpolyposis colorectal cancer differential screening|'''here''']]<br><br>
{{CMG}} {{AE}}; {{RAK}} Elliot B. Tapper, M.D.; Saarah T. Alkhairy, M.D.


'''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; Elliot B. Tapper, M.D., Beth Israel Deaconess Medical Center; {{MJM}}
==Overview==
Early detection of premalignant colorectal masses or early-stage colorectal cancers is essential in treating these patients and possibly preventing cancer or colorectal cancer related death. According to the [[United states preventive services task force recommendations scheme|USPSTF]] (United States Preventive Services Task Force): [[Screening]] for colorectal cancer is recommended among adults older than 50 years of age and do not have an increased risk of developing the disease (average-risk adults).
 
==Clinical practice guidelines==
 
According to the '''USPSTF''' (United States Preventive Services Task Force):<ref name="pmid27304597">{{cite journal| author=US Preventive Services Task Force. Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW et al.| title=Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. | journal=JAMA | year= 2016 | volume= 315 | issue= 23 | pages= 2564-2575 | pmid=27304597 | doi=10.1001/jama.2016.5989 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27304597  }}</ref>
* Screening for colorectal cancer is recommended among adults older than 50 years of age and do not have an increased risk of developing the disease ('''average-risk''' adults).
* Decision to screen for colorectal cancer among adults aged 76 to 85 years is an individual one.
** Screening would be more beneficial for healthier individuals that are able to undergo possible treatment.
* Screening for colorectal cancer among adults aged 86 years and older is not recommended.
* No preference is given to one screening modality over the other
** Decision should be shared and according to the patient's preferences when it comes to choosing an option.
* Screening options:<ref name="pmid27304597" />
*# '''[[Colonoscopy]]'''
*# '''FIT'''
*#* Fecal immunochemical testing for occult blood
*# '''[[Flexible sigmoidoscopy]]'''
*# '''Flexible sigmoidoscopy''' + '''FIT'''
*# '''CT colonography'''
*# '''FIT-DNA'''
*#* multitargeted stool DNA testing
*# '''gFOBT'''
*#* Guaiac-based fecal occult blood testing
 
Screening for colorectal cancer in individuals that are at increased risk of developing the disease is different and depends on several factors:<ref name="Lieberman2009">{{cite journal|last1=Lieberman|first1=David A.|title=Screening for Colorectal Cancer|journal=New England Journal of Medicine|volume=361|issue=12|year=2009|pages=1179–1187|issn=0028-4793|doi=10.1056/NEJMcp0902176}}</ref><ref name="pmid27304597" />
* Family history of colorectal cancer before age 50
** Begin screening at an earlier age
* Risk of rapid disease progression
** Perform screening more frequently
* Family history of [[Hereditary nonpolyposis colorectal cancer|HNPCC]] or [[FAP]]
** Use most sensitive screening modality: colonoscopy
 
== Screening protocols summarized in the figures below: ==
Protocols have been summarized according to USPSTF guidelines.<ref name="pmid27304597" />[[Image:Average risk CRC.jpg|center|500x500px|frame|Screening protocol for '''average risk''' patients]]
 
 
[[Image:Moderate risk CRC.jpg|center|500x500px|frame|Screening protocol for '''moderate risk''' patients]]
 
[[Image:High risk CRC.jpg|center|500x500px|frame|Screening protocol for '''high risk''' patients]]
 
==Types of Screening Methods==
 
===Fecal Occult Blood Testing===
*A [[fecal occult blood]] test is a test for blood in the stool.
* There are two types of tests that can be used for detecting occult blood in stools:<ref name="pmid27304597" /><ref name="pmid20824704">{{cite journal| author=Duffy MJ, van Rossum LG, van Turenhout ST, Malminiemi O, Sturgeon C, Lamerz R et al.| title=Use of faecal markers in screening for colorectal neoplasia: a European group on tumor markers position paper. | journal=Int J Cancer | year= 2011 | volume= 128 | issue= 1 | pages= 3-11 | pmid=20824704 | doi=10.1002/ijc.25654 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20824704  }}</ref>
*# '''FIT'''
*#* Fecal immunochemical testing for occult blood
*# '''gFOBT'''
*#* Guaiac-based fecal occult blood testing
* Use of low-sensitivity guaiac fecal tests is not recommended due to its of low sensitivity.<ref name="pmid27304597" />


==Overview==
===Endoscopy===
In recent memory, there have been improvements made in the screening process for colon cancer. Knowing a few of the most important facts can greatly help in reducing the risk of developing colon cancer.
*A [[sigmoidoscopy|'''sigmoidoscopy''']] is a lighted probe ([[sigmoidoscope]]) that is inserted into the [[rectum]] and lower [[colon]] to check for [[polyps]] and other abnormalities.<ref name="pmid16635231" />
# Research has shown that a colonoscopy detects colon cancer in 98-99% of the cases.<ref name="colorectal">American Society of Clinical Oncology. 2010. Progress in Cancer Screening. http://owl.english.purdue.edu/owl/resource/560/10/</ref>
*A [[colonoscopy|'''colonoscopy''']] is a lighted probe ([[colonoscope]]) that is inserted into the [[rectum]] and the entire [[colon]] to look for [[polyp (medicine)|polyp]]s and other abnormalities that may be caused by [[cancer]]. A [[colonoscopy]] has the advantage that if [[polyp (medicine)|polyp]]s are found during the procedure they can be immediately removed, and the tissue can also be taken for [[biopsy]]. The [http://www.asge.org/ American Society for Gastrointestinal Endoscopy] has released quality indicators for screening [[colonoscopy]], which include:<ref name="pmid16635231">{{cite journal| author=Rex DK, Petrini JL, Baron TH, Chak A, Cohen J, Deal SE et al.| title=Quality indicators for colonoscopy. | journal=Am J Gastroenterol | year= 2006 | volume= 101 | issue= 4 | pages= 873-85 | pmid=16635231 | doi=10.1111/j.1572-0241.2006.00673.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16635231  }} </ref>
# Current guidelines suggest that a colonoscopy is the best screening tool for colon cancer.
:*Documentation of prep quality
# A [[colonoscopy]] every 10 years reduces the risk of left sided colon cancer but not as much for right sided colon cancer.
:*Photo documentation of [[Cecum|cecal]] [[intubation]]
## Right sided colon cancers are more likely to be missed.
:*Withdrawal time of 6 minutes or more
### Right sided is harder to reach
:*[[Adenoma]] detection rate of greater than 25% in males and 15% in females greater than 50 years old
### Right sided could be flat, which means they would be harder to detect.


# Flat growths (non-polypoid)<ref name="colorectal">American Society of Clinical Oncology. 2010. Progress in Cancer Screening. http://owl.english.purdue.edu/owl/resource/560/10/</ref>
[[Image:Colorectal cancer endo 2.jpg|473x473px]]
## More difficult to detect.
## More likely to progress to colon cancer than cylindrical [[polyps]].
## Spray on dyes may better help to detect them.


==Screening procedures==
=== CT colonography ===
:* Also known as Virtual Colonoscopy
:* Requires special workstation software in order for the [[radiologist]] to interpret 
:* This technique is approaching [[colonoscopy]] in sensitivity for [[polyps]]
:* Any polyps found must still be removed by standard [[colonoscopy]]<ref name="pmid14657435">{{cite journal| author=Morrin MM, LaMont JT| title=Screening virtual colonoscopy--ready for prime time? | journal=N Engl J Med | year= 2003 | volume= 349 | issue= 23 | pages= 2261-4 | pmid=14657435 | doi=10.1056/NEJMe038181 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14657435  }}</ref>


Colorectal cancer can take many years to develop and early detection of colorectal cancer greatly improves the chances of a cure.  The U.S. Preventive Services Task Force (USPSTF) recommends screening all patients aged 50-75 for colorectal cancer.<ref>Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement.Ann Intern Med. 2008;149:627-637.</ref>  The modalities recommended are:
=== Fecal DNA testing ===
* [[Fecal occult blood]] test (FOBT): a test for blood in the stool. Two types of tests can be used for detecting occult blood in stools i.e. guaiac based (chemical test) and immunochemical. The sensitivity of immunochemical testing is superior to that of chemical testing without an unacceptable reduction in specifity. <ref>Weitzel JN: Genetic cancer risk assessment. Putting it all together. Cancer 86:2483,1999. PMID 10630174</ref>
:* Multitargeted stool DNA testing
* [[Endoscopy]]:
:* Ability to detect mutations from DNA shed by colorectal cancer<ref name="pmid15017656">{{cite journal| author=Calistri D, Rengucci C, Bocchini R, Saragoni L, Zoli W, Amadori D| title=Fecal multiple molecular tests to detect colorectal cancer in stool. | journal=Clin Gastroenterol Hepatol | year= 2003 | volume= 1 | issue= 5 | pages= 377-83 | pmid=15017656 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15017656  }}</ref>
** [[Sigmoidoscopy]]: A lighted probe (sigmoidoscope) is inserted into the rectum and lower colon to check for polyps and other abnormalities.
** [[Colonoscopy]]: A lighted probe called a colonoscope is inserted into the rectum and the entire colon to look for [[polyp (medicine)|polyp]]s and other abnormalities that may be caused by cancer.  A colonoscopy has the advantage that if [[polyp (medicine)|polyp]]s are found during the procedure they can be immediately removed.  Tissue can also be taken for [[biopsy]].


The American College of Gastroenterology<ref>Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009.Am J Gastroenterol. 2009 Mar;104(3):739-50.</ref> releases guidelines as well.  They add a few additional considerations:
==Accuracy of screening methods==
* Screening is recommended in African Americans beginning at age 45 years.
* [[CT colonography]] every 5 years is the radiographic screening alternative, when patients decline colonoscopy.
* Fecal immunochemical test for blood (FIT) is preferred over guaiac-based fecal occult blood testing.


[[Image:Colorectal cancer endo 2.jpg|left|thumb|200px|[[Colonoscopy|Endoscopic]] image of '''colon cancer''' identified in sigmoid [[Colon (anatomy)|colon]] on screening [[colonoscopy]] in the setting of [[Crohn's disease]].]]
Advanced adenomas are defined as being ≥10 mm, having villous histology, or having high grade dysplasia. Advanced neoplasia is defined as cancer or advanced adenoma<ref name="pmid27441328">{{cite journal| author=Lin JS, Piper MA, Perdue LA, Rutter C, Webber EM, O’Connor E | display-authors=etal| title=Screening for Colorectal Cancer: A Systematic Review for the U.S. Preventive Services Task Force | journal=U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews | year= 2016 | volume=  | issue=  | pages=  | pmid=27441328 | doi= | pmc= | url= }} </ref>.
<br clear="left"/>


===Other screening techniques===
{| class="wikitable"
* Double contrast barium enema (DCBE): First, an overnight preparation is taken to cleanse the colon.  An [[enema]] containing [[barium sulfate]] is administered, then air is insufflated into the colon, distending it.  The result is a thin layer of barium over the inner lining of the colon which is visible on X-ray films.  A cancer or a precancerous polyp can be detected this way.  This technique can miss the (less common) flat polyp.
|+ Accuracy of screening tests to detect colorectal cancer and advanced adenomas<ref name="pmid34003220">{{cite journal| author=Lin JS, Perdue LA, Henrikson NB, Bean SI, Blasi PR| title=Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. | journal=JAMA | year= 2021 | volume= 325 | issue= 19 | pages= 1978-1997 | pmid=34003220 | doi=10.1001/jama.2021.4417 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34003220 }} </ref>.
* [[Virtual colonoscopy]] replaces X-ray films in the double contrast barium enema (above) with a special [[computed tomography]] scan and requires special workstation software in order for the [[radiologist]] to interpret.  This technique is approaching [[colonoscopy]] in sensitivity for polyps. However, any polyps found must still be removed by standard colonoscopy.
|-
* Standard [[computed axial tomography]] is an x-ray method that can be used to determine the degree of spread of cancer, but is not sensitive enough to use for screening. Some cancers are found in CAT scans performed for other reasons.
! Method
* [[Blood tests]]: Measurement of the patient's blood for elevated levels of certain [[proteins]] can give an indication of tumor load.  In particular, high levels of [[carcinoembryonic antigen]] (CEA) in the blood can indicate [[metastasis]] of [[adenocarcinoma]].  These tests are frequently [[Type I and type II errors|false positive]] or [[Type I and type II errors|false negative]], and are not recommended for screening, it can be useful to assess disease recurrence.
! Sensitivity
* [[Genetic counseling]] and [[genetic testing]] for families who may have a hereditary form of colon cancer, such as [[hereditary nonpolyposis colorectal cancer]] (HNPCC) or [[familial adenomatous polyposis]] (FAP).
! Specificity
* [[Positron emission tomography]] (PET) is a 3-dimensional scanning technology where a radioactive sugar is injected into the patient, the sugar collects in tissues with high metabolic activity, and an image is formed by measuring the emission of radiation from the sugar.  Because cancer cells often have very high metabolic rate, this can be used to differentiate benign and malignant tumors.  PET is not used for screening and does not (yet) have a place in routine workup of colorectal cancer cases.
|-
* Whole-Body PET imaging is the most accurate diagnostic test for detection of recurrent colorectal cancer, and is a cost-effective way to differentiate resectable from non-resectable disease. A PET scan is indicated whenever a major management decision depends upon accurate evaluation of tumour presence and extent.
| colspan="3" style="text-align:center;" | Colorectal cancer
* Stool DNA testing is based on pre-malignant adenomas and cancers shedding DNA markers from their cells. The DNA is not degraded during the digestive process and remain stable in the stool. Capture, followed by [[Polymerase Chain Reaction]] amplifies the DNA to detectable levels for assay.  Clinical studies have shown a cancer detection sensitivity of 71%-91%<ref> {{cite web | author=B. Greenwald |year=2006 | title=The DNA Stool Test - An Emerging Technology in Colorectal Cancer Screening|url=http://http://www.touchalimentarydisease.com/articles.cfm?article_id=6375&level=2}}</ref>, and may be more sensitive than fecal immunochemical testing.<ref name="pmid24645800">{{cite journal| author=Imperiale TF, Ransohoff DF, Itzkowitz SH, Levin TR, Lavin P, Lidgard GP et al.| title=Multitarget stool DNA testing for colorectal-cancer screening. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 14 | pages= 1287-97 | pmid=24645800 | doi=10.1056/NEJMoa1311194 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24645800 }} </ref>
|-
| Colonoscopy
| NA
| NA
|-
| Fecal Immunochemical Test (FIT)
| 74
| 94
|-
| Cologuard (sDNA + FIT)
| 93
| 85
|-
| colspan="3" style="text-align:center;" | Advanced adenoma
|-
| Colonoscopy (for adenoma > 10 mm)
| 89 to 95
| NA
|-
| Fecal Immunochemical Test (FIT)
| 23
| 96
|-
| Cologuard (sDNA + FIT)
| 43
| 89
|}


==References==
== References ==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 15:03, 2 June 2021

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To view the screening of familial adenomatous polyposis (FAP), click here
To view the screening of hereditary nonpolyposis colorectal cancer (HNPCC), click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: ; Roukoz A. Karam, M.D.[2] Elliot B. Tapper, M.D.; Saarah T. Alkhairy, M.D.

Overview

Early detection of premalignant colorectal masses or early-stage colorectal cancers is essential in treating these patients and possibly preventing cancer or colorectal cancer related death. According to the USPSTF (United States Preventive Services Task Force): Screening for colorectal cancer is recommended among adults older than 50 years of age and do not have an increased risk of developing the disease (average-risk adults).

Clinical practice guidelines

According to the USPSTF (United States Preventive Services Task Force):[1]

  • Screening for colorectal cancer is recommended among adults older than 50 years of age and do not have an increased risk of developing the disease (average-risk adults).
  • Decision to screen for colorectal cancer among adults aged 76 to 85 years is an individual one.
    • Screening would be more beneficial for healthier individuals that are able to undergo possible treatment.
  • Screening for colorectal cancer among adults aged 86 years and older is not recommended.
  • No preference is given to one screening modality over the other
    • Decision should be shared and according to the patient's preferences when it comes to choosing an option.
  • Screening options:[1]
    1. Colonoscopy
    2. FIT
      • Fecal immunochemical testing for occult blood
    3. Flexible sigmoidoscopy
    4. Flexible sigmoidoscopy + FIT
    5. CT colonography
    6. FIT-DNA
      • multitargeted stool DNA testing
    7. gFOBT
      • Guaiac-based fecal occult blood testing

Screening for colorectal cancer in individuals that are at increased risk of developing the disease is different and depends on several factors:[2][1]

  • Family history of colorectal cancer before age 50
    • Begin screening at an earlier age
  • Risk of rapid disease progression
    • Perform screening more frequently
  • Family history of HNPCC or FAP
    • Use most sensitive screening modality: colonoscopy

Screening protocols summarized in the figures below:

Protocols have been summarized according to USPSTF guidelines.[1]

Screening protocol for average risk patients


Screening protocol for moderate risk patients
Screening protocol for high risk patients

Types of Screening Methods

Fecal Occult Blood Testing

  • A fecal occult blood test is a test for blood in the stool.
  • There are two types of tests that can be used for detecting occult blood in stools:[1][3]
    1. FIT
      • Fecal immunochemical testing for occult blood
    2. gFOBT
      • Guaiac-based fecal occult blood testing
  • Use of low-sensitivity guaiac fecal tests is not recommended due to its of low sensitivity.[1]

Endoscopy

  • Documentation of prep quality
  • Photo documentation of cecal intubation
  • Withdrawal time of 6 minutes or more
  • Adenoma detection rate of greater than 25% in males and 15% in females greater than 50 years old

CT colonography

  • Also known as Virtual Colonoscopy
  • Requires special workstation software in order for the radiologist to interpret
  • This technique is approaching colonoscopy in sensitivity for polyps
  • Any polyps found must still be removed by standard colonoscopy[5]

Fecal DNA testing

  • Multitargeted stool DNA testing
  • Ability to detect mutations from DNA shed by colorectal cancer[6]

Accuracy of screening methods

Advanced adenomas are defined as being ≥10 mm, having villous histology, or having high grade dysplasia. Advanced neoplasia is defined as cancer or advanced adenoma[7].

Accuracy of screening tests to detect colorectal cancer and advanced adenomas[8].
Method Sensitivity Specificity
Colorectal cancer
Colonoscopy NA NA
Fecal Immunochemical Test (FIT) 74 94
Cologuard (sDNA + FIT) 93 85
Advanced adenoma
Colonoscopy (for adenoma > 10 mm) 89 to 95 NA
Fecal Immunochemical Test (FIT) 23 96
Cologuard (sDNA + FIT) 43 89

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 US Preventive Services Task Force. Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW; et al. (2016). "Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement". JAMA. 315 (23): 2564–2575. doi:10.1001/jama.2016.5989. PMID 27304597.
  2. ↑ Lieberman, David A. (2009). "Screening for Colorectal Cancer". New England Journal of Medicine. 361 (12): 1179–1187. doi:10.1056/NEJMcp0902176. ISSN 0028-4793.
  3. ↑ Duffy MJ, van Rossum LG, van Turenhout ST, Malminiemi O, Sturgeon C, Lamerz R; et al. (2011). "Use of faecal markers in screening for colorectal neoplasia: a European group on tumor markers position paper". Int J Cancer. 128 (1): 3–11. doi:10.1002/ijc.25654. PMID 20824704.
  4. ↑ 4.0 4.1 Rex DK, Petrini JL, Baron TH, Chak A, Cohen J, Deal SE; et al. (2006). "Quality indicators for colonoscopy". Am J Gastroenterol. 101 (4): 873–85. doi:10.1111/j.1572-0241.2006.00673.x. PMID 16635231.
  5. ↑ Morrin MM, LaMont JT (2003). "Screening virtual colonoscopy--ready for prime time?". N Engl J Med. 349 (23): 2261–4. doi:10.1056/NEJMe038181. PMID 14657435.
  6. ↑ Calistri D, Rengucci C, Bocchini R, Saragoni L, Zoli W, Amadori D (2003). "Fecal multiple molecular tests to detect colorectal cancer in stool". Clin Gastroenterol Hepatol. 1 (5): 377–83. PMID 15017656.
  7. ↑ Lin JS, Piper MA, Perdue LA, Rutter C, Webber EM, O’Connor E; et al. (2016). "Screening for Colorectal Cancer: A Systematic Review for the U.S. Preventive Services Task Force". U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. PMID 27441328.
  8. ↑ Lin JS, Perdue LA, Henrikson NB, Bean SI, Blasi PR (2021). "Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force". JAMA. 325 (19): 1978–1997. doi:10.1001/jama.2021.4417. PMID 34003220 Check |pmid= value (help).


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