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


==Overview==
==Overview==
Current guidelines recommend that [[colonoscopy]] is the optimal screening tool for colon cancer since it detects 98-99% of the cases. High risk individuals include a first-degree relative with colorectal cancer. A [[colonoscopy]] every 10 years reduces the risk of left-sided colon cancer. Right sided colon cancers are more likely to be missed because they are harder to reach and they could be flat, which means they would be harder to detect.  Flat growths (non-polypoid) are difficult to detect and are more likely to progress to colon cancer compared to cylindrical [[polyps]].  
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).  


==Colorectal Cancer Screening==
==Clinical practice guidelines==


Colorectal cancer may take several years to develop. If colorectal cancer is detected early, the chances of a cure is greatly improved. The patient population can be divided into average, moderate, and high risk.  
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


The algorithm below demonstrates a screening protocol for '''average risk''' patients.<ref>https://www.rmf.harvard.edu/~/media/Files/_Global/KC/PDFs/RMFCRC.pdf</ref>  
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


<figure-inline>[[Image:Average risk CRC.jpg|800x800px]]</figure-inline>
== 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]]


The algorithm below demonstrates a screening protocol for '''moderate risk''' patients.<ref>https://www.rmf.harvard.edu/~/media/Files/_Global/KC/PDFs/RMFCRC.pdf</ref>


<figure-inline>[[Image:Moderate risk CRC.jpg|800x800px]]</figure-inline>
[[Image:Moderate risk CRC.jpg|center|500x500px|frame|Screening protocol for '''moderate risk''' patients]]


The algorithm below demonstrates a screening protocol for '''high risk''' patients.<ref>https://www.rmf.harvard.edu/~/media/Files/_Global/KC/PDFs/RMFCRC.pdf</ref>
[[Image:High risk CRC.jpg|center|500x500px|frame|Screening protocol for '''high risk''' patients]]


<figure-inline>[[Image:High risk CRC.jpg|800x800px]]</figure-inline>
==Types of Screening Methods==


The most common indicator of high risk is a first-degree relative with colorectal cancer, a personal history of [[inflammatory bowel disease]].<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>
===Fecal Occult Blood Testing===
*If the first-degree relative was diagnosed with CRC before 50 years of age
*A [[fecal occult blood]] test is a test for blood in the stool.
:*The individual should be suspected of a hereditary syndrome
* 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>  
:*A complete family history, genetic counseling and testing, and an appropriate timing for [[endoscopic]] surveillance should be obtained
*# '''FIT'''
*If a first-degree relative was diagnosed with CRC at 50 years of age or older the lifetime risk of CRC nearly doubles among his or her family members
*#* 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" />


===Clinical practice guidelines===
===Endoscopy===
'''[[Clinical practice guideline]]s by the United States Preventive Service Task Force ([[USPSTF]]) in 2008 stated:'''<ref name="pmid18838716">{{cite journal| author=U.S. Preventive Services Task Force| title=Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. | journal=Ann Intern Med | year= 2008 | volume= 149 | issue= 9 | pages= 627-37 | pmid=18838716 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18838716 }} </ref>
*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" />
*"The USPSTF recommends screening for colorectal cancer using [[Fecal occult blood test|fecal occult blood testing]], [[sigmoidoscopy]], or [[colonoscopy]] in adults, beginning at age 50 years and continuing until age 75 years"
*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>
*"The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient"
:*Documentation of prep quality
*"The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years"
:*Photo documentation of [[Cecum|cecal]] [[intubation]]
 
:*Withdrawal time of 6 minutes or more
The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of [[Computed tomographic imaging|computed topographic colonography]] and fecal DNA testing as screening modalities for colorectal cancer.
:*[[Adenoma]] detection rate of greater than 25% in males and 15% in females greater than 50 years old
 
'''The American College of Gastroenterology recommends:'''<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>
* Screening in African Americans should begin at age 45 years
* [[Computed tomography|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 test|fecal occult blood testing]]


===Types of Screening Methods===
[[Image:Colorectal cancer endo 2.jpg|473x473px]]


====Fecal Occult Blood Testing====
=== CT colonography ===
*A [[fecal occult blood]] test (FOBT) is a test for blood in the stool
:* Also known as Virtual Colonoscopy
* There are two types of tests that can be used for detecting occult blood in stools: guaiac-based (chemical test) and immunochemical
:* 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>


====Endoscopy====
=== Fecal DNA testing ===
*A [[sigmoidoscopy]] is a lighted probe ([[sigmoidoscope]]) that is inserted into the [[rectum]] and lower [[colon]] to check for [[polyps]] and other abnormalities
:* Multitargeted stool DNA testing
*A [[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>
:* 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>
:*Documentation of prep quality
:*Photo documentation of [[Cecum|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.


<figure-inline>[[Image:Colorectal cancer endo 2.jpg|473x473px]]</figure-inline>
==Accuracy of screening methods==


====Genetic Testing====
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>.
*[[Genetic counseling]] and [[genetic testing]] is a screening modality for families who may have a hereditary form of colon cancer, such as [[hereditary nonpolyposis colorectal cancer]] (HNPCC) or [[familial adenomatous polyposis]] (FAP)


====Other Screening Techniques====
{| class="wikitable"
*Double contrast barium enema (DCBE)
|+ 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>.
:*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. 
! Method
:*The result is a thin layer of [[barium]] over the inner lining of the [[colon]] which is visible on X-ray films. 
! Sensitivity
:*A [[cancer]] or a [[Precancerous|precancerous polyp]] can be detected this way. 
! Specificity
:*This technique can miss the (less common) flat [[polyp]].
|-
*[[Virtual colonoscopy]]
| colspan="3" style="text-align:center;" | Colorectal cancer
:* This is also known as CT colonography
|-
:* This replaces [[X-ray]] films in the double contrast barium enema (above) with a special [[computed tomography]] scan.
| Colonoscopy
:* It requires special workstation software in order for the [[radiologist]] to interpret. 
| NA
:* This technique is approaching [[colonoscopy]] in sensitivity for [[polyps]]. However, any polyps found must still be removed by standard [[colonoscopy]].
| NA
*[[Blood tests]]
|-
:*The measurement of the patient's blood for elevated levels of certain [[proteins]] can give an indication of tumor load. 
| Fecal Immunochemical Test (FIT)
:*High levels of [[carcinoembryonic antigen]] (CEA) in the blood can indicate [[metastasis]] of [[adenocarcinoma]]. 
| 74
:*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.
| 94
* Stool DNA testing
|-
:* This detects DNA that sheds into the stool from the cells of [[Precancerous|pre-malignant]] [[adenomas]] and [[cancers]]. 
| Cologuard (sDNA + FIT)
:* The DNA is not degraded during the digestive process and remains in the stool.
| 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}}


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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