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ASGE guideline: colorectal cancer screening and surveillance

GUIDELINEASGE guideline: colorectal cancer screening and surveillanceThis article is one of a series of statements discussingthe use of gastrointestinal endoscopy in common clinicalsituations. The Standards of Practice Committee of theAmerican Society for Gastrointestinal Endoscopy pre-pared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional refer-ences were obtained from the bibliographies of the iden-tified articles and from recommendations of expertconsultants. When little or no data exist from well-designed prospective trials, emphasis is given to resultsfrom large series and reports from recognized for appropriate use of endoscopy are basedon a critical review of the available data and expert con-sensus.

GUIDELINE ASGE guideline: colorectal cancer screening and surveillance This article is one of a series of statements discussing the use of gastrointestinal endoscopy in common clinical

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Transcription of ASGE guideline: colorectal cancer screening and surveillance

1 GUIDELINEASGE guideline: colorectal cancer screening and surveillanceThis article is one of a series of statements discussingthe use of gastrointestinal endoscopy in common clinicalsituations. The Standards of Practice Committee of theAmerican Society for Gastrointestinal Endoscopy pre-pared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional refer-ences were obtained from the bibliographies of the iden-tified articles and from recommendations of expertconsultants. When little or no data exist from well-designed prospective trials, emphasis is given to resultsfrom large series and reports from recognized for appropriate use of endoscopy are basedon a critical review of the available data and expert con-sensus.

2 Further controlled clinical studies are needed toclarify aspects of this statement, and revision may be nec-essary as new data appear. Clinical consideration mayjustify a course of action at variance to these recommen-dations. This guideline replaces and supplements ourprevious document on colorectal cancer screening cancer (CRC) is the fourth most commonlydiagnosed cancer and the second leading cause of can-cer-related deaths in the United Each year, ap-proximately 140,000 individuals are diagnosed with CRCand more than 50,000 will die from this 5-year survival rate for early-stage cancers is greaterthan 90%, whereas the 5-year survival rate for those diag-nosed with widespread cancer is less than 10%.

3 3 There isindirect evidence that most cancers develop from adeno-matous polyps and that on average it takes 10 years fora!1 cm polyp to transform into invasive ,5 Giventhe finding that adenomatous polyps are precursors tocancer and that polyps and early cancers are usuallyasymptomatic, there is a strong rationale to supportscreening asymptomatic individuals for early cancer detec-tion and STRATIFICATIONA pproximately 30% of individuals harbor risk factors risk factors include family or personal historyof CRC or adenomatous polyps, personal history of inflam-matory bowel disease, and familial polyposis syndromes(including familial adenomatous polyposis [FAP] and he-reditary nonpolyposis colon cancer [HNPCC]).

4 The other70% of individuals are considered average strategies for average-riskindividualsAverage-risk individuals should be offered screeningbeginning at age 50 choice of modality for CRCscreening along with the associated risks and benefitsmust be discussed between the practitioner and the indi-vidual patient8(Table 1). is the preferred modalityfor CRC screening . Both cancer and premalignant neo-plasms can be accurately detected by colonoscopy. It of-fers the advantages of complete visualization of theentire colon, detection and removal of polyps, and diag-nostic sampling of cancers. Colonoscopy with polypec-tomy has been shown to significantly reduce theexpected incidence of CRC by 76% to 90% in multiple co-hort the National Polyp Study, patients whounderwent colonoscopy with polypectomy had a 76% re-duction in CRC incidence compared with a general popu-lation CRC incidence after colonoscopicpolypectomy was reduced by 90% compared with the in-cidence in a cohort of patients who did not undergo a European cohort study of 1,693 patientswho underwent colonoscopy with the removal of at least1 adenomaR5 mm in size, the cancer incidence ratio compared to the incidence in a reference a study from Norway.

5 400 patients who wereidentified as having colon polyps on flexible sigmoidos-copy underwent colonoscopy with polypectomy andwere followed prospectively over 13 controlgroup of 399 patients who did not have any form of CRCscreening was also followed prospectively. At 13 years,both groups underwent colonoscopy; the relative risk ofcancer was in the group that had prior colonoscopicpolypectomy compared with the control are currently no published studies specificallyevaluating whether screening colonoscopy reducesCopyright 2006 by the American Society for Gastrointestinal Endoscopy0016-5107/$ ENDOSCOPYV olume 63, No. 4 : mortality. There is indirect evidence from fe-cal occult blood testing (FOBT) trials that colonoscopy re-duces CRC-related providesa more complete examination than sigmoidoscopy, forwhich there is direct evidence of reducing CRC-relatedmortality by up to two can extrapolatefrom this evidence that colonoscopy likely results in a sig-nificant reduction in CRC-related mortality.

6 However, fur-ther studies are needed to establish a benefit in is recent evidence that advanced neoplasia (ade-nomaR1cm in size, villous adenoma, adenoma with high-grade dysplasia, or invasive cancer ) in the proximal coloncan occur in the absence of adenomatous polyps in thedistal ,20 The overall prevalence of proximal ad-vanced adenomas in patients without distal adenomas isapproximately 2% to 5%.19-21 Lieberman et al19and Impe-riale et al20demonstrated that approximately 50% of pa-tients with proximal advanced neoplasia have no distalpolyps. In a prospective multicenter study of 116 aver-age-risk patients with established colon cancer locatedproximal to the splenic flexure, had no evidence favors the use of colonoscopy asthe primary method of screening for CRC, given that a sig-nificant portion of proximal advanced neoplasia will notbe detected with use of flexible disadvantages of colonoscopy as a screeningmethod include the inconvenience of bowel preparation,the risks of sedation, the risk of perforation, the risk ofnot identifying neoplasms, and the risk of perfo-ration associated with colonoscopy appears to be no morethan to ,25 The miss rate of colonoscopy forpolyps.

7 On the basis of studies of back-to-back colonoscop-ies, is 27% for adenomas%5 mm and 6% for recent study that used computed tomographic(CT) colography suggested that the miss rate for lesionsR10 mm may be as high as 11%.27 Colonoscopy miss ratesappear to be associated with the skill and technique of theendoscopist, with higher quality of withdrawal techniqueresulting in lower miss ,28 Finally, colonoscopy rep-resents a cost-effective means of screening for CRC com-pared with FOBT and flexible ,30 The role of endoscopy inthe diagnosis, staging, and man-agement of CRC is considered in another good-quality colonoscopic examination without findingsof colon cancer or adenomatous polyps is performed, fur-ther screening tests (eg, FOBT) should not be done for ap-proximately 10 years.

8 Currently, the American College ofGastroenterology endorses colonoscopy as the preferredscreening method for CRC in average-risk is recommended ap-proximately every 10 years for average-risk completeness of the examination and the quality ofthe preparation should be taken into account for the tim-ing of subsequent can be performed with use of a guaiac-based test, immunochemical test, or fluorometric quanti-tative assay. Two samples from each of 3 consecutivestools should be tested. Patients with positive FOBT re-sults are at increased risk of advanced neoplasia andshould undergo a complete colonoscopy. Prospective ran-domized trials of FOBT have demonstrated a 15% to 33%reduction in CRC-related mortality when positive resultswere followed by ,33 Dietary restrictionsare recommended when the more sensitive guaiac-basedtests are used; these restrictions include the avoidanceof red meat and peroxidase-containing foods for 1 to3 days before and during stool collection, to reduce falsepositive ,13 However, dietary restrictions may notbe needed if test development is delayed for 3 or ,35 Samples that are rehydrated or obtained by dig-ital rectal examination have higher false-positive tests are more specific but have re-duced sensitivity than do guaiac-based tests.

9 They maybe helpful in combination with guaiac-based tests to im-prove overall ,38 Currently, the American cancer Society39and the Multi-society Task Force on colorectal Cancer40recommendyearly FOBT with any positive test result followed by colo-noscopy. However, in a recent national survey of1,147 primary care physicians, of physicians useda single digital rectal examination as the primary methodto obtain stool for of physicians ad-hered strictly to the recommended home-based screeningwith 2 samples from 3 consecutive stools. Furthermore,approximately 30% of physicians recommended repeatFOBT to patients after a positive test result. Of the physi-cians who pursued workup of a positive FOBT result, recommended colonoscopy, with the rest orderingsigmoidoscopy, double contrast barium enema, or a combi-nation of several tests.

10 A recent study conducted in 13 Vet-eran Affairs medical centers found that the sensitivity ofa single digital rectal examination FOBT for the detectionof advanced colonic neoplasia is compared witha sensitivity of when the recommended home- screening protocol was practice of asingle digital rectal examination for FOBT, therefore, isTABLE 1. Recommended tests for CRC screening inaverage-risk individuals beginning at age 50 yearsPreferred modalityColonoscopy every 10 yAlternativesFOBT yearlyFlexible sigmoidoscopy every 5 yFOBT yearly and flexiblesigmoidoscopy every 5 yFOBT,Fecal occult blood guideline: colorectal cancer screening and 63, No. 4 : 2006 GASTROINTESTINAL ENDOSCOPY547considered a poor screening method for CRC and shouldnot be FOBT from 2 samples of 3consecutive stools is recommended.


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