The United States Multi-Society Task Force (MSTF) on Colorectal Cancer (CRC) Screening released new guidelines for colorectal cancer screening which rank the screening tests into three tiers according to the strength of the recommendation for average-risk people. The full recommendations have been published in three journals: Gastroenterology, The American Journal of Gastroenterology, and GIE: Gastrointestinal Endoscopy.

Although the incidence of CRC in patients aged ≥50 years is decreasing, the MSTF pointed to its growing rate in younger Americans for reasons unclear. The Task Force reviewed seven different types of screening tests based on efficacy at detecting cancer and pre-cancerous polyps. Each screening test is described along with its availability, current usage patterns, implementation challenges, and the likelihood of patients repeating the test appropriately. Additional sections on targets, cost, quality, practical considerations, risk factors (eg, family history), and age considerations are also included.

For patients at average risk, screening should begin at age 50 with colonoscopy and fecal immunochemical testing (FIT) considered “first tier” screening tests for this population. For African-Americans, earlier screening is suggested at age 45. 

Individuals with a family history of CRC in a first-degree relative diagnosed before age 60 should undergo colonoscopy every 5 years beginning at age 40 or 10 years before the age at which their relative was diagnosed, whichever comes first. If the patient has one first-degree relative diagnosed at age 60 or older they are recommended to begin screening at age 40.  

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Tier 1 (Cornerstone Tests) is a colonoscopy every 10 years or an annual FIT. The highly sensitive colonoscopy is the only test that can allow for patient diagnosis and treatment in a single session. The FIT Is less sensitive but is non-invasive, cheaper, and can effectively prevent cancer and cancer deaths when repeated yearly. 

Tier 2 includes a CT colonography every 5 years, a FIT-fecal DNA every 3 years, or a flexible sigmoidoscopy every 5–10 years. This is appropriate for patients who refuse colonoscopy. 

Tier 3 includes a capsule colonoscopy every 5 years. A capsule colonoscopy is suitable when patients decline colonoscopy, FIT, FIT-fecal DNA, CT colonography, and flexible sigmoidoscopy.

The MSTF recommended against using Septin9, a blood-based test.

When performing the colonoscopy, physicians should measure quality, including the adenoma detection rate; quality should be monitored when performing the FIT. 

Lead author, Douglas K. Rex, MD, FASGE, AGAF, MACG, stated, “We believe these recommendations make the presentation of screening options in the office easier for providers and patients, maximizing both effectiveness and adherence. The document also addresses important issues for organized screening programs that are sometimes used in large health plans.” The authors emphasized the importance of good technical performance, reporting of tests, and ensuring patients undergo appropriate follow-up to get optimal results from CRC screening.

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