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    Colorectal Cancer Screening 2021 (beta)

    Official guideline from the American College of Gastroenterology.

    Strength
    Strong recommendation
    Conditional recommendation
    Evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence
    Moderate for ADR; low for WT, CIR

    Screening Criteria

    Screening Criteria
    1. We recommend colorectal cancer (CRC) screening in average-risk individuals between ages 50 and 75 yr to reduce incidence of advanced adenoma, CRC, and mortality from CRC.
    2. We suggest CRC screening in average-risk individuals between ages 45 and 49 yr to reduce incidence of advanced adenoma, CRC, and mortality from CRC.
    3. We suggest that a decision to continue screening beyond age 75 yr be individualized.

    Screening

    Modalities
    1. We recommend colonoscopy and fecal immunochemical testing (FIT) as the primary screening modalities for CRC screening.
    2. We suggest consideration of the following screening tests for individuals unable or unwilling to undergo a colonoscopy or FIT: flexible sigmoidoscopy, multitarget stool DNA test, CT colonography, or colon capsule.
    3. We suggest against Septin 9 for CRC screening.
    Timing
    1. We recommend that the following intervals should be followed for screening modalities: FIT every 1 yr; colonoscopy every 10 yr.
    2. We suggest that the following intervals should be followed for screening modalities: multitarget stool DNA test every 3 yr; flexible sigmoidoscopy every 5–10 yr; CT colonography every 5 yr; colon capsule every 5 yr.
    3. We suggest initiating CRC screening with a colonoscopy at age 40 or 10 yr before the youngest affected relative, whichever is earlier, for individuals with CRC or advanced polyp in 1 first-degree relative (FDR) at age <60 yr, or CRC or advanced polyp in ≥2 FDR at any age. We suggest interval colonoscopy every 5 yr.
    4. We suggest initiating CRC screening at age 40 or 10 yr before the youngest affected relative and then resuming average-risk screening recommendations for individuals with CRC or advanced polyp in 1 FDR at age ≥60 yr.
    Familial Burden
    1. We suggest consideration of genetic evaluation with higher familial CRC burden (higher number and/or younger age of affected relatives).
    2. In individuals with 1 second-degree relative (SDR) with CRC or advanced polyp, we suggest following average-risk CRC screening recommendations.
    Procedure
    1. We recommend that all endoscopists performing screening colonoscopy should measure their individual cecal intubation rates (CIRs), adenoma detection rates (ADRs), and withdrawal times (WTs).
    2. We suggest that colonoscopists with ADRs below the recommended minimum thresholds (<25%) should undertake remedial training.
    3. We recommend that colonoscopists spend at least 6 min inspecting the mucosa during withdrawal.
    4. We recommend that colonoscopists achieve a CIR of at least 95% in screening subjects.

    Aspirin Use

    Aspirin Use
    1. We suggest low-dose aspirin in individuals between ages 50–69 yr with a cardiovascular disease risk of ≥10% over the next 10 yr, who are not at an increased risk for bleeding and willing to take aspirin for at least 10 yr to reduce the risk of CRC.
    2. We recommend against the use of aspirin as a substitute for CRC screening.

    Improving Adherence

    Improving Adherence
    1. We recommend organized screening programs to improve adherence to CRC screening compared with opportunistic screening.
    2. We suggest the following strategies to improve adherence to screening: patient navigation, patient reminders, clinician interventions, provider recommendations and clinical decision support tools.
    3. 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.
    What do the icons mean?  
    Research PaperShaukat A, Kahi CJ, Burke CA, Rabeneck L, Sauer BG, Rex DK. Acg clinical guidelines: colorectal cancer screening 2021. Am J Gastroenterol. 2021;116(3):458-479.