Case-Based Review

Colorectal Cancer: Screening and Surveillance Recommendations

Journal of Clinical Outcomes Management. 2015 March;22(3)

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Case Continued

The physician tells the patient that there are several environmental factors that may predispose him to developing CRC. He recommends that the patient follow a healthy lifestyle, including eating 5 servings of fruits and vegetables daily, minimizing consumption of red meats, exercising for 30 minutes at least 5 days per week, drinking only moderate amounts of alcohol, and continuing to take his aspirin in the setting of his diabetes. He also asks the patient if he would be interested in talking about weight loss and working together to make a plan.

The patient is appreciative of this information and wants to know what CRC creening test the physician recommends.

What screening test should be recommended?

Screening Options

There are several modalities for CRC screening, with current technology falling into 2 general categories: stool tests, which include tests for occult blood or exfoliated DNA; and structural exams, which include flexible sigmoidoscopy, colonoscopy, double-contrast barium enema (DCBE), and computed tomographic (CT) colonography. Stool tests are best suited for the detection of CRC, although they also will deliver positive findings for some advanced adenomas, while the structural exams can achieve both detection and prevention of CRC through identification and removal of adenomatous polyps [41]. These tests may be used alone or in combination to improve sensitivity or, in some instances, to ensure a complete examination of the colon if the initial test cannot be completed.

In principle, all adults should have access to the full range of options for CRC screening, and the availability of lower-cost, less invasive options in most practice settings is a public health advantage [11]. However, the availability of multiple testing options can overwhelm the primary care provider and presents challenges for practices in trying to support an office policy that can manage a broad range of testing choices, their follow-up requirements, and shared decision making related to the options. Shared decision making around CRC screening options is both demanding and time consuming and is complicated by the different characteristics of the tests and the test-specific requirements for individuals undergoing screening [42].

Recommended Tests

The joint guideline on screening for CRC from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology (the MSTF guideline) [11] is of the strong opinion that tests designed to detect early cancer and prevent cancer through the detection and removal of adenomatous polyps (the structural exams) should be encouraged if resources are available and patients are willing to undergo an invasive test [11]. In clinical settings in which economic issues preclude primary screening with colonoscopy, or for patients who decline invasive tests, clinicians may offer stool- based testing. However, providers and patients should understand that these tests are less likely to prevent cancer compared with the invasive tests, they must be repeated at regular intervals to be effective (ie, programmatic sensitivity), and if the test is abnormal, a colonoscopy will be needed to follow up. Therefore, if patients are not willing to have repeated testing or pursue colonoscopy if the test is abnormal, these programs will not be effective and should not be recommended [11].