Case-Based Review

Colorectal Cancer: Screening and Surveillance Recommendations

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

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Distal Hyperplastic Polyps < 10 mm

There is considerable evidence that patients with only rectal or sigmoid hyperplastic polyps (HPs) appear to represent a low-risk cohort. Studies have focused on whether the finding in the distal colon was a marker of risk for advanced neoplasia elsewhere and most studies show no such relationship [67]. Prior and current evidence suggests that distal HPs <10 mm are benign without neoplastic potential. If the most advanced lesions at baseline colonoscopy are distal HPs <10 mm, the interval for colonoscopic follow-up should be 10 years [66].

1-2 Tubular Adenomas < 10 mm

Prior evidence suggested that patients with low-risk adenomas (<10 mm, no villous histology or high-grade dysplasia) had a lower risk of developing advanced adenomas during follow-up compared with patients with high risk adenomas (≥ 10mm, villous histology or high -grade dysplasia). At that time in 2006, consensus on the task force was that an interval of 5 years would be acceptable in this low-risk group [75]. Data published since 2006 endorse the assessment that patients with 1–2 tubular adenomas with low-grade dysplasia <10 mm represent a low-risk group. Three new studies suggest that this group may have only a small, nonsignificant increase in risk of advanced neoplasia within 5 years compared with individuals with no baseline neoplasia. The evidence now supports a surveillance interval of longer than 5 years for most patients and can be extended to 10 years based on the quality of the preparation and colonoscopy [66].

3–10 Tubular Adenomas

Two independent meta-analyses in 2006 found that patients with 3 or more adenomas at baseline had an increased RR for adenomas during surveillance, ranging from 1.7 to 4.8 [47,75]. New information from the VA study and the National Cancer Institute Pooling Project also support these prior findings. Patients with 3 or more adenomas have a level of risk for advanced neoplasia similar to other patients with advanced neoplasia (adenoma >10 mm, adenoma with high grade dysplasia) and thus, repeat examination should be performed in 3 years [66,68,76].

> 10 Adenomas

Only a small proportion of patients undergoing screening colonoscopy will have >10 adenomas. The 2006 guidelines for colonoscopy surveillance after polypectomy noted that such patients should be considered for evaluation of hereditary CRC syndromes [67]. Early follow-up surveillance colonoscopy is based on clinical judgment because there is little evidence to support a firm recommendation. At present, the recommendation is to consider follow-up in less than 3 years after a baseline colonoscopy [66].

1 or More Tubular Adenomas ≥ 10mm

The 2006 MSTF guideline reviewed data related to adenoma size, demonstrating that most studies showed a 2- to 5-fold increased risk of advanced neoplasia during follow-up if the baseline examination had one or more adenomas ≥ 10 mm [67]. Newer, additional data shows that patients with one or more adenomas ≥ 10 mm have an increased risk of advanced neoplasia during surveillance compared with those with no neoplasia or small (< 10 mm) adenomas [68,76]. Thus, the recommendations remains that repeat examination should be performed in 3 years [66]. If there is question about complete removal of an adenoma (ie, piecemeal resection), early follow-up colonoscopy is warranted [66].