The American College of Physicians Weighs In on Colorectal Cancer Screening

Sponsoring Organization: American College of Physicians (ACP)

Background

The most influential U.S. guidelines on colorectal cancer screening probably are those of the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS). In their most recent iterations, both groups lowered the age at which average-risk people should begin screening to age 45 (NEJM JW Gen Med Jun 15 2021 and JAMA 2021; 325:1965; and CA Cancer J Clin 2018; 68:250). Now, the American College of Physicians (ACP) has weighed in with a “Guidance Statement”: The authors reviewed the evidence that informed the USPSTF and ACS recommendations and drew their own conclusions — several of which disagree with those of other organizations.

Key Recommendations

• The ACP favors initiating routine screening at age 50 rather than age 45. Although the actual wording is a bit tentative (“Clinicians should consider not screening asymptomatic average-risk adults between the ages of 45 to 49 years”), the authors argue that the microsimulation models used by the USPSTF overestimate the net benefit of screening in this age group.
• Screening should stop at age 75, or when life expectancy is less than 10 years.
• The ACP finds the following screening tests acceptable: Fecal immunochemical testing (FIT) or high-sensitivity guaiac fecal occult blood testing every 2 years; colonoscopy every 10 years; or flexible sigmoidoscopy every 10 years plus FIT every 2 years. The ACP believes that evidence supports biennial FIT or guaiac testing, rather than the annual testing recommended by the USPSTF and ACS.
• Unlike the USPSTF and ACS, the ACP recommends against using stool DNA testing (i.e., Cologuard) based on its considerable expense, higher false-positive rate, and lack of data on morbidity and mortality (compared with other fecal tests). Readers should note that Cologuard includes both a stool DNA test and FIT.