So many guidelines!
It’s tough to find two doctors who agree with each other. Hence the plethora of guidelines for everything from appropriate antibiotic usage to screening for cancer. It’s not that clinicians are contrary, it’s because they’re passionate about health.
In an attempt to bring order to colorectal cancer (CRC) screening guidelines, the American College of Physicians in November 2019 published a guideline statement to guide clinicians on 1) the age to start and stop CRC screening, 2) frequency of screening, and 3) the optimal screening test in asymptomatic, average-risk adults. It wasn’t easy.
“Guidelines disagree on the age to start and stop screening, screening interval, and recommended screening method,” wrote the authors of a paper in the Annals of Internal Medicine. “Strategies differ in the quality of evidence regarding clinical effectiveness, harms, patient burden, recommended frequency of administration, and test accuracy.”
Nevertheless, the ACP Clinical Guidelines Committee published the following three guidelines after examining the evidence behind CRC screening guidelines from the U.S. Preventive Services Task Force (USPSTF), the Canadian Task Force on Preventive Health Care, the American College of Radiology, the American Cancer Society and other professional organizations:.
Scanning them over, Repertoire readers may find some talking points to share with their physician customers.
- Guidance Statement 1: Clinicians should screen for colorectal cancer in average-risk adults between the ages of 50 and 75 years. Although the median age for CRC diagnosis is 67 years, and persons aged 65 to 75 years derive the most direct benefit from screening for CRC, screening in adults aged 50 to 75 years also has benefit.
- Guidance Statement 2: Clinicians should select the colorectal cancer screening test with the patient on the basis of a discussion of benefits, harms, costs, availability, frequency, and patient preferences. Suggested screening tests and intervals are fecal immunochemical testing (FIT) or high-sensitivity guaiac-based fecal occult blood testing (HSgFOBT) every 2 years, colonoscopy every 10 years, or flexible sigmoidoscopy every 10 years plus fecal immunochemical testing every 2 years. No evidence from the assessed guidelines and their evidence reviews directly compares various CRC screening interventions, notes the ACP. All screening tests are associated with potential benefits as well as harms. Clinical decisions need to be individualized using patient clinical characteristics, patient preferences, and screening test frequency and availability.
- Guidance Statement 3: Clinicians should stop screening for colorectal cancer in average-risk adults older than 75 years or in adults with a life expectancy of 10 years or less. When to discontinue screening is important for older adults because the harms of screening tests outweigh the benefits in most adults aged 75 years or older. High on the list are false positives, leading to injury to the colon or other complications related to colonoscopy.
The American College of Physicians suggests any of the following screening strategies:
Screening test Interval
| FIT | Every two years |
| High-sensitivity gFOBT | Every two years |
| Colonoscopy | Every 10 years |
| Flexible sigmoidoscopy plus FIT | Every 10 years for flexible sigmoidoscopy and every two years for FIT |
March is Colorectal Cancer Awareness Month
The Office of Disease Prevention and Health Promotion, part of the Department of Health and Human Services, recommends that physicians and others use Colorectal Cancer Awareness Month to spread the word about colorectal cancer and its prevention. Repertoire readers can direct physician practices to this URL – https://healthfinder.gov/nho/marchtoolkit.aspx. – for tools they can use to heighten awareness of colorectal cancer among their patients and community members. Those tools include:
- Verbiage about colorectal cancer for use on Facebook or in the practice’s newsletter.
- Potential tweets about Colorectal Cancer Awareness Month.
- Information on hosting a community event where families can be active while learning about local health resources.
- A badge about Colorectal Cancer Awareness Month to add to the practice’s home page.