Colorectal Cancer: Screening and Surveillance Recommendations

Follow-up After Surveillance

In a 2009 study, 564 participants underwent 2 surveillance colonoscopies after an index procedure and 10.3% had high-risk findings at the third study examination. If the second examination showed high-risk findings, then results from the first examination added no significant information about the probability of high-risk findings on the third examination (18.2% for high-risk findings on the first examination vs. 20.0% for low-risk findings on the first examination; P = 0.78). If the second examination showed no adenomas, then the results from the first examination added significant information about the probability of high-risk findings on the third exam-ination (12.3% if the first examination had high-risk findings vs. 4.9% if the first examination had low-risk findings; P = 0.015) [80]. Thus, information from 2 previous colonoscopies appears to be helpful in defining the risk of neoplasia for individual patients and in the future, guidelines might consider accounting for the results of 2 exams to tailor surveillance intervals for patients.

• When should screening / surveillance be stopped?

There is considerable new evidence that the risks of colonoscopy increase with advancing age [81,82]. Neither surveillance nor screening colonoscopy should be performed when the risk of the preparation, sedation, or procedure outweighs the potential benefit. For patients aged 75–85 years, the USPSTF recommends against routine screening but argues for individualization based on comorbidities and findings on any prior colonoscopy. The USPSTF recommends against continued screening after age 85 years because risk could exceed potential benefit [44].

In terms of surveillance of prior adenomas, the 75-85 year age group may still benefit from surveillance because patients with prior HRA are at higher risk for developing advanced neoplasia compared with average-risk screenees. However, the decision to continue surveillance in this population should be individualized and based on an assessment of benefit and risk in the context of the person’s estimated life expectancy [66]. More importantly, it should be noted that an individual’s most important and impactful screening colonoscopy is his or her first one and therefore, from a public health standpoint, great effort should be taken to increase the number of people in a population who undergo screening rather than simply targeting those who need surveillance for prior polyps. This is ever true in settings with limited resources.

Case Conclusion

The physician discusses the findings from the colonoscopy (2 small adenomas) with the patient and recommends a repeat colonoscopy in 5 to 10 years.

Summary

Colorectal cancer is one of the leading causes of cancer-related death in the United States. Since the advent of colonoscopy and the implementation of CRC screening efforts, the rates of CRC have started to decline. There are several environmental factors which have been associated with the development of CRC including obesity, dietary intake, physical activity and smoking. At present, there are multiple tools available for CRC prevention, but the most accurate and effective method is currently colonoscopy. Stool-based tests like FIT should be offered when a patient declines colonoscopy. For those interested in colonoscopy, average-risk individuals should be screened starting at the age of 50 with subsequent examinations every 10 years. Surveillance examinations should occur based on polyp findings on index colonoscopy. There is no recommendation to continue screening after the age of 75, though physicians can determine this based on patients health and risk/benefit profile. Current guidelines recommend against offering any screening to patients over the age of 85. Despite these recommendations, almost half of the eligible screening population has yet to undergo appropriate CRC screening. Future work should include public health efforts to improve access and appeal of widespread CRC screening regardless of modality. While colonoscopy is considered the most effective screening test, the best test is still the one the patient gets.