acs colorectal cancer screening guideline for average risk ... · of crc in younger individuals,...

ACS Colorectal Cancer Screening Guideline for Average Risk Adults 2018

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Publication

External Review (Experts and Stakeholder

Organizations)

ACS Board of Directors

Mission Outcomes Committee

Guideline Development

Group (GDG) & GDG CRC Sub-

group

Staff

Systematic Evidence Review & Modeling Reports [existing (and

supplemented) or Commissioned]

External Expert Advisors

ACS Guideline Development Process

How are Cancer Screening Guidelines Developed?

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• The ACS recommends that adults aged 45 years and older with an average risk of colorectal cancer undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) exam, depending on patient preference and test availability.

• As a part of the screening process, all positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy.

ACS 2018 Recommendations for CRC Screening

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• Age to start screening The recommendation is based on the preponderance of benefits of CRC screening over harms, the overall quality of the evidence on screening outcomes, and the high value individuals place on preventing and avoiding death from CRC.

ü Start at age 45 y (Qualified) ü Aged 50 and older (Strong)


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• The ACS recommends that average-risk adults in good health with a life expectancy of greater than 10 years continue colorectal cancer screening through the age of 75 years. (qualified recommendation)

• The ACS recommends that clinicians individualize colorectal cancer screening decisions for individuals aged 76 through 85 years, based on patient preferences, life expectancy, health status, and prior screening history. (qualified recommendation)

• The ACS recommends that clinicians discourage individuals over age 85 years from continuing colorectal cancer screening. (qualified recommendation)


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Options for CRC screeningStool-based tests:• Fecal immunochemical test (FIT) every year• High sensitivity guaiac-based fecal occult blood test (HS-gFOBT) every year• Multi-target stool DNA test (mt-sDNA) every 3 years

Structural (visual) exams:• Colonoscopy (CSY) every 10 years• CT Colonography (CTC) every 5 years• Flexible sigmoidoscopy (FS) every 5 years

As a part of the screening process, all positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy.


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• Change in age to start screening to 45y from 50y• A General Recommendation vs. Specific Test Recommendations• Emphasis on choice

ü The recommendation for CRC screening includes offering patients the opportunity to select either a structural (visual) exam or a high-sensitivity stool-based test, depending on patient preference and test availability.

ü Barium enema no longer recommended• Guidance on when to stop screening • Reinforce importance of follow up colonoscopy as part of the screening

process

What has changed? (2018 vs 2008)

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GRADE (Grading of Recommendations, Assessment, Development and Evaluation) criteria• Quality of evidence - high-quality studies of test performance

and effectiveness of screening• Evidence on the burden of disease by age and race• Modeling studies • Balance between desirable and undesirable effects - benefits of

each of the included screening modalities are significantly greater than the harms.

• Values and preferences –Since there is no single test that is consistently preferred by adults in the U.S., the GDG emphasized the importance of offering choice, rather than ranking tests based solely on quality of evidence for individual tests.

What informed the GDG decisions?

Source: Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974-2013. JNCI 2017;109;djw322.

Trends in CRC incidence by age and year of birth

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Rationale – Disease Burden of CRC

0

5

10

1519

75

1978

1981

1984

1987

1990

1993

1996

1999

2002

2005

2008

2011

2014

Colo

rect

al c

ance

r ca

ses

per

100,

000

pers

ons

<50

year

s

Year or diagnosis

Figure 1. Trends in Colorectal Cancer Incidence Rates in Adults Younger than Aged 50 years by Race, 1975-2014

White Black

Source: Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018; 68: 000-000 [epub ahead of print]. URL to be: https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21457

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Rationale – Disease Burden of CRC

0

2

4

6

8

10

12

14

1975

-76

1977

-78

1979

-80

1981

-82

1983

-84

1985

-86

1987

-88

1989

-90

1991

-92

1993

-94

1995

-96

1997

-98

1999

-00

2001

-02

2003

-04

2005

-06

2007

-08

2009

-10

2011

-12

2013

-14

Colo

rect

al ca

ncer

case

s per

100

,000

per

sons

ag

ed 2

0-49

year

s

Year of diagnosis

Aged 20-49 yearsTrends in Colorectal Cancer Incidence Rates by Age and Sex, 1975-2014

0

50

100

150

200

250

300

1975-76

1978-79

1981-82

1984-85

1987-88

1990-91

1993-94

1996-97

1999-00

2002-03

2005-06

2008-09

2011-12

Colo

rect

al ca

ncer

case

s per

100

,000

pe

rson

s age

d 50

+ ye

ars

Year of diagnosis

Aged 50+ years

MenWomen


Percentage of Years of Potential Life Lost Due to Death from Colorectal Cancer by Age at Diagnosis (incidence-based mortality 2010-14 with follow-up 20 years after diagnosis)

0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 0.2

30-34 years

35-39 years

40-44 years

45-49 years

50-54 years

55-59 years

60-64 years

65-69 years

70-74 years

75-79 years

80-84 years

85+ yearsBoth sexes

> 10 % of all LYL is due to a diagnosis of CRC between ages 45-49

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Model-estimated Benefit CRC Screening by Starting Age

050

100150200250300350400450500

CSY CTC FS FIT HSgFOBT mt-sDNA

Mod

el-e

stim

ated

LYG

Screening test

Model-estimated Life Years Gained from CRC Screening Starting at Aged 45y vs 50y, per 1000 Screened Over a Lifetime

LYG 45y-75y LYG 50y-75 y


Starting Age of 45: Conclusions

• Modeling convincingly demonstrates that, due to the rising incidence of CRC in younger individuals, screening all average-risk persons between the ages of 45 and 75 reduces mortality from CRC with an acceptable risk (as measured by number of colonoscopies per LYG).

• The previously expected benefit of starting screening at age 45 versus 50 can no longer be considered “modest.”

• The trend of increasing CRC incidence in successively younger birth cohorts suggests that the recommended starting age of 45 will likely continue to be relevant.

• The benefit-burden balance strongly favors changing the starting age from 50 to 45.

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CRC Screening Guidelines for Average Risk Adults: ACS (2018); USPSTF (2016)

Recommendations ACS, 2018 USPSTF, 2016

Age to start screening

S-strong Q-qualified

Age 45y Starting at 45y (Q)Screening at aged 50y and older - (S)

Aged 50y (A)

Choice of test High-sensitivity stool-based test or a structural exam. Different methods can accurately detect early stage CRC and adenomatous polyps.

Acceptable Test options

• FIT annually, • HSgFOBT annually• mt-sDNA every 3y• Colonoscopy every 10y • CTC every 5y • FS every 5y All positive non-colonoscopy tests should be followed up with colonoscopy.

• HSgFOBT annually • FIT annully• sDNA every 1 or 3 y• Colonoscopy every 10y• CTC every 5y• FS every 5y• FS every 10y plus FIT every year

Age to stop screening Continue to 75y as long as health is good and life expectancy 10+y (Q) 76-85y individual decision making (Q)>85y discouraged from screening (Q)

76-85 y individual decision making (C)

Guideline Resources

• Visit cancer.org/colonmd to find more information, including:ü Materials for health professionals ü Materials for patients/consumers ü Tools to facilitate conversations between clinicians and patients

about selecting a screening test option that is consistent with patient preferences

ü Links to the 2018 guidelines article and modeling papers

Key References• Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk

adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018; 68: 000-000 [epub ahead of print].

• Peterse EFP, Meester RGS, Siegel , et al. The Impact of the Rising Colorectal Cancer Incidence in Young Adults on the Optimal Age to Start Screening: Microsimulation Analysis to Inform the American Cancer Society Colorectal Cancer Screening Guideline. Cancer. 10.1002/cncr.31543 [epub ahead of print].

• Meester RGS, Peterse EFP, Knudsen AB, et al. Optimizing colorectal cancer screening by race and sex: microsimulation analysis II to inform the American Cancer Society Colorectal Cancer Screening Guideline. Cancer. 10.1002/cncr.31542 [epub ahead of print].

• Volk RJ, Leal VB, Jacobs LE, et al. From Guideline to Practice: New Shared Decision-Making Tools for Colorectal Cancer Screening From the American Cancer Society. CA Cancer J Clin. 2018; 68: 000-000 [epub ahead of print].

• Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal Cancer Incidence Patterns in the United States, 1974-2013. Journal of the National Cancer Institute 2017;109.

• Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. Jama 2016;315:2564-75.

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Thank You!

acs colorectal cancer screening guideline for average risk ... · of crc in younger individuals,...

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