Screening for Colorectal Cancer

Abstract

Colorectal cancer (CRC) is the second-leading cause of cancer death in the United States. Screening reduces CRC incidence and mortality. 2021 US Preventive Service Task Force (USPSTF) guidelines and available evidence support routine screening from ages 45 to 75, and individualized consideration of screening ages 76 to 85. USPSTF guidelines recommend annual guaiac fecal occult blood testing, annual fecal immunochemical testing (FIT), annual to every 3-year multitarget stool DNA-FIT, every 5-year sigmoidoscopy, every 10-year sigmoidoscopy with annual FIT, every 5-year computed tomographic colonography, and every 10-year colonoscopy as options for screening. The "best test is the one that gets done."

Keywords: Colorectal cancer; Early detection; Incidence; Mortality; Prevention; Screening.

Figure 1.

Pathogenesis and natural history of colorectal cancer. Concepts regarding the pathogenesis and natural history of colorectal cancer are shown. Most CRCs arise from a normal mucosa to polyp to cancer sequence, which can ultimately result in metastatic disease. Endoscopically, polyps and cancers are detectable, offering an opportunity for early CRC detection and even prevention. The progression from normal mucosa to cancer is accompanied by progressive accumulation of epigenetic and genetic changes in the mucosa, which may include loss of tumor suppressors, activation of oncogenes, and chromosomal instability.

Figure 2.

Age-Specific Colorectal Cancer Incidence and Mortality, 2014–2018, US Surveillance Epidemiology and End Results Program. Colorectal cancer incidence and mortality are highly age specific, with rates markedly increasing by age group. Source: Surveillance, Epidemiology, and End Results 21 program delay-adjusted incidence and colorectal cancer mortality data, accessed 8/27/21.

Figure 3.

Age-Specific Colorectal Cancer Incidence for Males and Females, 2014–2018, US Surveillance, Epidemiology and End Results Program. Age-specific colorectal cancer incidences for males and females are shown, demonstrating that the rise in age-specific incidence is delayed for females compared to males. Source: Surveillance, Epidemiology, and End Results 21 program delay-adjusted incidence, accessed 8/27/21.

Figure 4.

Colorectal Cancer Stage Specific 5-year Survival, US Surveillance, Epidemiology, and End Results Program, 2011–2017. 5-year stage specific colorectal cancer survival is shown, demonstrating over 90% survival for localized disease, and less than 15% survival for distant disease. Source: Surveillance, Epidemiology, and End Results Program 18 data, accessed 8/27/21.

Figure 5.

Colorectal Cancer Incidence and Mortality Rates, 2000–2018, US Surveillance Epidemiology and End Results Program. Trends in delay-adjusted colorectal cancer incidence, and colorectal cancer mortality from the Surveillance Epidemiology and End Results 21 program are shown, demonstrating a trend towards reduced incidence and mortality that appears to be flattening over time. Source: Surveillance, Epidemiology, and End Results Program 21 data, accessed 8/27/21.

Figure 6.

Modeled Colorectal Cancer Cases Prevented and Deaths Averted Across Screening Strategies. The number of CRC cases prevented and CRC deaths averted per 1,000 persons screened is shown for a range of strategies recommended by the US Preventive Services Task Force for screening, beginning at age 45 and continuing through age 75 years. Data show similar numbers of cases and deaths averted across all strategies. Note that the Task Force also recommended consideration of a strategy of annual sDNA-FIT, as well as sigmoidoscopy q 10 years combined with annual FIT (data not shown). CRC, colorectal cancer; gFOBT, guaiac FOBT; FIT, fecal immunochemical test; sDNA, stool DNA; CTC, CT colonography. Reference: Davidson et al. JAMA 2021.