Title of Guideline: Colorectal cancer screening in adults



Title of Guideline: Screening: Colorectal Cancer Screening in Adults.

Rationale for Guideline: The U.S. Preventive Services Task Force supports colorectal cancer screening in all persons aged 50 and over ("B" recommendation) using either fecal occult blood testing (FOBT) or flexible sigmoidoscopy (SIG). Given the lack of evidence in support of one method of screening over the other, the Regional Prevention Committee has recommends either every 10 year SIG or annual FOBT screening for members of average risk for CRC.

Target Population: All members between the ages of 50 and 75 years. Also included in the target population are members age 40 years and older who may be at increased risk for CRC because of a family history of CRC or the existence of a predisposing medical condition.

Source of Evidence:

Guide to Clinical Preventive Services (1996), the U.S. Preventive Services Task Force and the current medical literature (see reference list).

Settings for Application: Internal Medicine, OB/GYN, and Family Practice departments.

Method(s) for Measuring Compliance: The proportion age-eligible members screened with either SIG or FOBT will be measured using the laboratory database and CIS procedure codes. Also, the proportion of hemoccult cards returned and the FOBT positivity rate will be measured as will the follow-up rate of positive test results as monitored by each department.

Responsible Party: Ned Calonge, M.D., M.P.H., Regional, Preventive Medicine, 344-7380

Guidelines for Routine Colorectal Cancer Screening

These guidelines are informational only and are not intended or designed to substitute the reasonable exercise of independent clinical judgment by providers in any particular set of circumstances for each patient encounter. The guidelines are flexible and are intended to be used as a resource for integration with a sound exercise of clinical judgment. They can be used to create an approach to care that is unique to the needs of each individual patient.

Guideline:

Screening for colorectal cancer (CRC) is recommended for all persons aged 50 to 75. For members at average risk for CRC, annual screening with either flexible sigmoidoscopy (SIG) screening every 10 years or non-rehydrated fecal occult blood testing annually is recommended.

Background:

Colorectal cancer (CRC) is the second most common form of cancer and has the second highest mortality rate, accounting for over 150,000 new cases and about 57,000 deaths each year. Recommendations (1996) by the US Preventive Services Task Force (USPSTF) support screening for colorectal cancer in all persons aged 50 or over (“B” recommendation*) using either fecal occult blood testing (FOBT) or sigmoidoscopy screening (SIG)1.

In 1995, our region’s colorectal cancer screening task force (CRCTF) reviewed the evidence in support of CRC screening and concluded that there is evidence to support the effectiveness of CRC screening. The Task Force at that time chose not to recommend periodic SIG screening, given the start-up costs of such a program and the absence of randomized controlled trial data demonstrating an increased effectiveness of SIG screening on CRC mortality compared to FOBT. This document will describe the evidence in favor of colorectal cancer screening and the rationale behind the recommendations of the CRCTF.

EVIDENCE REVIEW

Fecal Occult Blood Testing

Three large randomized controlled trials (RCTs) have been completed evaluating the effect of FOBT screening on CRC mortality. The first of these trials, the Minnesota Colon Cancer Control Study2 (MCCCS) found a 33 percent reduction in CRC mortality in the screened group versus the non-screened group. Screening reduced mortality when the test was performed on an annual basis: biennial (every two year) testing did not significantly reduce CRC mortality.

Because the MCCCS used rehydrated Hemoccult slides, the positivity rate for screening was high (9.8 percent), generating a large volume of diagnostic evaluations: during the 13 year study period, 38 percent of members in the FOBT cohort underwent a colonoscopy exam. This led to the speculation that the protective effect found with annual FOBT screening did not arise from its ability to identify early bleeding CRCs, but rather from the high cumulative frequency of colonoscopy which accompanies the chance finding of a positive test.

Two European CRC screening trials have since demonstrated the efficacy of screening with non-rehydrated Hemoccult cards: The Lancaster, England(FT) and Fuhnen, Denmark(FT) studies found reductions in CRC deaths of 15 and 18 percent, respectively, with biennial screening. In both studies, a small proportion of subjects ( ................
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