Screening for Colorectal Cancer: A Guidance Statement From the
American College of Physicians
Amir Qaseem, MD, PhD, MHA; Thomas D. Denberg, MD, PhD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Joel Levine, MD;
Donna E. Sweet, MD; and Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians*
Description: Colorectal cancer is the second leading cause of
cancer-related deaths for men and women in the United States.
The American College of Physicians (ACP) developed this guidance
statement for clinicians by assessing the current guidelines devel-
oped by other organizations on screening for colorectal cancer.
When multiple guidelines are available on a topic or when existing
guidelines conflict, ACP believes that it is more valuable to provide
clinicians with a rigorous review of the available guidelines rather
than develop a new guideline on the same topic.
Methods: The authors searched the National Guideline Clearing-
house to identify guidelines developed in the United States. Four
guidelines met the inclusion criteria: a joint guideline developed by
the American Cancer Society, the U.S. Multi-Society Task Force on
Colorectal Cancer, and the American College of Radiology and
individual guidelines developed by the Institute for Clinical Systems
Improvement, the U.S. Preventive Services Task Force, and the
American College of Radiology.
Guidance Statement 1: ACP recommends that clinicians perform
individualized assessment of risk for colorectal cancer in all adults.
Guidance Statement 2: ACP recommends that clinicians screen for
colorectal cancer in average-risk adults starting at the age of 50
years and in high-risk adults starting at the age of 40 years or 10
years younger than the age at which the youngest affected relative
was diagnosed with colorectal cancer.
Guidance Statement 3: ACP recommends using a stool-based test,
flexible sigmoidoscopy, or optical colonoscopy as a screening test in
patients who are at average risk. ACP recommends using optical
colonoscopy as a screening test in patients who are at high risk.
Clinicians should select the test based on the benefits and harms of
the screening test, availability of the screening test, and patient
preferences.
Guidance Statement 4: ACP recommends that clinicians stop
screening for colorectal cancer in adults over the age of 75 years or
in adults with a life expectancy of less than 10 years.
Ann Intern Med. 2012;156:378-386. www.annals.org
For author affiliations, see end of text.
Colorectal cancer is the second leading cause of cancer-related deaths among both men and women in the
United States (1). The incidence of colorectal cancer was
102 900 people in 2010, and prevalence was 1 110 077
people in 2008, including 542 127 men and 567 950
women (2, 3). Americans have a 5% lifetime risk for colo-
rectal cancer (2), and approximately 51 370 Americans die
of the disease each year (3). However, the incidence of
colorectal cancer has been declining in the United States by
2% to 3% per year over the past 15 years (4). Colorectal
cancer is rare before age 40 years in both men and women,
with 90% of cases occurring after age 50 years (2).
The usual pathogenesis of colorectal cancer is an ad-
enomatous polyp that slowly increases in size, followed by
dysplasia and finally cancer. Screening for colorectal cancer
is valuable because early detection and removal of pre-
malignant adenomas or localized cancer can prevent cancer
or cancer-related deaths. Good evidence shows that screen-
ing reduces mortality from colorectal cancer (5). Several
methods are currently available for colorectal cancer
screening. They fall under 2 categories: stool-based tests,
including guaiac-based fecal occult blood test (gFOBT),
immunochemical-based fecal occult blood test (iFOBT),
and stool DNA panel (sDNA); and endoscopic and radio-
logic tests, including flexible sigmoidoscopy, optical
colonoscopy, double-contrast barium enema (DCBE), and
computed tomography colonography (CTC) (virtual
colonoscopy). Of these screening methods, only gFOBT
and flexible sigmoidoscopy have been evaluated in ran-
domized, controlled trials that showed that they are asso-
ciated with decreased colorectal cancer–related mortality.
The purpose of this guidance statement is to critically
review available guidelines to help internists and other cli-
* This paper, written by Amir Qaseem, MD, PhD, MHA; Thomas D. Denberg, MD, PhD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Joel Levine, MD; Donna
E. Sweet, MD; and Paul Shekelle, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians: Paul Shekelle, MD, PhD (Chair); Roger Chou,
MD; Paul Dallas, MD; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; Mary Ann Forciea, MD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Tanveer P. Mir,
MD; Holger J. Schu¨nemann, MD, PhD; Donna E. Sweet, MD; and David S. Weinberg, MD, MSc. Approved by the ACP Board of Regents on 19 November 2011.
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Guidance Statements
Clinical Guideline
378 © 2012 American College of Physicians
nicians in making decisions about screening for colorectal
cancer. The target patient population for this guideline is
all men and women. This statement is derived from an
evaluation of current guidelines in the United States on
screening for colorectal cancer.
METHODS
The Clinical Guidelines Committee of the American
College of Physicians (ACP) developed this guidance state-
ment for clinicians, according to methods published previ-
ously (6), by assessing current guidelines from other organiza-
tions on screening for colorectal cancer. When multiple
guidelines are available on a topic or when existing guidelines
conflict, ACP believes that providing clinicians with a rigorous
review of the available guidelines is more useful than develop-
ing a new guideline on the same topic.
We searched the National Guideline Clearinghouse
(NGC) to identify all discrete guidelines on screening for
colorectal cancer developed in the United States. After review-
ing the titles and abstracts of each identified document, we
excluded articles that simply restated guidelines from other
organizations. The NGC included 4 U.S. guidelines on
screening for colorectal cancer: the joint guideline developed
by the American Cancer Society (ACS), the U.S. Multi-
Society Task Force on Colorectal Cancer (USMSTF), and the
American College of Radiology (ACR) (7) and individual
guidelines developed by the Institute for Clinical Systems Im-
provement (ICSI) (8), the U.S. Preventive Services Task Force
(USPSTF) (9), and the ACR (10). The 7 co-authors reviewed
these guidelines independently by using the Appraisal of
Guidelines for Research and Evaluation II (AGREE II) ap-
praisal instrument (11), which asks 23 questions in 6 do-
mains: scope and purpose, stakeholder involvement, rigor of
development, clarity and presentation, applicability, and edi-
torial independence. We selected 1 guideline to calibrate our
scores on the 6 domains of the AGREE II instrument, scored
each guideline independently, and then compared the scores.
Although total quantitative scores varied somewhat, the qual-
itative assessment of guideline quality was consistent among
the 7 reviewers; indeed, the overall rankings of the quality of
the guidelines were similar (Table 1).
Of note, the American College of Gastroenterology
(ACG) published a 2008 update to its colorectal cancer
screening guideline (12), but this guideline is not currently
included in the NGC database. Because many clinicians
involved in decision making about colorectal cancer screen-
ing consult the ACG guidelines, we chose to summarize
this guideline despite its absence from the NGC. However,
we did not formally evaluate it by using the AGREE II
instrument because our predefined methods were to rate
guidelines available in the NGC. In addition, the ACG was
a contributor to the joint ACS/USMSTF/ACR guideline.
SUMMARY AND EVALUATION OF REVIEWED GUIDELINES
ACS/USMSTF/ACR (2008)
ACS/USMSTF/ACR recommends screening average-risk
adults starting at age 50 years.
ACS/USMSTF/ACR recommends that individuals
should have an opportunity to make an informed deci-
sion when choosing one the following screening tests:
flexible sigmoidoscopy every 5 years, colonoscopy every
10 years, double-contrast barium enema every 5 years,
CT colonography every 5 years, annual gFOBT with
high test sensitivity for cancer or annual fecal immuno-
chemical testing with high test sensitivity for cancer,
and/or fecal sDNA with high test sensitivity for cancer
at an unspecified interval.
ACS/USMSTF/ACR recommends that tests that are
designed to detect both early cancer and adenomatous
polyps should be encouraged if resources are available
and patients are willing to undergo an invasive test.
Comments
The stated purpose of the ACS/USMSTF/ACR guide-
line is to assess the data and comparative evidence for var-
ious screening tests for colorectal cancer and to assess when
to screen adults who are at average risk for colorectal can-
cer. The guideline divides screening methods into tests that
can detect adenomatous polyps and cancer and can there-
fore be considered preventive (flexible sigmoidoscopy,
colonoscopy, DCBE, and CTC) and tests that primarily
detect cancer (gFOBT, fecal immunochemical test [FIT],
and sDNA). The ACS/USMSTF/ACR encourages using,
when possible, the structural methods that are considered pre-
ventive techniques. The guideline presents a very clear ratio-
nale for the starting age of screening and acknowledges that
none of the currently available screening tests is perfect for
detecting cancer or adenomas. The guideline acknowledges
the limitations of evidence related to sensitivity and specificity
of various screening tests and relies on the judgment of the
expert panel that developed the guideline. It presents informa-
tion on the advantages, cost-effectiveness, limitations, and
risks of each test. The strengths of this guideline include a
collaborative effort; a good discussion on the benefits, harms,
and limitations of various screening tests; and a discussion of
the issues related to shared and informed decision making
with patients. Limitations include that it did not use a system-
atic literature review of evidence and, in many situations, used
expert opinion. In addition, the evidence that was presented
did not include evaluation of the quality.
ICSI (2010)
ICSI recommends routine colorectal cancer screening
for all average-risk patients 50 years of age and older—
age 45 and older for African Americans or American
Indians. Patients with average risk for colorectal cancer
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www.annals.org 6 March 2012 Annals of Internal Medicine Volume 156 • Number 5 379
Table 1. Mean Guideline Scores and Scaled Domain Scores Across Domains of the AGREE II Instrument*
AGREE II Domain ACS/USMSTF/ACR ICSI USPSTF ACR
Scope and purpose
1. The overall objective(s) of the guideline is (are) specifically described. 6 5 6 4
2. The health question(s) covered by the guideline is (are) specifically
described.
6 6 6 4
3. The population (patients, public, etc.) to whom the guideline is meant to
apply is specifically described.
6 6 6 4
Domain score 17 17 18 12
Scaled domain score, % 79 77 84 48
Stakeholder involvement
4. The guideline development group includes individuals from all relevant
professional groups.
4 4 6 3
5. The views and preferences of the target population (patients, public, etc.)
have been sought.
2 2 3 1
6. The target users of the guideline are clearly defined. 4 5 4 3
Domain score 10 12 13 7
Scaled domain score, % 40 49 48 20
Rigor of development
7. Systematic methods were used to search for evidence. 4 4 6 2
8. The criteria for selecting the evidence are clearly described. 3 2 6 2
9. The strengths and limitations of the body of evidence are clearly described. 4 3 5 2
10. The methods for formulating the recommendations are clearly described. 3 3 4 2
11. The health benefits, side effects, and risks have been considered in
formulating the recommendations.
5 4 6 3
12. There is an explicit link between the recommendations and the supporting
evidence.
4 3 6 3
13. The guideline has been externally reviewed by experts prior to its
publication.
3 4 6 2
14. A procedure for updating the guideline is provided. 2 4 3 1
Domain score 28 27 42 17
Scaled domain score, % 41 38 71 17
Clarity of presentation
15. The recommendations are specific and unambiguous. 5 5 6 5
16. The different options for management of the condition or health issue are
clearly presented.
6 6 6 4
17. Key recommendations are easily identifiable. 5 6 6 5
Domain score 16 17 18 13
Scaled domain score, % 71 77 83 56
Applicability
18. The guideline describes facilitators and barriers to its application. 3 3 2 2
19. The guideline provides advice and/or tools on how the recommendations
can be put into practice.
2 3 2 2
20. The potential resource implications of applying the recommendations have
been considered.
3 2 2 2
21. The guideline presents monitoring and/or auditing criteria. 2 5 2 1
Domain score 11 14 8 6
Scaled domain score, % 29 40 18 10
Editorial independence
22. The views of the funding body have not influenced the content of the
guideline.
4 4 5 3
23. Competing interests of guideline development group members have been
recorded and addressed.
4 5 4 2
Domain score 8 9 9 5
Scaled domain score, % 49 58 61 21
Overall guideline assessment
1. Rate the overall quality of this guideline. 4 4 6 2
2. I would recommend this guideline for use (please respond: yes, yes with
modifications, or no).
4 yes
2 yes with modifications
1 no
2 yes
3 yes with modifications
2 no
7 yes 7 no
ACR� American College of Radiology; ACS� American Cancer Society; AGREE II� Appraisal of Guidelines for Research and Evaluation II; ICSI� Institute for Clinical
Systems Improvement; USMSTF � U.S. Multi-Society Task Force on Colorectal Cancer; USPSTF � U.S. Preventive Services Task Force.
* Each question was rated on a Likert scale with a maximum of 7 points. The scores were averaged for each of the 7 reviewers. The scaled domain score is calculated as
follows: (obtained score minus minimum possible score)/(maximum possible score minus minimum possible score).
Clinical Guideline Guidance Statement on Screening for Colorectal Cancer
380 6 March 2012 Annals of Internal Medicine Volume 156 • Number 5 www.annals.org
are defined by: 50 years or older, or if African American
or American Indian, 45 years or older with no personal
history of polyps, colorectal cancer, or inflammatory
bowel disease; no family history of colorectal cancer in:
one first-degree relative diagnosed before age 60, or two
first-degree relatives diagnosed at any age; and no fam-
ily history of adenomatous polyps in one first-degree
relative diagnosed before age 60.
ICSI recommends the following methods for colorectal
cancer screening of average-risk patients based on joint
decision making by patient and provider: stool testing:
gFOBT annually or FIT annually; 60-cm flexible sig-
moidoscopy every five years with or without stool test
for occult blood annually; CT colonography every five
years; or colonoscopy every 10 years.
ICSI considers the following for patients at increased
risk of colorectal cancer and recommends different
screening for these patients:
One first-degree relative with either colorectal cancer or
adenomatous polyps diagnosed before age 60 years or two
or more first-degree relatives diagnosed at any age: colono-
scopy every five years beginning at age 40 or 10 years
before the age of the youngest case in the immediate
family.
Inflammatory bowel disease (chronic ulcerative colitis
and Crohn’s disease): colonoscopy every one to two
years starting eight years after the onset of pancolitis or
12 to 15 years after the onset of left-sided colitis.
Genetic diagnosis of familial adenomatous polyposis
(FAP) or suspected FAP without genetic testing evi-
dence: annual flexible sigmoidoscopy beginning at age
10 to 12 years, along with genetic counseling.
Genetic or clinical diagnosis of hereditary nonpolyposis
colorectal cancer (HNPCC): colonoscopy every one to
two years beginning at age 20 to 25 years or 10 years
before the age of the youngest case in the immediate family.
Comments
The purpose of the ICSI guideline is to address the
appropriate screening method for patients at average and
increased risk for colorectal cancer. The guideline provides
clear recommendations, discusses the benefits and harms of
various tests, and presents various implementation strate-
gies. However, the details regarding the development pro-
cess are not very clear in the guideline or in the available
information on the ICSI Web site. Although the evidence
is graded, the scoring system does not adequately differen-
tiate between the high-quality and low-quality random-
ized, controlled trials. The guideline does not provide an
upper age limit to stop screening but recognizes that co-
morbid conditions may influence the decision.
USPSTF (2008 Update)
USPSTF recommends screening for colorectal cancer
using fecal occult blood testing, sigmoidoscopy, or
colonoscopy in adults, beginning at age 50 years and
continuing until age 75 years. The risks and benefits of
these screening methods vary.
USPSTF recommends against routine screening for
colorectal cancer in adults 76 to 85 years of age. There
may be considerations that support colorectal cancer
screening in an individual patient.
USPSTF recommends against screening for colorectal
cancer in adults older than age 85 years.
USPSTF concludes that the evidence is insufficient to as-
sess the benefits and harms of CT colonography and fecal
DNA testing as screening modalities for colorectal cancer.
Comments
The purpose of the USPSTF guideline is to update its
2002 guideline and present the evidence on the benefits
and harms of screening technologies as well as a decision
analytic model to compare the expected health outcomes
and resource requirements of available screening methods.
The strengths of this guideline include the use of rigorous
methods, evaluation of evidence through a systematic lit-
erature review, and linkages between the evidence and rec-
ommendations. Recommendations have a very clear age
specification for the purpose of screening. The USPSTF
guideline is the only guideline we reviewed that does not
recommend CTC as an option for colorectal cancer screen-
ing. It does not discuss specific patient populations, such as
high-risk populations, or differences based on race, such as
African American. In addition, the guideline did not dis-
cuss implementation-related issues, such as information on
shared decision making with the patient.
ACR (2010)
ACR recommends CT colonography every 5 years after a
negative CTC screen or X-ray colon barium enema
double-contrast every 5 years after negative screen for av-
erage risk patients (age�50 years) and those with moder-
ate risk (personal history of adenoma or carcinoma or first-
degree family history of cancer or adenoma).
ACR recommends CT colonography or X-ray colon
barium enema double-contrast for average risk patients
following positive fecal occult blood test and for pa-
tients with average, moderate or high risk after incom-
plete colonoscopy.
ACR recommends colonoscopy for high risk patients
with ulcerative colitis or Crohn’s colitis and those with
HNPCC.
Clinical GuidelineGuidance Statement on Screening for Colorectal Cancer
www.annals.org 6 March 2012 Annals of Internal Medicine Volume 156 • Number 5 381
Comments
The ACR guideline evaluates the evidence on whom
and how to screen for colorectal cancer and focuses only o