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## Complete Summary

#### GUIDELINE TITLE

Practice parameter for the detection of colorectal neoplasms: an interim
report (revised).

#### BIBLIOGRAPHIC SOURCE(S)

Ko C, Hyman NH, Standards Committee of The American Society of Colon and
Rectal Surgeons. Practice parameter for the detection of colorectal
neoplasms: an interim report (revised). Dis Colon Rectum 2006
Mar;49(3):299-301. \[4 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16421663)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Colorectal neoplasms

#### GUIDELINE CATEGORY

Prevention\
Risk Assessment\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Gastroenterology\
Internal Medicine\
Medical Genetics\
Oncology\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide a summary of the Task Force guidelines to serve as an interim
updated practice parameter for the detection of colorectal neoplasms

#### TARGET POPULATION

-   People in the United States (U.S.) at average risk for colorectal
    cancer

-   People in the U.S. at increased risk for colorectal cancer (history
    of adenomatous polyps or colorectal cancer; inflammatory bowel
    disease; family history of colon cancer, familial adenomatous
    polyposis, or hereditary nonpolyposis colorectal cancer)

**Note**: People with symptoms or signs that suggest the presence of
colorectal cancer or polyps fall outside the domain of screening and
should be offered an appropriate diagnostic evaluation.

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Risk stratification based on personal, family, and medical history

2.  Patient education regarding screening options

3.  Screening tests, including:

    -   Fecal occult blood test (FOBT)

    -   Flexible sigmoidoscopy

    -   Combined FOBT and flexible sigmoidoscopy

    -   Colonoscopy

    -   Double-contrast barium enema (DCBE)

4.  Genetic counseling and testing in select populations

5.  Follow-up of positive screening test

6.  Surveillance of patients at increased risk

**Note**: Computed tomography (CT) colonography and fecal DNA tests were
considered but not recommended outside of the research setting.

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A MEDLINE search of the literature since the 2003 Guideline Report\* was
accomplished using the keywords \"screening, colorectal cancer, fecal,
stool, and DNA\" with related articles to ensure that new data did not
exist to substantively modify the Task Force recommendations. If so, the
new evidence is cited.

\*Note: This guideline is a partial adaptation of an earlier guideline:
Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, Ganiats T,
Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C,
Gastrointestinal Consortium Panel. Colorectal cancer screening and
surveillance: clinical guidelines and rationale. Update based on new
evidence. Gastroenterology 2003 Feb;124(2):544-60

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

***Note from National Guideline Clearinghouse (NGC) and the American
Society of Colon and Rectal Surgeons (ASCRS)**: These guidelines are
partially adapted from guidelines published in 2003*: See the NGC
summary of the U.S. Multisociety Task Force on Colorectal Cancer
guideline, [Colorectal cancer screening and surveillance: clinical
guidelines and rationale-update based on new
evidence](http://www.guideline.gov/summary/summary.aspx?doc_id=3686&nbr=002912).

*The Standards Committee has decided to provide a summary of the task
force guidelines to serve as an interim updated practice parameter. Two
emerging technologies, including fecal deoxyribonucleic acid (DNA)
screening and computed tomography (CT) colonography, are discussed at
the end of this summary*.

**[General Recommendations]{.underline}**

-   People with symptoms or signs that suggest the presence of
    colorectal cancer or polyps fall outside the domain of screening and
    should be offered an appropriate diagnostic evaluation.

-   Screening programs should begin by classifying the individual
    patient\'s level of risk based on personal, family, and medical
    history, which will determine the appropriate approach to screening
    for that person.

-   They should be offered options for screening, with information about
    the advantages and disadvantages associated with each approach, and
    should be given an opportunity to apply their own preferences in
    selecting how they should be screened.

-   If the result of a screening test is abnormal, physicians should
    recommend a complete structural examination of the colon and rectum
    by colonoscopy (or flexible sigmoidoscopy and double contrast barium
    enema if colonoscopy is not available).

-   Surveillance with colonoscopy should be considered for patients who
    are at increased risk because they have been treated for colorectal
    cancer, have an adenomatous polyp diagnosed, or have a disease that
    predisposes them to colorectal cancer, such as inflammatory bowel
    disease.

-   Health care providers who perform the tests should have appropriate
    proficiency, and the tests should be performed correctly. To achieve
    these goals, care systems should establish standards and operating
    procedures.

-   Screening should be accompanied by efforts to optimize the
    participation of patients and health care providers\--both with
    screening tests and appropriate diagnostic evaluation of abnormal
    screening test results\--and to remind patients and providers about
    the need for rescreening at recommended intervals.

**Recommendations for Average Risk People**

-   Offer yearly screening with fecal occult blood test (FOBT) using a
    guaiac-based test with dietary restriction or an immunochemical test
    without dietary restriction. Two samples from each of three
    consecutive stools should be examined without rehydration. Patients
    with a positive test on any specimen should be followed up with
    colonoscopy.

-   Offer flexible sigmoidoscopy every five years.

-   Offer screening with FOBT every year combined with flexible
    sigmoidoscopy every five years. When both tests are performed, the
    FOBT should be done first.

-   Offer colonoscopy every ten years.

-   Offer double-contrast barium enema (DCBE) every five years

**[Recommendations for Increased Risk People]{.underline}**

-   People with a first-degree relative (parent, sibling, or child) with
    colon cancer or adenomatous polyps diagnosed at age younger than 60
    years or two first-degree relatives diagnosed with colorectal cancer
    at any age should be advised to have screening colonoscopy starting
    at age 40 years or 10 years younger than the earliest diagnosis in
    their family, whichever comes first, and repeated every 5 years.

-   People with a first-degree relative with colon cancer or adenomatous
    polyp diagnosed at age 60 years or older or two second-degree
    relatives with colorectal cancer should be advised to be screened as
    average risk persons, but beginning at age 40 years.

-   People with one second-degree relative (grandparent, aunt, or uncle)
    or third-degree relative (great grandparent or cousin) with
    colorectal cancer should be advised to be screened as average risk
    persons.

**Familial Adenomatous Polyposis**

-   People who have a genetic diagnosis of familial adenomatous
    polyposis (FAP), or are at risk of having FAP but genetic testing
    has not been performed or is not feasible, should have annual
    sigmoidoscopy, beginning at age 10 to 12 years, to determine if they
    are expressing the genetic abnormality. Genetic testing should be
    considered in patients with FAP who have relatives at risk. Genetic
    counseling should guide genetic testing and considerations of
    colectomy.

**Hereditary Nonpolyposis Colorectal Cancer**

-   People with a genetic or clinical diagnosis of hereditary
    nonpolyposis colorectal cancer (HNPCC) or who are at increased risk
    for HNPCC should have colonoscopy every 1 to 2 years beginning at
    age 20 to 25 years, or 10 years earlier than the youngest age of
    colon cancer diagnosis in the family\--whichever comes first.
    Genetic testing for HNPCC should be offered to first-degree
    relatives of persons with a known inherited mismatch repair (MMR)
    gene mutation. It also should be offered when the family mutation is
    not previously known, but one of the first three of the modified
    Bethesda Criteria is met.

**[Surveillance of People at Increased Risk]{.underline}**

**People with a History of Adenomatous Polyps**

-   Patients who have had one or more adenomatous polyps removed at
    colonoscopy should be managed according to the findings on that
    colonoscopy. Patients who have had numerous adenomas, a malignant
    adenoma (with invasive cancer), a large sessile adenoma, or an
    incomplete colonoscopy should have a short interval follow-up
    colonoscopy based on clinical judgment. Patients who have advanced
    or multiple adenomas ([\>]{.underline}3) should have their first
    follow-up colonoscopy in three years. Patients who have one or two
    small (\<1 cm) tubular adenomas should have their first follow-up
    colonoscopy at five years. It is not unreasonable, given available
    evidence, to choose even longer intervals. However, the evidence is
    still evolving. Future evidence may clarify the intervals more
    precisely.

-   The timing of the subsequent colonoscopy should depend on the
    pathology and number of adenomas detected at follow-up colonoscopy.
    For example, if the first follow-up colonoscopy is normal or only
    one or two small (\<1 cm) tubular adenomas are found, the next
    colonoscopy can be in five years.

**People with a History of Colorectal Cancer**

-   Patients with a colon cancer that has been resected with curative
    intent should have a colonoscopy around the time of initial
    diagnosis to rule out synchronous neoplasms. If the colon is
    obstructed preoperatively, colonoscopy can be performed
    approximately six months after surgery. If this or a complete
    preoperative examination is normal, subsequent colonoscopy should be
    offered after three years, and then, if normal, every five years.

**People with Inflammatory Bowel Disease**

-   In patients with long-standing, extensive inflammatory bowel
    disease, surveillance colonoscopy with systematic biopsies should be
    considered. This applies to both ulcerative colitis and Crohn´s
    colitis because the cancer risk is similar in both diseases.

**[Emerging Screening Tests]{.underline}**

**CT Colonography**

-   At the time of the consensus panel, the conclusion regarding CT
    colonography was that the technology was still improving but not yet
    ready for widespread screening outside the research setting. Since
    publication of these guidelines, several studies have been performed
    to investigate the use of CT colonography for colorectal cancer
    screening. The majority of these studies still show that further
    improvements in the technique are required.

**Fecal DNA Tests**

-   The panel acknowledged that screening tests searching for altered
    DNA in the stool may be a promising approach. Trials measuring the
    performance of the test in large numbers of average-risk people are
    needed. No literature since the publication of the 2003 report
    changes these conclusions.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate screening and diagnostic evaluation of colorectal neoplasms

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Ko C, Hyman NH, Standards Committee of The American Society of Colon and
Rectal Surgeons. Practice parameter for the detection of colorectal
neoplasms: an interim report (revised). Dis Colon Rectum 2006
Mar;49(3):299-301. \[4 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16421663)

#### ADAPTATION

This guideline is a partial adaptation of the following source:

Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, Ganiats T,
Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C,
Gastrointestinal Consortium Panel. Colorectal cancer screening and
surveillance: clinical guidelines and rationale. Update based on new
evidence. Gastroenterology 2003 Feb;124(2):544-60

#### DATE RELEASED

2006 Mar

#### GUIDELINE DEVELOPER(S)

American Society of Colon and Rectal Surgeons - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society of Colon and Rectal Surgeons

#### GUIDELINE COMMITTEE

Standards Practice Task Force of the American Society of Colon and
Rectal Surgeons

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: Clifford Ko, MD; Neil H. Hyman, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Society of Colon and Rectal Surgeons (ASCRS) Web
site](http://www.fascrs.org/files/pp_neoplasm.pdf).

Print copies: Available from the ASCRS, 85 W. Algonquin Road, Suite 550,
Arlington Heights, Illinois 60005.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI Institute on May 31, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008