Screening guidelines tool

Screening guidelines tool Disclaimer: This material is intended as a general summary of screening and management recommendations; it is not intended to be comprehensive. Colorectal cancer (CRC) screening guidelines are updated at regular intervals and may change over time. Providers should view the most up-to-date version of the relevant NCCN Colorectal Screening guidelines at nccn.org/professionals/physician_gls/f_guidelines.asp, and the American College of Gastroenterology Guidelines for Colorectal Cancer Screening. Screening recommendations for individual patients vary according to their level of risk, with patients at higher risk requiring more intensive and more frequent interventions to reduce morbidity and mortality. Risk is not static and may change over time based on changes in both personal and family medical history. Therefore, it is important to update patient information regularly and to store this information in a format that is easy to interpret and modify. Screening guidelines for individuals at average (population) risk Summary of CRC screening recommendations guide Average risk Age 50; Age 45 for African American men No history of adenoma or hamartoma No history of inflammatory bowel disease Negative family history Most patients fall into this category; they have little or no family history and no personal risk factors. These patients can be advised that specific lifestyle changes may modify the risk for colon and other cancers. Colonoscopy every 10 years; or Flexible sigmoidoscopy every 5 years; or Double contrast barium enema every 5 years; or Computed tomographic colonography every 5 years; or Fecal immunochemical test (FIT) Colonoscopy is the most effective and most invasive. All other screening tests may result in referral for colonoscopy if the test is abnormal or if a polyp is found that needs removal. References: Screening at average risk NCCN Clinical Practice Guidelines in Oncology (2011). Colorectal Cancer Screening V.2.2011 Accessed December 6, 2010 from www.nccn.org/professionals/physician_gls/f_guidelines.asp NOTE: Free registration and login are required to view guidelines. Scroll down to Guidelines for Detection, Prevention, & Risk Reduction, click on Colorectal Cancer Screening. US Multi-Society Task Force on Colorectal Cancer, and the American College of Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the Screening and Surveillance for the Early Detection of Colorectal Cancer and Radiology (2008). CA: a Cancer Journal for Clinicians, 58, 130 160. Accessed December 6, 2010 from http://caonline.amcancersoc.org/cgi/reprint/58/3/130 ACG Guidelines for Colorectal Cancer Screening 2009. American Journal of Gastroenterology 104(3):739-750. http://s3.gi.org/physicians/guidelines/ccsjournalpublicationfebruary2009.pdf Colorectal Cancer Fact Sheets: Screening guidelines 1

Screening guidelines for individuals at increased risk This category includes those who have one first- or two second-degree relatives* with colon cancer, and those with personal risk factors such as inflammatory bowel disease or a history of polyps. These patients are at higher-than-average risk but do not meet the criteria for a hereditary colon cancer syndrome. Regular updates of family history are important because the diagnosis of polyps, CRC or a Lynch-related cancer in one or more relatives may change a patient s risk category. Patients can be counseled that lifestyle changes may help modify their risk. Summary of patient history and CRC screening recommendations Increased risk NOTE: Evaluate for possible hereditary cancer syndrome 1 2 small tubular adenoma(s); <1cm Colonoscopy every 5 10 years after initial polypectomy 3 10 adenomas or 1 adenoma > 1cm, villous features or high-grade dysplasia Colonoscopy 3 years after initial polypectomy, if normal or if 1 2 small tubular adenomas, then every 5 years Personal history of CRC, after curative surgery Colonoscopy in one year or earlier in absence of complete preoperative colonoscopy; repeat every 1 3 years depending on results; periodic limited endoscopic evaluation of rectal anastomosis to identify local recurrence; new primary cancer should prompt update of family history and consideration of possible hereditary cancer syndrome >10 adenomas on a single exam Individual management including colonoscopy <3 years after initial polypectomy; evaluate for FAP/AFAP CRC or adenomatous polyps in any FDR* <60, or two or more in FDRs at any age, or multiple cases of Lynch/HNPCC** related cancers Colonoscopy every 3 5 years starting at age 40 or 10 years before youngest case in immediate family CRC or adenomatous polyps in any FDR* 60 or two SDRs* with CRC Colonoscopy every 5 years beginning at age 50 Inflammatory bowel disease (Chronic ulcerative colitis, Crohn s colitis) Colonoscopy with biopsies for dysplasia every 1 2 years starting 8 10 years after onset of symptoms Additional sampling of strictures and masses Endoscopic polypectomy with appropriate biopsies of surrounding mucosa for assessment of dysplasia If dysplasia or intraepithelial neoplasia, prophylactic protocolectomy with ileoanal pouch preferred *A first-degree relative (FDR) is a parent, sibling or child. A second-degree relative (SDR) is a grandparent, grandchild, uncle, aunt, nephew, niece, half-sibling. **HNPCC related cancers [CRC, endometrial, ovarian, duodenal/small bowel, gastric, ureteral/renal pelvis, hepatobillary/pancreas, brain (particularly glioblastoma), sebaceous adenoma/or sebaceous carcinoma]. Note that the American College of Gastroenterology considers CRC or adenomatous polyps in any FDR 60 as average risk, with colonoscopy every 10 years beginning at age 50. Colorectal Cancer Fact Sheets: Screening guidelines 2

Screening guidelines for individuals at high risk This category includes patients who have been diagnosed with a hereditary colon cancer syndrome such as Lynch/HNPCC or FAP/AFAP, or have a highly suggestive family or personal history. Because of the high risk for colon and other cancers, these individuals require more intensive and frequent screening. Prophylactic surgery for risk reduction and participation in clinical trials are often options for these patients. They benefit from a referral to a cancer genetics specialist to discuss the implications of their diagnosis in more detail. Summary of CRC and extra colonic high-risk screening and surveillance recommendations Colorectal Gastric and small bowel Urothelial Central nervous system Pancreatic Endometrial and ovarian (women) Diagnosis of Lynch syndrome/hnpcc (hereditary non-polyposis syndrome) Colonoscopy every 1 2 years starting at age 20 25 or 2 5 years prior to the earliest colon cancer in the family if diagnosed under age 25 Consider EGD with extended duodenoscopy and polypectomy beginning at age 30, repeat every 2 3 years Consider annual urinalysis Annual physical exam, no added screening No recommendations due to limited data Consider endometrial sampling and concurrent transvaginal ultrasound (preferably day 1 10 of cycle if premenopausal) annually starting age 30 35 or 5 10 years prior to earliest age at first diagnosis if these cancers are in the family Consider prophylactic hysterectomy and bilateral salpingo-oophrectomy after childbearing is completed Diagnosis of familial adenomatous polyposis (FAP) Colorectal: APC gene positive Flexible sigmoidoscopy or colonoscopy annually starting age 10 15, consider colectomy Colorectal: Suspected FAP, not tested Flexible sigmoidoscopy or colonoscopy starting age 10 15 - annually until age 24 - every 2 years until age 34 - every 3 years until age 44 Colorectal Duodenal, gastric, or periampular (near the Ampulla of Vater or union of pancreatic duct and common bile duct) Thyroid CNS cancer Personal history of FAP: Screening, surveillance and treatment (post-colectomy) Endoscopic evaluation every 6 months to 3 years, depending on proctocolectomy or colectomy status Consider NSAID chemoprevention to reduce polyp as pharmacologic adjunct to endoscopy Baseline upper endoscopy (including side-viewing exam), and repeat every 1 3 years depending on severity of polyposis Examine stomach at time of duodenoscopy Annual thyroid exam starting in late teens Annual physical exam, no added screening 11-0456:2/12:jt:Updated Feb 2012 Colorectal Cancer Fact Sheets: Screening guidelines 3

Intra-abdominal desmoids (benign soft tissue tumors occurring most often in the abdomen with FAP) Small bowel polyps and cancer Hepatoblastoma (childhood cancer associated with FAP) Pancreatic Annual abdominal palpation; with a family history of desmoids, consider abdominal CT or MRI every 1 3 years post-colectomy and then at 5 10 year intervals Consider adding small bowel visualization with CT or MRI for desmoids as outlined above, especially with advanced duodenal polyps Consider liver palpation, abdominal ultrasound and measurement of α-fetoprotein every 3 6 months until age 5 Recommend FAP genetic testing in untested children with hepatoblastoma No recommendations have been made < 21 years, small adenoma 21 40 years, small adenoma > 40 years, small adenoma Significant polyposis not manageable with polypectomy Screening/ chemoprevention AFAP, personal history Personal history of AFAP (attenuated familial adenomatous polyposis) Colonoscopy and polypectomy every 1 2 years; surgical evaluation and counseling Colectomy with ileorectal anastomosis (IRA), or colonoscopy and polypectomy every 1 2 years; surgical evaluation and counseling Strongly consider colectomy with IRA; surgical evaluation and counseling Colectomy with IRA (preferred in most cases) or proctocolectomy with ileal J-pouch anal anastomosis If patient had colectomy with IRS, endoscopic exam of rectum every 6 12 months depending on polyp Annual physical exam; annual thyroid exam Consider NSAID chemoprevention Baseline upper endoscopy every 6 months to 4 years starting at age 25 30 APC positive or not tested APC negative Family history of AFAP (attenuated familial adenomatous polyposis) Colonoscopy starting in late teens, then every 2 3 years Average risk screening Sibling with MYH polyposis + pt is asymptomatic + MYH mutation positive or untested Note: MYH polyposis has a recessive pattern Diagnosis of MYH-associated polyposis, family history of sibling with MYH polyposis Colonoscopy starting age 25 30 and every 3 5 years if negative (consider shorter intervals with advancing age) Consider upper endoscopy and side viewing duodenoscopy starting age 30 35 and every 3 5 years Patients with duodenal adenomas are treated as in FAP Genetic counseling and testing for the familial MYH polyposis mutation(s) is recommended 11-0197:5/11:jt Colorectal Cancer Fact Sheets: Screening guidelines 4

Personal history of being MYH mutation positive; or History of adenomatous polyposis + negative APC testing (>10 at one time or >15 in 10 years) Note: MYH polyposis has a recessive inheritance pattern MYH-associated polyposis, personal history No MYH testing + polyposis + negative APC testing Genetic counseling and testing for MYH polyposis mutation(s) is recommended; if negative, refer to increased risk colorectal cancer screening guidelines for multiple adenomatous polyps MYH positive + adenomas manageable with colonoscopy and polypectomy Colonoscopy and polypectomy every 1 2 years Consider upper endoscopy and side viewing duodenoscopy starting age 30 35 every 3 5 years Patients with duodenal adenomas treated as in FAP MYH positive + dense or large polyps not manageable with colonoscopy and polypectomy Subtotal colectomy or proctocolectomy depending on ademona density and distribution; counseling regarding surgical options Upper endoscopy and side viewing duodenoscopy starting age 30 35 every 3 5 years Patients with duodenal adenomas treated as in FAP Counseling regarding surgical options References: Screening at increased and high risk NCCN Clinical Practice Guidelines in Oncology (2011). Colorectal Cancer Screening V.2.2011 Accessed December 6, 2010 from www.nccn.org/professionals/physician_gls/f_guidelines.asp NOTE: Free registration and login are required to view guidelines. Scroll down to Guidelines for Detection, Prevention, & Risk Reduction, click on Colorectal Cancer Screening US Multi-Society Task Force on Colorectal Cancer, and the American College of Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the Screening and Surveillance for the Early Detection of Colorectal Cancer and Radiology (2008). CA: a Cancer Journal for Clinicians, 58, 130 160. Accessed December 6, 2010 from http:// caonline.amcancersoc.org/cgi/reprint/58/3/130 Lindor, N. M., Petersen, G. M., Hadley, D. W., Kinney, A. Y., Miesfeldt, S., Lu, K. H., et al. (2006). Recommendations for the care of individuals with an inherited predisposition to Lynch syndrome: a systematic review. JAMA, 296(12), 1507 1517. Nielsen, M., Franken, P. F., Reinards, T. H., Weiss, M. M., Wagner, A., van der Klift, H., et al. (2005). Multiplicity in polyp count and extracolonic manifestations in 40 Dutch patients with MYH associated polyposis coli (MAP). Journal of Medical Genetics, 42(9), e54. Winawer, S., Fletcher, R., Rex, D., Bond, J., Burt, R., Ferrucci, J., et al. (2003). Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology, 124(2), 544 560. ACG Guidelines for Colorectal Cancer Screening 2009. American Journal of Gastroenterology 104(3):739-750. http://s3.gi.org/physicians/guidelines/ccsjournalpublicationfebruary2009.pdf 11-0456:2/12:jt:Updated Feb 2012 Colorectal Cancer Fact Sheets: Screening guidelines 5