So doc, what should I do?
Multiple guidelines, levels of evidence, different screening methods with varying efficacy, individual risk factors – how can clinicians make sense of all these data at the practice level?
“Any modality can be used for screening. Colorectal cancer screening can be done in a number of different ways, and I think that sometimes gets lost in the shuffle, and the thought becomes that everybody has to get a colonoscopy at 45, but there are certainly other tests,” Dr. Kupfer said.
“This just reminds us that we should be thinking about ways we can be doing screening on a population basis, so that we make sure there is equity,” she said.
It’s also important to remember that patients with familial CRC syndromes should begin screening at an even earlier age than average-risk adults, she emphasized.
“To really make a dent in early-onset colorectal cancer, we have to continue to take an active case-finding approach,” she said.
Dr. Rex noted that despite minor differences, the major guidelines are all similar in their initial statements that screening works.
“We’ve still got 50,000 people a year dying from colorectal cancer, lots more than that of new cases,” he said. “If you look at a single factor contributing to that the most, it’s that a lot of the American public is not getting screened at all – it can be up to 40% of the population, depending on what state you’re in.”
Although there are a variety of screening methods available, there are few studies directly comparing them, leaving clinicians at the practice level with the task of presenting all or some of them to patients.
“What the Multi-Society Task Force says that is different, and I think that they get right, is that we don’t have any data [indicating] that offering five, six, or seven options increases the chance of screening – there’s really no evidence that going past two does,” Dr. Rex said.
“The list of options also includes things that nobody actually does,” he added. “For example, flexible sigmoidoscopy has dropped off the map, and FIT has largely replaced guaiac-based testing, even high-sensitivity guaiac. Nobody is really doing CT colonography. The three tests that are being used are colonoscopy, FIT, and [stool DNA-FIT].”
Dr. Rex said that he favors sequential offers, presenting colonoscopy first, emphasizing the benefits for higher-risk patients, and if the patients refuse, offering a fecal-based test.
“Minimizing the number of options makes the conversation feasible, and it’s still very responsible,” he said.
Dr. Kupfer has performed collaborative research with Myriad Genetic Laboratories. She is an editorial advisory board member for GI & Hepatology News from MDedge, part of the Medscape Professional Network. Dr. Rex serves or served as a consultant for Olympus Corporation; Boston Scientific; Medtronic; and Aries; and received research support from Endo-Aid; Olympus Corporation; and Medivators. He has ownership in ai4gi. He is an editorial board member for Medscape Gastroenterology. Dr. Chan has served as a consultant to Pfizer, Bayer AG, and Boehringer Ingelheim.
A version of this article first appeared on Medscape.com.
This article was updated June 8, 2021.