Colorectal cancer screening tests

• Tests that can find both colorectal polyps and cancer: These tests look at the structure of the colon itself to find any abnormal areas. This is done either with a scope inserted into the rectum or with special imaging (x-ray) tests. Polyps found before they turn cancerous can be removed, so these tests may prevent colorectal cancer. Because of this, they are preferred if they are available and you are willing to have them.
• Tests that mainly find cancer: These involve testing the stool (feces) for signs that cancer may be present. These tests are less invasive and easier to have done, but they are less likely to detect polyps. These tests as well as others can also be used when people have symptoms of colorectal cancer and other digestive diseases.

Tests that can find both colorectal polyps and cancer

Flexible sigmoidoscopy

During this test, the doctor looks at part of the colon and rectum with a sigmoidoscope -- a flexible, lighted tube about the thickness of a finger with a small video camera on the end. It is inserted through the rectum and into the lower part of the colon. Images from the scope are viewed on a display monitor.

Using the sigmoidoscope, your doctor can view the inside of the rectum and part of the colon to detect (and possibly remove) any abnormality. Because the sigmoidoscope is only 60 centimeters (about 2 feet) long, the doctor is able to see the entire rectum but less than half of the colon with this procedure.

Before the test: You will need to have a bowel preparation to clean out your lower colon. The colon and rectum must be empty and clean so your doctor can view the lining of the sigmoid colon and rectum. Your doctor will give you specific instructions to follow. You may be asked to follow a special diet (such as drinking only clear liquids) for a day before the exam. You may also be asked to use enemas or to drink a strong laxative solution to clean out your colon before the exam.

During the test: A sigmoidoscopy usually takes 10 to 20 minutes. Most people do not need to be sedated for this test, but this may be an option you can discuss with your doctor. While sedation may make the test less uncomfortable, it requires having someone with you to take you home after the test. You will likely be placed on a table on your left side with your knees positioned near your chest.

Your doctor should do a digital rectal exam (DRE) before inserting the sigmoidoscope. The sigmoidoscope is lubricated so it is easy to insert into the rectum. The scope may feel cool going in. The sigmoidoscope may stretch the wall of the colon, which may cause muscle spasms or lower abdominal pain. Air will be placed into the sigmoid colon through the sigmoidoscope so the doctor can see the colon better. During the procedure, you might feel pressure and slight cramping in your lower abdomen. To ease discomfort and the urge to have a bowel movement, it helps to breathe deeply and slowly through your mouth. You will feel better after the test once the air leaves your colon.

If a small polyp is found during the test your doctor may remove it with a small instrument passed through the scope. The polyp will be sent to a lab to be looked at by a pathologist. If a pre-cancerous polyp (an adenoma) or colorectal cancer is found during the test, you will need to have a colonoscopy at a later date to look for polyps or cancer in the rest of the colon.

Possible complications and side effects: This test may be uncomfortable because of the air put into the colon, but it should not be painful. Be sure to let your doctor know if you feel pain during the procedure. You may see a small amount of blood in your first bowel movement after the test. Significant bleeding and puncture of the colon are possible complications, but they are very uncommon.

Colonoscopy

For this test, the doctor looks at the entire length of the colon and rectum with a colonoscope, which is basically a longer version of a sigmoidoscope. It is inserted through the rectum into the colon. The colonoscope has a video camera on the end that is connected to a display monitor so the doctor can see and closely examine the inside of the colon. Special instruments can be passed through the colonoscope to remove any suspicious looking areas such as polyps, if needed.

Colonoscopy may be done in a hospital outpatient department, in a clinic, or in a doctor's office.

Before the test: The colon and rectum must be empty and clean so your doctor can view their inner linings during the test. You will need to take laxatives (liquids, pills, or both) the day before the test and possibly an enema that morning. Your doctor will give you specific instructions. It is important to read these carefully a few days ahead of time, since you may need to shop for special supplies and get laxatives from a pharmacy. If you are not sure about any of the instructions, call the doctor's office and go over them step by step with the nurse. Many people consider the bowel preparation to be the most unpleasant part of the test, as it usually requires you to be in the bathroom quite a bit.

You may be given other instructions as well. For example, your doctor may instruct that you drink only clear liquids (water, apple or cranberry juice, and any gelatin except red or purple) for a day or 2 before the exam. Plain tea or coffee with sugar is usually okay, but no milk or creamer is allowed. Clear broth, ginger ale, and most soft drinks or sports drinks are usually allowed unless they have red or purple food colorings, which can discolor the colon.

You will likely also be told not to eat or drink anything after midnight the night before your test. If you normally take prescription medicines in the mornings, talk with your doctor or nurse about how to manage them for the day. You may need to arrange for someone to drive you home from the test because the sedative used during the test can affect your ability to drive. Depending on the medicines that are used, some doctors require that someone drive you home.

During the test: The test itself usually takes about 30 minutes, although it may take longer if a polyp is found and removed. Before the colonoscopy begins, you will be given a sedating medicine through your vein to make you feel comfortable and sleepy during the procedure. You will probably be awake, but you may not be aware of what is going on and may not remember the procedure afterward. Most people will be fully awake by the time they get home from the test.

During the procedure, you will be placed on your side with your knees flexed and a drape will cover you. Your blood pressure, heart rate, and breathing rate will be monitored during and after the test.

Your doctor should do a digital rectal exam (DRE) before inserting the colonoscope. The colonoscope is lubricated so it can be easily inserted into the rectum. Once in the rectum, the colonoscope is passed through the transverse colon and into the ascending colon. You may feel an urge to have a bowel movement when the colonoscope is inserted or pushed further up the colon. To ease any discomfort it may help to breathe deeply and slowly through your mouth. The colonoscope will deliver air into the colon so that it is easier to see the lining of the colon and use the instruments to perform the test. Suction will be used to remove any blood or liquid stools.

If a small polyp is found, the doctor may remove it. Some small polyps may eventually become cancerous. For this reason, they are usually removed. This is done by passing a wire loop through the colonoscope to cut the polyp from the wall of the colon with an electrical current. The polyp can then be sent to a lab to be checked under a microscope to see if it has any areas that have changed into cancer.

If your doctor sees a large polyp or tumor or anything else abnormal, a biopsy may be done. For this procedure, a small piece of tissue is taken out through the colonoscope. The tissue is looked at under a microscope to determine if it is a cancer, a benign (non-cancerous) growth, or a result of inflammation.

Possible side effects and complications: The bowel preparation before the test can be unpleasant. The test itself may be uncomfortable, but the sedative usually prevents this, and most people feel normal once the effects of the sedative wear off. Some people may have gas pains or cramping for a while after the test.

In some cases, people may have low blood pressure or changes in heart rhythms due to the sedation during the test, although these are rarely serious.

If a polyp is removed or a biopsy is done during the colonoscopy, you may notice some blood in your stool for a day or 2 after the test. Significant bleeding is slightly more likely with colonoscopy than with sigmoidoscopy, but it is still uncommon. In rare cases, continued bleeding might require treatment.

Although colonoscopy is a safe procedure, on rare occasions the colonoscope can puncture the wall of the colon or rectum. This is called a perforation. It can be a serious complication and at times requires surgical repair. Talk to your doctor about the risk of this complication.

Double contrast barium enema (DCBE)

This procedure is also called an air-contrast barium enema or a barium enema with air contrast. It is basically a type of x-ray test. Barium sulfate, which is a chalky liquid, and air are used to outline the inner part of the colon and rectum to look for abnormal areas on x-rays. If suspicious areas are seen on this test, a colonoscopy will be needed to explore them further.

Before the test: As with colonoscopy, it is very important that the colon and rectum are empty and clean so your doctor can view them during the test. Your doctor will give you specific instructions on preparing for the test. Be sure to follow them. For example, you may be asked to clean your bowel the night before with laxatives and/or take an enema the morning of the exam. You will likely be asked to follow a clear liquid diet for a day or 2 before the procedure. You may also be told to avoid eating or drinking dairy products the day before the test, and to not eat or drink anything after midnight on the night before the procedure. Many people consider the bowel preparation to be the most unpleasant part of the test, as it usually requires you to be in the bathroom quite a bit.

During the test: The procedure takes about 30 to 45 minutes to perform, and it does not require sedation. For this test, you lie on a table on your side in an x-ray room. A small, flexible tube is inserted into the rectum, and barium sulfate is used to partially fill and open up the colon. When the colon is about half-full of barium, you are turned on the x-ray table so the barium spreads throughout the colon. Then air is pumped into the colon through the same tube to make it expand. This may cause some discomfort, and you may feel the urge to have a bowel movement.

X-ray pictures of the lining of your colon are then taken, allowing the doctor to identify any polyps or cancers. You may be asked to change positions so that different views of the colon and rectum can be seen on the x-rays. If polyps or other suspicious areas are seen on this test, a colonoscopy will likely be needed to remove them or to explore them fully.

Possible side effects and complications: You may have bloating or cramping after the test, and will likely feel the need to empty your bowels almost immediately after the test is done. The barium can cause constipation for a few days, and your stool may appear grey or white until the barium leaves the body. There is a very small risk that inflating the colon with air could injure or puncture the colon, but this risk is thought to be much less than with colonoscopy.

CT colonography (virtual colonoscopy)

This test is an advanced type of computed tomography (CT or CAT) scan of the colon and rectum. A CT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied. CT colonography involves the use of special computer programs to create both two dimensional x-ray pictures and a three-dimensional "fly-through" view of the inside of the colon and rectum, which allows the doctor to look for polyps or cancer.

This test may be especially useful for some people who can't have or don't want to have more invasive tests such as colonoscopy. It can be done fairly quickly and does not require sedation. But while this test is not invasive like colonoscopy, it still requires the same type of bowel preparation. If polyps or other suspicious areas are seen on this test, a colonoscopy will likely be needed to remove them or to explore them fully.

Before the test: It is important that the colon and rectum are emptied before this test to provide the best images. Because of this, the preparation for this test is similar to that for a double contrast barium enema or colonoscopy. You will likely be told to follow a clear liquid diet for a day or 2 before the test. You will also be given instructions for taking strong laxatives and/or enemas the night before or morning of the exam. This will likely require you to be in the bathroom quite a bit.

During the test: This test is done in a special room with a CT scanner, and takes about 10 minutes. You may be asked to drink a contrast solution before the test to help "tag" any remaining stool in the colon or rectum, which helps the doctor when looking at the test images. You will be asked to lie in a thin table that is part of the CT scanner, and will have a small, flexible tube inserted into your rectum. Air is pumped through the tube into the colon to expand it to provide better images. The table then slides into the CT scanner, and you will be asked to hold your breath while the scan takes place. You will likely have 2 scans: one while you are lying on your back and one while you are on your stomach. Each scan typically takes only about 10 to 15 seconds.

Possible side effects and complications: There are usually very few side effects after CT colonography. You may feel bloated or have cramps due to the air in the colon, but this should go away once the air passes from the body. There is a very small risk that inflating the colon with air could injure or puncture the colon, but this risk is thought to be much less than with colonoscopy.

Tests that mainly find colorectal cancer

These tests examine the stool to look for signs of cancer. Most people find these tests to be easier because they are not invasive and can often be done at home. But they are not as good at detecting polyps as the tests described above, and a positive result on one of these screening tests will likely require a more invasive test such as colonoscopy.

Fecal occult blood test

The fecal occult blood test (FOBT) is used to find occult (hidden) blood in feces. The idea behind this test is that blood vessels at the surface of larger colorectal polyps or cancers are often fragile and easily damaged by the passage of feces. The damaged vessels usually release a small amount of blood into the feces, but only rarely is there enough bleeding to be noticeable in the stool.

The FOBT detects blood in the stool through a chemical reaction. This test cannot tell whether the blood is from the colon or from other portions of the digestive tract (such as the stomach). Therefore, if this test is positive, a colonoscopy is needed to see if there is a cancer, polyp, or other cause of bleeding such as ulcers, hemorrhoids, diverticulosis (tiny pouches that form at weak spots in the colon wall), or inflammatory bowel disease (colitis).

This is a take-home kit that is used in the privacy of your own home. An FOBT done during a digital rectal exam in the doctor's office is not sufficient for screening. In order to be beneficial the test must be repeated every year.

People having this test will receive a kit with instructions from their doctor's office or clinic. The kit will explain how to take a stool or feces sample at home (usually specimens from 3 consecutive bowel movements that are smeared onto small squares of paper). The kit should then be returned to the doctor's office or medical lab (usually within 2 weeks) for testing. See below for more details.

Before the test: Some foods or drugs can affect the test, so your doctor may suggest that you try to avoid the following before this test:

• non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil), naproxen (Aleve), or aspirin (more than 1 adult aspirin per day), for 7 days before testing (they can cause bleeding, which can lead to a false-positive result). Acetaminophen (Tylenol) can be taken as needed.
• vitamin C in excess of 250 mg daily from either supplements or citrus fruits and juices for 3 days before testing (this can affect the chemicals in the test and make it show negative)
• red meats (beef, lamb, or liver) for 3 days before testing (components of blood in the meat may cause the test to show positive)

Some people who are given the test never do it or don't give it to their doctor because they worry that something they ate may interfere with the test. For this reason, many doctors tell their patients it isn't essential to follow any restrictions in their diet. The most important thing is to get the test done. People should try to avoid taking aspirin or related drugs for minor aches. But if you take these medicines daily for heart problems or other conditions, don't stop them for this test without approval from your doctor.

Collecting the samples: Have all of your supplies ready and in one place. Supplies will include a test kit, test cards, either a brush or wooden applicator, and a mailing envelope. The kit will give you detailed instructions on how to collect the specimen. The instructions below can be used as a guide, but your kit instructions might be a little different. Always follow the instructions on your kit.

• You will need to collect a sample from your bowel movement. You can place a sheet of plastic wrap across the toilet bowl to catch the stool or you can use a dry container to collect the stool. Do not let the stool specimen mix with urine. After you obtain a sample, you can flush the remaining stool down the toilet.
• Use a wooden applicator or a brush to smear a thin film of the stool sample onto one of the slots in the test card or slide. Next, collect a specimen from a different area of the same stool and smear a thin film of the sample onto the other slot in the test card or slide.
• Close the slots and put your name and the date on the test kit. Store the kit overnight in a paper envelope to allow it time to dry.
• Repeat the test on your next 2 bowel movements if instructed. Most tests require collecting more than one sample from different bowel movements. This improves the accuracy of the test because many cancers bleed intermittently and blood may not be present in all stool samples.
• Place the test kit in the mailing pouch provided and return it to your doctor or lab as soon as possible (but within 14 days of taking the first sample).

If this test finds blood, a colonoscopy will be needed to look for the source. It is not sufficient to simply repeat the FOBT or follow up with other types of tests.

Fecal immunochemical test

The fecal immunochemical test (FIT), also called an immunochemical fecal occult blood test (iFOBT), is a newer kind of test that also detects occult (hidden) blood in the stool. This test reacts to part of the hemoglobin molecule, which is found on red blood cells.

The FIT is done essentially the same way as the FOBT, but some people may find it easier to use because there are no drug or dietary restrictions (vitamins or foods do not affect the FIT) and sample collection may take less effort. This test is also less likely to react to bleeding from the upper digestive tract, such as the stomach.

As with the FOBT, the FIT may not detect a tumor that is not bleeding, so multiple stool samples should be tested. And if the results are positive for hidden blood, a colonoscopy is required to investigate further. In order to be beneficial the test must be repeated every year.

Collecting the samples: Have all of your supplies ready and in one place. Supplies will include a test kit, test cards, long brushes, waste bags, and a mailing envelope. The kit will give you detailed instructions on how to collect the specimen. The instructions below can be used as a guide, but your kit instructions might be a little different. Always follow the instructions on your kit.

• Flush the toilet before your bowel movement. After you go, place used toilet paper in the waste bag from the kit, not in the toilet.
• Brush the surface of the stool with one of the brushes, then dip the brush in the toilet water. Dab the end of the brush onto one of the slots in the test card or slide.
• Close the slot and put your name and the date on the test kit.
• Repeat the test on your next bowel movement if instructed. Most tests require collecting more than one sample from different bowel movements. This improves the accuracy of the test because many cancers bleed intermittently and blood may not be present in all stool samples.
• Place the test kit in the mailing envelope provided and return it to your doctor or lab as soon as possible (but within 14 days of taking the first sample).

Stool DNA tests

Instead of looking for blood in the stool, these tests look for certain abnormal sections of DNA (genetic material) from cancer or polyp cells. Colorectal cancer cells often contain DNA mutations (changes) in certain genes such as APC, K-ras, and p53. Cells from colorectal cancers or polyps with these mutations are often shed into the stool, where tests may be able to detect them.

This is a newer test, and the best length of time to go between tests is not yet clear. This test is also much more expensive than other forms of stool testing.

This test is not invasive and doesn't require any special preparation. But as with other stool tests, if the results are positive, a colonoscopy is required to investigate further.

People having this test will receive a kit with detailed instructions from their doctor's office or clinic on how to collect the specimen. Always follow the instructions on your kit.

This test requires an entire stool sample. It is obtained using a special container, which is placed in a bracket that stretches across the seat of the toilet. You have your bowel movement while sitting on the toilet, making sure it goes into the container. You then place the container and an ice pack in a shipping box and close and label the box. The specimen must be shipped to the lab within 24 hours of having the bowel movement.

What are some of the pros and cons of these screening tests?

People at average risk

The American Cancer Society believes that preventing colorectal cancer (and not just finding it early) should be a major reason for getting tested. Finding and removing polyps keeps some people from getting colorectal cancer. Tests that have the best chance of finding both polyps and cancer are preferred if these tests are available to you and you are willing to have them.

Beginning at age 50, both men and women at average risk for developing colorectal cancer should use one of the screening tests below:

Tests that find polyps and cancer

• flexible sigmoidoscopy every 5 years*
• colonoscopy every 10 years
• double contrast barium enema every 5 years*
• CT colonography (virtual colonoscopy) every 5 years*

Tests that mainly find cancer

• fecal occult blood test (FOBT) every year*,**
• fecal immunochemical test (FIT) every year*,**
• stool DNA test (sDNA), interval uncertain*

*Colonoscopy should be done if test results are positive.
**For FOBT or FIT used as a screening test, the take-home multiple sample method should be used. A FOBT or FIT done during a digital rectal exam in the doctor's office is not adequate for screening.

In a digital rectal examination (DRE), a doctor examines your rectum with a lubricated, gloved finger. Although a DRE is often included as part of a routine physical exam, it is not recommended as a stand-alone test for colorectal cancer. This simple test, which is not usually painful, can detect masses in the anal canal or lower rectum. By itself, however, it is not a very sensitive test for detecting colorectal cancer due to its limited reach.

Doctors often find a small amount of stool when doing a DRE. However, simply checking stool obtained in this fashion for evidence of bleeding with a FOBT or FIT is not an acceptable method of screening for colorectal cancer. Research has shown that this type of stool examination will miss more than 90% of colon abnormalities, including most cancers.

People at increased or high risk

If you are at an increased risk or higher than average risk of colorectal cancer, you should begin colorectal cancer screening earlier and/or be screened more often. The following conditions place you at higher than average risk:

a personal history of colorectal cancer or adenomatous polyps
a personal history of inflammatory bowel disease (ulcerative colitis or Crohn's disease) a strong family history of colorectal cancer or polyps (see "Risk factors for colorectal cancer" above)
a known family history of hereditary colorectal cancer syndromes such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC)

The table below suggests screening guidelines for those with increased or high risk of colorectal cancer based on specific risk factors. Some people may have more than one risk factor. Refer to the table below and discuss these recommendations with your doctor. Based on your individual situation and any risk factors you may have, your doctor can suggest the best screening option for you, as well as any changes in the schedule based on your individual risk.

American Cancer Society Guidelines on Screening and Surveillance for the Early Detection of Colorectal Adenomas and Cancer in People at Increased Risk or at High Risk

Risk Category	Age to Begin	Recommended Test(s)	Comment
INCREASED RISK -- Patients With a History of Polyps on Prior Colonoscopy
People with small rectal hyperplastic polyps	Same as those with average risk	Colonoscopy, or other screening options at regular intervals as for those at average risk	Those with hyperplastic polyposis syndrome are at increased risk for adenomatous polyps and cancer and should have more intensive follow-up.
People with 1 or 2 small (less than 1 cm) tubular adenomas with low-grade dysplasia	5 to 10 years after the polyps are removed	Colonoscopy	Time between tests should be based on other factors such as prior colonoscopy findings, family history, and patient and doctor preferences.
People with 3 to 10 adenomas, or a large (1 cm +) adenoma, or any adenomas with high-grade dysplasia or villous features	3 years after the polyps are removed	Colonoscopy	Adenomas must have been completely removed. If colonoscopy is normal or shows only 1 or 2 small tubular adenomas with low-grade dysplasia, future colonoscopies can be done every 5 years.
People with more than 10 adenomas on a single exam	Within 3 years after the polyps are removed	Colonoscopy	Doctor should consider possibility of genetic syndrome (such as FAP or HNPCC).
People with sessile adenomas that are removed in pieces	2 to 6 months after adenoma removal	Colonoscopy	If entire adenoma has been removed, further testing should be based on doctor’s judgment
INCREASED RISK – Patients With Colorectal Cancer
People diagnosed with colon or rectal cancer	At time of colorectal surgery, or can be 3 to 6 months later if person doesn't have cancer spread that can't be removed	Colonoscopy to view entire colon and remove all polyps	If the tumor presses on the colon/rectum and prevents colonoscopy, CT colonoscopy (with IV contrast) or DCBE may be done to look at the rest of the colon.
People who have had colon or rectal cancer removed by surgery	Within 1 year after cancer resection (or 1 year after colonoscopy to make sure the rest of the colon/rectum was clear)	Colonoscopy	If normal, repeat exam in 3 years. If normal then, repeat exam every 5 years. Time between tests may be shorter if polyps are found or there is reason to suspect HNPCC. After low anterior resection for rectal cancer, exams of the rectum may be done every 3 to 6 months for the first 2 to 3 years to look for signs of recurrence.
INCREASED RISK – Patients With a Family History
Colorectal cancer or adenomatous polyps in any first-degree relative before age 60, or in 2 or more first-degree relatives at any age (if not a hereditary syndrome).	Age 40, or 10 years before the youngest case in the immediate family, whichever is earlier	Colonoscopy	Every 5 years.
Colorectal cancer or adenomatous polyps in any first-degree relative aged 60 or higher, or in at least 2 second-degree relatives at any age	Age 40	Same options as for those at average risk.	Same intervals as for those at average risk.
HIGH RISK
Familial adenomatous polyposis (FAP) diagnosed by genetic testing, or suspected FAP without genetic testing	Age 10 to 12	Yearly flexible sigmoidoscopy to look for signs of FAP; counseling to consider genetic testing if it hasn't been done	If genetic test is positive, removal of colon (colectomy) should be considered.
Hereditary non-polyposis colon cancer (HNPCC), or at increased risk of HNPCC based on family history without genetic testing	Age 20 to 25 years, or 10 years before the youngest case in the immediate family	Colonoscopy every 1 to 2 years; counseling to consider genetic testing if it hasn't been done	Genetic testing should be offered to first-degree relatives of people found to have HNPCC mutations by genetic tests. It should also be offered if 1 of the first 3 of the modified Bethesda criteria is met.1
Inflammatory bowel disease -Chronic ulcerative colitis -Crohn's disease	Cancer risk begins to be significant 8 years after the onset of pancolitis (involvement of entire large intestine), or 12-15 years after the onset of left-sided colitis	Colonoscopy every 1 to 2 years with biopsies for dysplasia	These people are best referred to a center with experience in the surveillance and management of inflammatory bowel disease.

¹The Bethesda criteria can be found in the "Can Colorectal Cancer Be Prevented?" section of our larger Colorectal Cancer document.

Revised: 03/05/2008