American Cancer Society Guideline for Colorectal Cancer Screening

For people at average risk

The COVID-19 pandemic has resulted in many elective procedures being put on hold, and this has led to a substantial decline in cancer screening. Health care facilities are providing cancer screening during the pandemic with many safety precautions in place. Learn how you can talk to your doctor and what steps you can take to plan, schedule, and get your regular cancer screenings in Cancer Screening During the COVID-19 Pandemic.

The ACS recommends that people at average risk* of colorectal cancer start regular screening at age 45. This can be done either with a sensitive test that looks for signs of cancer in a person’s stool (a stool-based test), or with an exam that looks at the colon and rectum (a visual exam). These options are listed below.

People who are in good health and with a life expectancy of more than 10 years should continue regular colorectal cancer screening through the age of 75.

For people ages 76 through 85, the decision to be screened should be based on a person’s preferences, life expectancy, overall health, and prior screening history.

People over 85 should no longer get colorectal cancer screening.

*For screening, people are considered to be at average risk if they do not have:

  • A personal history of colorectal cancer or certain types of polyps
  • A family history of colorectal cancer
  • A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
  • A confirmed or suspected hereditary colorectal cancer syndrome, such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC)
  • A personal history of getting radiation to the abdomen (belly) or pelvic area to treat a prior cancer

Test options for colorectal cancer screening

Several test options are available for colorectal cancer screening:

Stool-based tests

  • Highly sensitive fecal immunochemical test (FIT) every year
  • Highly sensitive guaiac-based fecal occult blood test (gFOBT) every year
  • Multi-targeted stool DNA test (mt-sDNA) every 3 years

Visual (structural) exams of the colon and rectum

  • Colonoscopy every 10 years
  • CT colonography (virtual colonoscopy) every 5 years
  • Flexible sigmoidoscopy (FSIG) every 5 years

There are some differences between these tests to consider (see Colorectal Cancer Screening Tests), but the most important thing is to get screened, no matter which test you choose. Talk to your health care provider about which tests might be good options for you, and to your insurance provider about your coverage.

If a person chooses to be screened with a test other than colonoscopy, any abnormal test result should be followed up with a timely colonoscopy.

For people at increased or high risk

People at increased or high risk of colorectal cancer might need to start colorectal cancer screening before age 45, be screened more often, and/or get specific tests. This includes people with:

  • A strong family history of colorectal cancer or certain types of polyps (see Colorectal Cancer Risk Factors)
  • A personal history of colorectal cancer or certain types of polyps
  • A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
  • A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome (also known as hereditary non-polyposis colon cancer or HNPCC)
  • A personal history of radiation to the abdomen (belly) or pelvic area to treat a prior cancer

The American Cancer Society does not have screening guidelines specifically for people at increased or high risk of colorectal cancer. However, some other professional medical organizations, such as the US Multi-Society Task Force on Colorectal Cancer (USMSTF), do put out such guidelines. These guidelines are complex and are best looked at along with your health care provider. In general, these guidelines put people into several groups (although the details depend on each person’s specific risk factors).

People at increased risk for colorectal cancer

People with one or more family members who have had colon or rectal cancer

Screening recommendations for these people depend on who in the family had cancer and how old they were when it was diagnosed. Some people with a family history will be able to follow the recommendations for average risk adults, but others might need to get a colonoscopy (and not any other type of test) more often, and possibly starting before age 45.

People who have had certain types of polyps removed during a colonoscopy

Most of these people will need to get a colonoscopy again after 3 years, but some people might need to get one earlier (or later) than 3 years, depending on the type, size, and number of polyps.

People who have had colon or rectal cancer

Most of these people will need to start having colonoscopies regularly about one year after surgery to remove the cancer. Other procedures like MRI or proctoscopy with ultrasound might also be recommended for some people with rectal cancer, depending on the type of surgery they had.

People who have had radiation to the abdomen (belly) or pelvic area to treat a prior cancer

Most of these people will need to start having colorectal screening (colonoscopy or stool based testing) at an earlier age (depending on how old they were when they got the radiation). Screening often begins 5 years after the radiation was given or at age 30, whichever comes last. These people might also need to be screened more often than normal (such as at least every 3 to 5 years).

People at high risk for colorectal cancer

People with inflammatory bowel disease (Crohn’s disease or ulcerative colitis)

These people generally need to get colonoscopies (not any other type of test) starting at least 8 years after they are diagnosed with inflammatory bowel disease. Follow-up colonoscopies should be done every 1 to 3 years, depending on the person’s risk factors for colorectal cancer and the findings on the previous colonoscopy.

People known or suspected to have certain genetic syndromes

These people generally need to have colonoscopy (not any of the other tests). Screening is often recommended to begin at a young age, possibly as early as the teenage years for some syndromes – and needs to be done much more frequently. Specifics depend on which genetic syndrome you have, and other factors.

If you’re at increased or high risk of colorectal cancer (or think you might be), talk to your health care provider to learn more. Your provider can suggest the best screening option for you, as well as determine what type of screening schedule you should follow, based on your individual risk.

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Children’s Oncology Group. Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer. Version 5.0 - October 2018. Accessed at http://www.survivorshipguidelines.org/pdf/2018/COG_LTFU_Guidelines_v5.pdf on Feb 11, 2020.

Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol. 2018 Apr;113(4):481-517. doi: 10.1038/ajg.2018.27. Epub 2018 Mar 27.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Genetic/Familial High-Risk Assessment: Colorectal. V.3.2019. Accessed at https://www.nccn.org/professionals/physician_gls/pdf/genetics_colon.pdf on Feb 10, 2020.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer. V.1.2020. Accessed at https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf on Feb 10, 2020.

Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019 Mar;114(3):384-413. doi: 10.14309/ajg.0000000000000152.

Screening for colon and rectal cancer in average-risk adults. CA Cancer J Clin. 2018 Jul;68(4):282-283. doi: 10.3322/caac.21458. Epub 2018 May 30.

Smith RA, Andrews KS, Brooks D, Fedewa SA, Manassaram-Baptiste D, Saslow D et al. Cancer screening in the United States, 2018: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: Cancer J Clin. 2018;68(4):297-316. doi: 10.3322/caac.21446. Epub 2018 May 30. 

Wolf AMD, Fontham ETH, Church TR, Flowers CR, Guerra CE, LaMonte SJ, Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018 Jul;68(4):250-281. doi: 10.3322/caac.21457. Epub 2018 May 30.

References

Children’s Oncology Group. Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer. Version 5.0 - October 2018. Accessed at http://www.survivorshipguidelines.org/pdf/2018/COG_LTFU_Guidelines_v5.pdf on Feb 11, 2020.

Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol. 2018 Apr;113(4):481-517. doi: 10.1038/ajg.2018.27. Epub 2018 Mar 27.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Genetic/Familial High-Risk Assessment: Colorectal. V.3.2019. Accessed at https://www.nccn.org/professionals/physician_gls/pdf/genetics_colon.pdf on Feb 10, 2020.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer. V.1.2020. Accessed at https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf on Feb 10, 2020.

Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019 Mar;114(3):384-413. doi: 10.14309/ajg.0000000000000152.

Screening for colon and rectal cancer in average-risk adults. CA Cancer J Clin. 2018 Jul;68(4):282-283. doi: 10.3322/caac.21458. Epub 2018 May 30.

Smith RA, Andrews KS, Brooks D, Fedewa SA, Manassaram-Baptiste D, Saslow D et al. Cancer screening in the United States, 2018: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: Cancer J Clin. 2018;68(4):297-316. doi: 10.3322/caac.21446. Epub 2018 May 30. 

Wolf AMD, Fontham ETH, Church TR, Flowers CR, Guerra CE, LaMonte SJ, Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018 Jul;68(4):250-281. doi: 10.3322/caac.21457. Epub 2018 May 30.

Last Revised: November 17, 2020

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