Screening (asymptomatic persons with no prior history of colorectal cancer or adenomas)

Average-risk (age > 45* years, without other risk factors)

Recommended screening:
  • annual fecal occult blood test (FOBT)  or
  • flexible sigmoidoscopy every 5 years or
  • annual FOBT plus flexible sigmoidoscopy every 5 years or
  • colonoscopy every 10 years or
  • double contrast barium enema every 5 years
*In 2018, secondary to new data on the increased risks of colon cancer in those under 50, the American Society of Colon and Rectal Surgery changed recommendations to consider starting screening at age 45. 

First-degree relative (parent, sibling, or child) with colorectal cancer or adenomas diagnosed at age <60y or two first-degree relatives at any age

Recommended screening: colonoscopy every 5 years, beginning at age 40 years or 10 years before the age of the youngest affected relative (whichever is first)

First-degree relative with colorectal cancer or adenomas diagnosed at age >60y, or two second degree relatives with colorectal cancer

Recommended screening: same options as average-risk but begin at age 40y

Inherited syndromes of colorectal cancer

Familial adenomatous polyposis

Recommended screening: refer for genetic testing or annual screening by sigmoidoscopy, beginning at age 10-12 years

Hereditary Nonpolyposis Colorectal Cancer

Recommended screening: refer for genetic testing, or colonoscopy every 1-2 years beginning at age 20-25 years; or 10 years younger than youngest age of colorectal cancer diagnosis in family 

Surveillance (persons with a personal history of colorectal cancer or adenomas, or who have long-standing ulcerative colitis or Crohn’s colitis)

Personal history of adenomas – recommended surveillance

Findings of most recent colonoscopy Recommended Interval
  • 1-2 tubular adenomas <1cm in size 5 years
  • 3 or more adenomas 3 years
  • advanced adenomas (>1cm, high grade 3 years dysplasia or villous elements)
  • numerous adenomas or large sessile short interval based adenoma removed piecemeal on clinical judgment
  • follow-up exam normal (patients with only 5 years hyperplastic polyps are generally considered to have a normal examination)

Personal history of colorectal cancer – recommended surveillance

  • perform colonoscopy pre-operatively or within 6 months post-operatively if pre-operative obstruction
  • if normal perform colonoscopy in 3 years, and then, if normal, in 5 years

Long-standing ulcerative colitis or Crohn’s colitis – recommended surveillance

  • interval colonoscopy with systematic biopsies should be considered

American Cancer Society/US Multisociety Task Force on Colorectal Cancer/American College of Radiology (ACS/USMSTF/ACR). Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008 May-Jun;58(3):130-60.