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All persons at average risk of colorectal cancer, which equates to all asymptomatic individuals age 50 years and older who have no other risk factor but age, should be screened using:
- Annual fecal occult blood test (FOBT)* and/or flexible sigmoidoscopy at least every five years
- colonoscopy every 10 years
- double-contrast barium enema every 5-10 years
Surveillance of patients at high risk with colonoscopy at intervals individualized for age, duration of disease, and comorbidities is justified for individuals with a personal history of colorectal cancer or adenomatous polyps,or with a history of colorectal cancer or adenomatous polyps in a first degree relative, or diagnosed with inflammatory bowel disease, including ulcerative colitis or Crohn's disease.
While there is demonstrated significant benefit to biennial screening with FOBT, the benefit from annual screening appears to be greater. Despite inadequate evidence to demonstrate that FOBT in combination with flexible sigmoidoscopy is more effective than either test alone, the low sensitivity of FOBT in detecting polyps may warrant the use of both tests. The exact time interval for use of these screening tests is currently uncertain.When colonoscopy is not feasible, double-contrast barium enema plus flexible sigmoidoscopy may be used as an alternative. When colonoscopy is incomplete, double-contrast barium enema may be used, unless the patient has been diagnosed with inflammatory bowel disease, including ulcerative colitis or Crohn's disease.
Note: Recently published studies have determined that screening individuals at average risk of colorectal cancer with colonoscopy in comparison with sigmoidoscopy increases the detection of advanced proximal neoplasia in individuals without distal colonic lesions.
- Screening average risk Medicare patients with annual FOBT and sigmoidoscopy every 4 years is covered by Medicare
- Barium enema may be used as an alternative to either sigmoidoscopy or colonoscopy
- Direct colonoscopy screening of average risk patients every 10 years is covered by Medicare beginning July 1, 2001
- Surveillance of high risk Medicare patients (as described above) with colonoscopy every 2 years is covered by Medicare; barium enema may be used as an alternative to colonoscopy
- The incidence of colorectal cancers-especially proximal lesions-increases with age. This increased risk should be weighed against decreased life expectancy and tolerance for screening and diagnostic procedures.
- Certain environmental factors, including a diet high in fat, excessive caloric and alcohol intake,obesity, sedentary life style, and smoking are associated with an increased risk of colorectal cancer.
- Effective serologic screening tools are lacking