Recommendations

Document Overview

Design and created by Guideline Central in participation with the American Cancer Society.

Colorectal Cancer Screening

American Cancer Society

Publication Date: May 27, 2026

Page Last Updated: May 27, 2026

Table 2. Considerations in choosing a colorectal cancer screening test

Screening test	Recommended screening interval	Evidence of effectiveness and test performance	Limitations	Patient considerations	Cost and reimbursement
Stool-based screening tests
FIT with high sensitivity for cancer	Annual	Indirect evidence of CRC incidence and mortality reductions from RCTs of gFOBT Equivalent or better performance compared with high-sensitivity gFOBT FIT sensitivity varies substantially by assay and hemoglobin detection threshold.	Low adherence to repeat annual testing in absence of reminder systems One-time testing is less effective than mt-sDNA for detecting APL. Few available FIT tests have published peer-reviewed performance data.	Done at home. Most brands require only a single sample. No diet or medication restrictions Positive test requires follow-up colonoscopy.	Inexpensive compared with visual examinations, mt-sDNA, mt-sRNA, and blood tests
gFOBT with high sensitivity for cancer	Annual	RCT evidence for CRC incidence and mortality reductions with lower sensitivity gFOBT Low-sensitivity gFOBT versions are not recommended because of poor performance.	Low adherence to annual testing in absence of reminder systems One-time testing is less effective than mt-sDNA for detecting APL. Difficulty in ascertaining diagnostic test performance among the FDA-cleared tests	Done at home. Requires multiple samples Requires dietary and medication restrictions Positive test requires follow-up colonoscopy.	Inexpensive compared with visual examinations, mt-sDNA, mt-sRNA, and blood tests
mt-sDNA (original and next-generation)	Every 3 years (according to manufacturer)	Indirect evidence of CRC incidence and mortality reductions from RCTs of gFOBT Higher sensitivity for cancer and APLs compared with FIT Lower specificity for ACN compared with FIT		Done at home. Higher likelihood of needing follow-up colonoscopy than with FIT because of lower specificity Positive test requires follow-up colonoscopy.	More expensive than FIT and gFOBT
mt-sRNA	Every 3 years	Indirect evidence of CRC mortality and incidence reductions from RCTs of gFOBT Higher sensitivity for cancer and APLs compared with FIT Lower specificity for ACN compared with FIT	New test with limited data on screening outcomes; performance needs to be monitored over time Self-reported smoking history required for prediction model	Done at home. Higher likelihood of needing follow-up colonoscopy than with FIT because of lower specificity Positive test requires follow-up colonoscopy.	More expensive than FIT and gFOBT CMS coverage determination pending at time of publication
Structural (visual) examinations for screening
Colonoscopy	Every 10 years	There is only observational evidence of CRC mortality reduction. Extrapolation from RCTs of sigmoidoscopy demonstrating mortality and incidence reductions Offers both early CRC detection and prevention (through polypectomy)	Risk of bowel perforation/bleeding and cardiopulmonary complications of anesthesia. Performance quality depends on adequacy of bowel preparation and endoscopist factors, including cecal intubation rate, withdrawal time, and adenoma detection rate. Limited performance quality data available in many settings Surveillance colonoscopy has marginal clinical benefit for patients with low-risk polyps.	Requires full bowel cleansing Requires time off work and a chaperone (sedation is used)	Expensive test but currently reimbursable for those with insurance coverage Polypectomy and anesthesia may incur out-of-pocket costs.
Computed tomographic colonography	Every 5 years	Extrapolation from RCTs of sigmoidoscopy demonstrating CRC mortality and incidence reductions Sensitivity and specificity for ACN comparable to colonoscopy	Incidental extracolonic findings may require work-up, with unclear benefit-burden balance. Exposure to low-dose radiation	Requires full bowel cleansing Positive test requires follow-up colonoscopy. Positive test requires two separate bowel cleansings if diagnostic colonoscopy not immediately available. Not widely performed	Relatively expensive and may not be covered by insurance (not routinely covered by Medicare at this time)
Flexible sigmoidoscopy	Every 5 years	RCT evidence for CRC mortality and incidence reductions	Does not examine the proximal colon Concerns about lack of quality standards, limited availability, failure to achieve a complete examination	Pain and discomfort Requires enema before procedure Positive test requires follow-up colonoscopy. Not widely performed
Blood-based tests
Cell-free DNA blood testsb	Every 3 years (CMS coverage for Guardant Shield)	Prospective cross-sectional validation with colonoscopy reference standard Good sensitivity for CRC detection, lower than for mt-sDNA test Fair to good specificity for ACN, lower than for stool-based tests	Very low sensitivity for APLs Lower sensitivity for stage I cancers than for later stage cancers Optimal testing interval not established Real-world adherence to repeat testing and diagnostic follow-up unknown Reduction in overall CRC mortality expected to be substantially lower than for colonoscopy or stool-based screening tests Specificity for ACN declines with age, which may lead to more colonoscopies in older adults.	Simple blood draw in clinic or laboratory May be preferred by individuals unwilling to complete stool tests or structural tests Positive test requires follow-up colonoscopy.	Guardant Shield covered by CMS; coverage status pending for Freenome SimpleScreen More expensive than stool-based tests

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American Cancer Society Rcommendation Grades

Document Overview

Document Title: Colorectal Cancer Screening

Authoring Society: American Cancer Society

Document Publication Date: May 27, 2026

Page Last Reviewed/Updated: May 27, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.70083

Source Citation: Wolf, Andrew M D et al. “Colorectal cancer screening: An update to the American Cancer Society guideline, 2026.” CA: a cancer journal for clinicians vol. 76,3 (2026): e70083. doi:10.3322/caac.70083

Document Scope, Criteria, and Use Cases

Document Objectives: Colorectal cancer (CRC) is a leading cause of cancer incidence and mortality in the United States, with rates recently increasing among adults younger than 65 years. In 2018, the American Cancer Society (ACS) lowered the recommended age to initiate screening for average-risk adults to age 45 years. Since then, new molecular-based screening tests-a multitarget stool RNA test (mt-sRNA), a next-generation mt-sDNA test, and a blood-based cell-free DNA assay-have received regulatory approval for CRC screening. For this update, the ACS Guideline Development Group commissioned a targeted, systematic evidence review evaluating diagnostic performance and published modeling studies to judge the potential impact of these tests on CRC incidence and mortality. The ACS reaffirms the recommendation that average-risk adults should initiate CRC screening at age 45 years and continue through age 75 years for those with a life expectancy greater than 10 years. Consistent with prior guidelines, the ACS emphasizes that offering multiple, recommended screening options supports informed patient choice and may improve participation, because the most effective screening test is the one that the patient completes. The next-generation mt-sDNA test, which is an updated version of an already recommended mt-sDNA test, and the mt-sRNA test demonstrated high sensitivity for CRC and moderate sensitivity for advanced precancerous lesions and are recommended, along with annual high-sensitivity fecal immunochemical and high-sensitivity guaiac-based fecal occult blood tests, as preferred stool-based screening options at 3-year intervals. Compared with established stool-based tests, blood-based tests demonstrated lower sensitivity for both advanced precancerous lesions and stage I cancers, with modeling studies predicting less effectiveness in reducing CRC incidence and mortality. At this time, blood-based tests should be recommended only to individuals who decline or do not complete preferred screening tests. Ongoing evaluation of adherence, real-world implementation, and clinical outcomes will inform future updates for these new tests. For screening to be effective, a positive result on any noncolonoscopy screening test requires timely follow-up with colonoscopy, preferably within 6 months, to complete the screening process.

Scope: Assessment and Screening, Diagnosis

Diseases/Conditions (MeSH)

D015179 - Colorectal Neoplasms

D003107 - Colorectal Surgery

D011315 - Preventive Medicine

D000076862 - Diagnostic Screening Programs

Keywords: colorectal, colorectal cancer, colorectal neoplasm, preventive care

Target Patient Population: Patients with risk of colorectal cancer

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Ambulatory, Outpatient

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Number of Source Documents: 211

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: No

Grade	Based on
Strong	High‐quality evidence
Qualified	Limited evidence

Colorectal Cancer Screening

Recommendations

Preferred screening options

Blood-based colorectal cancer screening

Table 2. Considerations in choosing a colorectal cancer screening test

Figure 1. Colorectal cancer screening (%). Adults 45 years and older, by age

American Cancer Society Rcommendation Grades

Document Overview

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology