Key Points
Treatment
Design and created by Guideline Central in participation with the American Society of Clinical Oncology.
Colorectal Cancer Early Detection
American Society of Clinical Oncology
Publication Date: February 25, 2019
Key Points
- This pocket guide focuses on the role of the early detection of colorectal cancer and the management of any polyps found during colorectal cancer screening among those at average risk, as well as the workup and diagnosis of colorectal cancer.
- Different regions of the world differ with respect to access to early detection.
- Very few locations outside of high-income countries (HICs) have mass or even opportunistic screening. Even within countries/regions, variations occur between rural and urban and between areas with basic primary care and better-resourced medical care not available in the local area but rather further away.
Treatment
Table 1. Framework of Resource Stratification
| Setting | |
|---|---|
| Basic | Core resources or fundamental services that are absolutely necessary for any public health/primary health care system to function; basic-level services typically are applied in a single clinical interaction. |
| Limited | Second-tier resources or services that are intended to produce major improvements in outcome such as incidence and cost-effectiveness and are attainable with limited financial means and modest infrastructure; limited-level services may involve single or multiple interactions. Universal public health interventions feasible for greater percentage of population than primary target group. |
| Enhanced | Third-tier resources or services that are optional but important; enhanced-level resources should produce further improvements in outcome and increase the number and quality of options and individual choice. (Perhaps ability to track patients and links to registries). |
| Maximal | May use high-resource settings’ guidelines. High-level/state-of-the art resources or services that may be used/available in some high-resource countries and/or may be recommended by high-resource setting guidelines that do not adapt to resource constraints but that nonetheless should be considered a lower priority than those resources or services listed in the other categories on the basis of extreme cost and/or impracticality for broad use in a resource-limited environment. |
NOTE: Data adapted. To be useful, maximal-level resources typically depend on the existence and functionality of all lower level resources.
Table 2. Screening/Treatment Capacities by Setting
| Intervention | Basic | Limited | Enhanced | Maximal |
|---|---|---|---|---|
| Screening | No screening available. | No mass screening available. Individuals may only access 1 screening per lifetime. | Limited mass screening; primarily opportunistic screening. | Invitation, reminder, registration, monitoring, evaluation, recall systems already in place. Population likely to access more than one screening per lifetime. |
| Reflex testing/Endoscopy | DRE or barium enema possible. | Flex sigmoidoscopy available | Colonoscopy available | Colonoscopy available |
| Imaging | X-Ray and someone to read it. | CT | CT/MRI available | CR/MRI/PET widely available |
| Surgery | General surgery with minor operating room available. | General surgery with operating room. | OR, ICU, colorectal surgery available, may or may not have access to laparascopic approaches. | Specialist surgery services widely available with minimally invasive surgical options (e.g, laparascopic, robotic). |
| Chemotherapy | Availability of chemotherapy drugs is unpredictable. | Some chemotherapy available (maybe not so specific). | More chemotherapy options available, targeted therapy may or may not be available. | Chemotherapy available; targeted therapy available. |
| Radiation therapy | No radiation therapy available. In some Basic settings, radiation may be available but very limited, unpredictable. | Limited external RT with no brachytherapy available services may not always be available/unpredictable. | RT including external beam and brachytherapy available; interventional radiology not available. | RT including external beam and brachytherapy available; interventional radiology available (e.g. IMRT, IORT). |
| Pathology | If there is a way to send pathology for review when needed, that should occur. | Pathology services in development H&E usually available, IHC and molecular tests are usually not available. | Pathology services usually available and IHC and molecular tests may be available. | Pathology available with specialist pathology templates, genetic/molecular testing available. |
| Palliative care | Palliative care service is not available. Limited medications for pain may be available. | Pain and symptom management available; palliative care service is in development | Palliative care specialty service not always available. | Specialist palliative care service available. |
Table 3. Screening: Asymptomatic, Average-Risk Population, High-Incidence Areas, Age 50 - 75
1.1 gFOBT
Basic
People should receive highly sensitive gFOBT every 1 (preferred) – 2 years if resources are available (based on resources and patient adherence).
Limited, Enhanced, Maximal
People should receive highly sensitive gFOBT annually. ( H, S )
People should receive highly sensitive gFOBT every 1 (preferred) – 2 years if resources are available (based on resources and patient adherence).
Limited, Enhanced, Maximal
People should receive highly sensitive gFOBT annually. ( H, S )
1.2 FIT
Basic
People may receive FIT, if available, every 1 (preferred) – 2 years (based on resources and patient adherence).
Limited, Enhanced, Maximal
People may receive FIT annually. ( I, M )
People may receive FIT, if available, every 1 (preferred) – 2 years (based on resources and patient adherence).
Limited, Enhanced, Maximal
People may receive FIT annually. ( I, M )
1.3 Flexible Sigmoidoscopy
Basic
N/A
Limited, Enhanced, Maximal
People should receive Flexible Sigmoidoscopy every 5 years. ( H, S )
N/A
Limited, Enhanced, Maximal
People should receive Flexible Sigmoidoscopy every 5 years. ( H, S )
1.4 Flexible Sigmoidoscopy plus (FIT or FOBT)
Basic
N/A
Limited, Enhanced, Maximal
People may receive Flexible Sigmoidoscopy every 10 yrs plus FIT (or if FIT not available, then FOBT) every year. ( I, S )
N/A
Limited, Enhanced, Maximal
People may receive Flexible Sigmoidoscopy every 10 yrs plus FIT (or if FIT not available, then FOBT) every year. ( I, S )
1.5 Colonoscopy
Basic/ Limited
N/A
Enhanced, Maximal
People may receive colonoscopy every 10 years. ( L, W )
N/A
Enhanced, Maximal
People may receive colonoscopy every 10 years. ( L, W )
1.6 CT colonography
Basic/ Limited/ Enhanced
N/A
Maximal
People may receive CT colonography. ( L, W )
N/A
Maximal
People may receive CT colonography. ( L, W )
1.7 FIT-DNA
Basic/ Limited/ Enhanced
N/A
Maximal
People may receive FIT-DNA. ( L, W )
N/A
Maximal
People may receive FIT-DNA. ( L, W )
Table 4. Reflex Testing: If Patients Have a Positive Result From CRC Screening
2.
Basic
If patients have a positive result from CRC screening, then clinicians should refer patients to colonoscopy (first choice) or sigmoidoscopy (second choice) if available. However, because endoscopy is not available in most Basic settings, clinicians should perform or refer patients to reflex testing with double contrast barium enema.
After reflex testing:
if a patient’s barium enema results are positive refer to colonoscopy, if available, otherwise refer the patient to surgery.
Limited
If patients have a positive result from CRC screening, then clinicians should perform or refer patients to a colonoscopy, if available. If clinicians cannot refer patients to a colonoscopy, then clinicians should administer a double contrast barium enema.
After reflex testing:
If a patient’s barium enema results are positive refer to colonoscopy, if available, otherwise refer the patient to surgery.
Note: If person in Limited Setting received positive results from Flexible Sigmoidoscopy screening (± stool screening) and there is low availability of colonoscopy, a completion colonoscopy is not mandatory. The colonoscopy or DCBE as reflex testing is more warranted for positive gFOBT, FIT, stool DNA, DCBE, or CT colonography.
Enhanced, Maximal
If patients have a positive result from a non-colonoscopy CRC screening, then clinicians should perform or refer patients to a colonoscopy. ( IC, Ins, S )
If patients have a positive result from CRC screening, then clinicians should refer patients to colonoscopy (first choice) or sigmoidoscopy (second choice) if available. However, because endoscopy is not available in most Basic settings, clinicians should perform or refer patients to reflex testing with double contrast barium enema.
After reflex testing:
if a patient’s barium enema results are positive refer to colonoscopy, if available, otherwise refer the patient to surgery.
Limited
If patients have a positive result from CRC screening, then clinicians should perform or refer patients to a colonoscopy, if available. If clinicians cannot refer patients to a colonoscopy, then clinicians should administer a double contrast barium enema.
After reflex testing:
If a patient’s barium enema results are positive refer to colonoscopy, if available, otherwise refer the patient to surgery.
Note: If person in Limited Setting received positive results from Flexible Sigmoidoscopy screening (± stool screening) and there is low availability of colonoscopy, a completion colonoscopy is not mandatory. The colonoscopy or DCBE as reflex testing is more warranted for positive gFOBT, FIT, stool DNA, DCBE, or CT colonography.
Enhanced, Maximal
If patients have a positive result from a non-colonoscopy CRC screening, then clinicians should perform or refer patients to a colonoscopy. ( IC, Ins, S )
Table 5. People With Positive Pre-Malignant Polyps or Other Abnormal Screening Results
Pedunculated
3.1 Colonoscopy
Basic/ Limited
N/A
Enhanced, Maximal
Colonoscopy should be performed always with therapeutic intent. ( Ins, S )
N/A
Enhanced, Maximal
Colonoscopy should be performed always with therapeutic intent. ( Ins, S )
Basic/ Limited
N/A
Enhanced, Maximal
Performed by endoscopist with training in polypectomy. ( L, S )
N/A
Enhanced, Maximal
Performed by endoscopist with training in polypectomy. ( L, S )
3.2 Polypectomy
Basic/ Limited
N/A
Enhanced, Maximal
Lesions should be removed with polypectomy. ( I, S )
N/A
Enhanced, Maximal
Lesions should be removed with polypectomy. ( I, S )
Refer to guidelines for special considerations including anti-coagulants and coronary stents.
3.3 Evaluation of morphology
Basic/ Limited
N/A
Enhanced, Maximal
Large pre-malignant lesions not suitable for endoscopic resection should be referred for surgical resection. ( Ins, S )
N/A
Enhanced, Maximal
Large pre-malignant lesions not suitable for endoscopic resection should be referred for surgical resection. ( Ins, S )
3.4 Mucosal tattooing
Basic/ Limited
N/A
Enhanced, Maximal
If lesion cannot be removed (in BSG guidelines); if large lesion has a high likelihood of malignancy (informal consensus) may be performed. ( Ins, W )
N/A
Enhanced, Maximal
If lesion cannot be removed (in BSG guidelines); if large lesion has a high likelihood of malignancy (informal consensus) may be performed. ( Ins, W )
3.5 Histology/ pathology
Basic/ Limited
N/A
Enhanced, Maximal
Removed lesions should be retrieved for histologic exam; confirm negative borders of resection. ( Ins, S )
N/A
Enhanced, Maximal
Removed lesions should be retrieved for histologic exam; confirm negative borders of resection. ( Ins, S )
3.6 Referral to surgery
Basic/ Limited
N/A
Enhanced, Maximal
Only patients with lesions that cannot be removed endoscopically should be referred to surgery. ( Ins, S )
N/A
Enhanced, Maximal
Only patients with lesions that cannot be removed endoscopically should be referred to surgery. ( Ins, S )
Non-Pedunculated
3.7 Colonoscopy
Basic/ Limited
N/A Enhanced, Maximal
Yes always with therapeutic intent; ( Ins, S )
N/A Enhanced, Maximal
Yes always with therapeutic intent; ( Ins, S )
Basic/Limited
N/A
Enhanced, Maximal
endoscopic resection first line therapy for LNPCP with no suspicion of malignancy.
Basic/Limited
N/A
Enhanced, Maximal
Should be performed by endoscopists with training in large complex polyps. ( L, W )
N/A
Enhanced, Maximal
Should be performed by endoscopists with training in large complex polyps. ( L, W )
Basic/ Limited
N/A
Enhanced, Maximal
Multidisciplinary team may perform colonoscopies. ( Ins, W )
N/A
Enhanced, Maximal
Multidisciplinary team may perform colonoscopies. ( Ins, W )
3.8 Polypectomy
Basic/ Limited
N/A
Enhanced, Maximal
Lesions should be removed with polypectomy; removal of lesions is dependent on the low likelihood of malignancy. ( I, S )
N/A
Enhanced, Maximal
Lesions should be removed with polypectomy; removal of lesions is dependent on the low likelihood of malignancy. ( I, S )
Basic/ Limited
N/A Enhanced, Maximal
Possibility of complete resection, refer to BSG/ACGB guidelines. ( L, S )
N/A Enhanced, Maximal
Possibility of complete resection, refer to BSG/ACGB guidelines. ( L, S )
Refer to guidelines for special considerations including anti-coagulants and coronary stents.
3.9 Evaluation of morphology
Basic/ Limited
N/A
Enhanced, Maximal
Endoscopic assessment of lesion using enhanced endoscopy methods (if available may include chromoendoscopy); clinicians should follow the BSG guideline. ( Ins, S )
N/A
Enhanced, Maximal
Endoscopic assessment of lesion using enhanced endoscopy methods (if available may include chromoendoscopy); clinicians should follow the BSG guideline. ( Ins, S )
3.10 Mucosal tattooing
Basic/ Limited
N/A
Enhanced, Maximal
If lesion cannot be removed (in BSG guidelines); if large lesion has a high likelihood of malignancy should be performed. For patients with polyps that are completely removed, clinicians may perform tattooing for surveillance purposes. ( Ins, W )
N/A
Enhanced, Maximal
If lesion cannot be removed (in BSG guidelines); if large lesion has a high likelihood of malignancy should be performed. For patients with polyps that are completely removed, clinicians may perform tattooing for surveillance purposes. ( Ins, W )
3.11 Histology/ pathology
Basic/ Limited
N/A
Enhanced, Maximal
Removed lesions should be retrieved for histologic exam; confirm negative borders of resection. ( Ins, S )
N/A
Enhanced, Maximal
Removed lesions should be retrieved for histologic exam; confirm negative borders of resection. ( Ins, S )
3.12 Referral to surgery
Basic/ Limited
N/A
Enhanced, Maximal
Only patients with lesions that cannot be removed endoscopically should be referred to surgery. ( Ins, S )
N/A
Enhanced, Maximal
Only patients with lesions that cannot be removed endoscopically should be referred to surgery. ( Ins, S )
1 BSG = British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps.
Source: Rutter MD, et al. Gut 2015;0:1–27. doi:10.1136/gutjnl-2015-309576 Availabe at: https://www.bsg.org.uk/asset/14074495-3BF4-4EA8-BED8E740BA1E6177 .
Source: Rutter MD, et al. Gut 2015;0:1–27. doi:10.1136/gutjnl-2015-309576 Availabe at: https://www.bsg.org.uk/asset/14074495-3BF4-4EA8-BED8E740BA1E6177 .
Table 6. Optimal Strategy For Workup/Diagnosis for Those With Symptoms
4.1 DRE
Basic, Limited
DRE may be performed (standard part of physical).
Enhanced, Maximal
N/A physical exam ( IC, Ins )
DRE may be performed (standard part of physical).
Enhanced, Maximal
N/A physical exam ( IC, Ins )
4.2 Double contrast barium enema
4.3 For those without contraindications to colonoscopy
Basic, Limited
Colonoscopy with biopsy for those without contraindications should be performed, if colonoscopy is available, including by referral.
Enhanced, Maximal
Colonoscopy with biopsy for those without contraindications should be performed.
Colonoscopy with biopsy for those without contraindications should be performed, if colonoscopy is available, including by referral.
Enhanced, Maximal
Colonoscopy with biopsy for those without contraindications should be performed.
4.4 For those with contraindications to colonoscopy (or colonoscopy not available) but no contraindications to flexible sigmoidoscopy – if the patient can't tolerate colonoscopy then full visualization.
Basic, Limited
Flexible sigmoidoscopy with biopsy, if no contraindication, may be performed with barium enema.
Enhanced, Maximal
Flexible sigmoidoscopy with biopsy, if no contraindication, may be performed with full visualization of the colon (either barium enema or CT colonography). ( L, W )
Flexible sigmoidoscopy with biopsy, if no contraindication, may be performed with barium enema.
Enhanced, Maximal
Flexible sigmoidoscopy with biopsy, if no contraindication, may be performed with full visualization of the colon (either barium enema or CT colonography). ( L, W )
4.5 Patients with contraindications to colonoscopy and to flexible sigmoidoscopy.
Basic Limited
N/A – refer to 4.2
Enhanced
CT colonography if suspicious findings and if other two tests contraindicated may be performed.
Or if 2nd tier DCBE is not possible.
Maximal
CT colonography if suspicious findings and if other two tests contraindicated may be performed.
2nd tier DCBE if CT colonography not possible. ( H, M )
N/A – refer to 4.2
Enhanced
CT colonography if suspicious findings and if other two tests contraindicated may be performed.
Or if 2nd tier DCBE is not possible.
Maximal
CT colonography if suspicious findings and if other two tests contraindicated may be performed.
2nd tier DCBE if CT colonography not possible. ( H, M )
4.6 Patients who have had an incomplete colonoscopy
Basic
N/A (patient would not have received colonoscopy in basic)
N/A (patient would not have received colonoscopy in basic)
Limited
Barium enema (Note: colonoscopy may not have been available, therefore incomplete colonoscopy would not apply) ( IC, Ins, S )
Barium enema (Note: colonoscopy may not have been available, therefore incomplete colonoscopy would not apply) ( IC, Ins, S )
Enhanced
If a patient in the Enhanced setting had an incomplete colonoscopy, then patients may receive an double contrast enhanced-barium enema or CT colonography (for CT colonography, if the local radiology service can demonstrate competency in this technique). ( I, S )
If a patient in the Enhanced setting had an incomplete colonoscopy, then patients may receive an double contrast enhanced-barium enema or CT colonography (for CT colonography, if the local radiology service can demonstrate competency in this technique). ( I, S )
Maximal
Repeat colonoscopy or, if not feasible, the next tier would be one of the two following:
CT colonography, if the local radiology service can demonstrate competency in this technique OR
Barium enema may be offered (if nothing else is possible).
Repeat colonoscopy or, if not feasible, the next tier would be one of the two following:
CT colonography, if the local radiology service can demonstrate competency in this technique OR
Barium enema may be offered (if nothing else is possible).
Recommendation Grading
| Type | Evidence Quality | Strength of Recommendation | ||
|---|---|---|---|---|
| EB | Evidence-based | H | High | Strong |
| I | Intermediate | Moderate | ||
| IC | Informal consensus | L | Low | Weak |
| Ins | Insufficient | |||
Abbreviations
- (g)FOBT
- (guaiac) fecal occult blood test
- CRC
- colorectal cancer
- CT
- computed tomography
- DCBE
- double contrast barium enema
- DNA
- deoxyribonucleic acid
- DRE
- digital rectal examination
- FIT
- fecal immunochemical test
- HIC
- high-income country
- IMRT
- intensity-modulated radiation therapy
- IORT
- intraoperative radiation therapy
- LNPCP
- large non-pedunculated colorectal polyps
- MRI
- magnetic resonance imaging
- N/A
- not applicable
- OR
- operating room
- PET
- positron emission tomography
- RT
- radiation therapy
Source Citation
DOI: 10.1200/JGO.18.00213 Journal of Global Oncology , no. 5 (December 01, 2019) 1-22.
Disclaimer
This pocket guide is derived from recommendations in the American Society of Clinical Oncology Guideline. This resource is a practice tool based on ASCO® practice guidelines and is not intended to substitute for the independent professional judgment of the treating physician. Practice guidelines do not account for individual variation among patients. This pocket guide does not purport to suggest any particular course of medical treatment. Use of the practice guidelines and this resource are voluntary. The practice guidelines and additional information are available at www.asco.org/supportive-care-guidelines. Copyright © 2021 by American Society of Clinical Oncology. All rights reserved.
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