ACP reminds physicians to assess risk, screen for colorectal cancer

A guest column by the American College of Physicians, exclusive to

Colorectal cancer is the second leading cause of cancer-related deaths for men and women in the United States. Although the effectiveness of colorectal cancer screening in reducing deaths is supported by the available evidence, only about 60 percent of American adults aged 50 and older get screened.

A new colorectal cancer screening guidance statement from the American College of Physicians (ACP) published earlier this month in Annals of Internal Medicine is a welcome resource for busy doctors and our patients. We want to do the right thing for our patients but there are several clinical guidelines available for colorectal cancer screening. Some of those guidelines are less than flexible when a patient is not inclined to have a certain intervention.

The benefit of ACP’s guidance statement is that it provides a rigorous review of the current guidelines developed by other organizations and makes recommendations based on the existing guidelines. Specifically, ACP recommends:

  • that clinicians perform individualized assessment of risk for colorectal cancer in all adults.
  • that clinicians screen for colorectal cancer in average-risk adults starting at the age of 50 and in high-risk adults starting at the age of 40 or 10 years younger than the age at which the youngest affected relative was diagnosed with colorectal cancer.
  • using a stool-based test, flexible sigmoidoscopy, or optical colonoscopy as a screening test in patients who are at average risk. ACP recommends using optical colonoscopy as a screening test in patients who are at high risk. Clinicians should select the test based on the benefits and harms of the screening test, availability of the screening test, and patient preferences.
  • that clinicians stop screening for colorectal cancer in adults over the age of 75 years or in adults with a life expectancy of less than 10 years.

As with all clinical recommendation, ACP recognizes that they are “guides” only and may not apply to all patients and all clinical situations. They are not intended to override a physician’s judgment and the shared decision making process.

If, for example, a physician had a healthy 75 year old patient whose brother was diagnosed with colorectal cancer at the age of 85, it would be important  to discuss with him or her the benefits, risks, and harms of the multiple colorectal cancer screening options. Medical treatment decisions should always reflect individual desires, values, and preferences of patients as expressed in consultation with their physicians.

The guidance statement also includes a Best Practice Advice section. I find this information helpful because the analysis reminds us what we really know and that we haven’t proven some things we think we know.

I have patients whose insurance does not cover screening colonoscopy and others who simply will not have the procedure unless a problem is detected. ACP’s guidance statement outlines the advantages and disadvantages of the other options and reminds us of the start and stop ages for various groups.

Fred Ralston practices internal medicine in Fayetteville, Tennessee, and is the Immediate Past President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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