2020 CRC Screening Guidelines Flashcards
define a pt who is average risk for CRC
Absence of inflammatory bowel disease, family history of CRC, hereditary syndrome associated with increased risk, serrated polyposis syndrome, personal history of CRC
define normal colo
normal colo:
A colonoscopy where no adenoma, sessile serrated polyp, traditional serrated adenoma, hyperplastic polyp >10 mm, or CRC is found
define low risk adenoma
1–2 nonadvanced adenomas <10 mm in size
define advanced adenoma
1 or more of the following findings:
- Adenoma >= 10 mm in size
- Adenoma with tubulovillous/villous histology
- Adenoma with high-grade dysplasia
define advanced neoplasia
1 or more of the following findings:
- Adenoma >= 10 mm in size
- Adenoma with tubulovillous/villous histology
- Adenoma with high-grade dysplasia
- CRC
define high risk adenoma
1 or more of the following findings:
- Advanced neoplasia
- 3 or more adenomas
define adequate adenoma detection rate (ADR)
ADR >= 30% in men and >= 20% in women
define adequate bowel preparation
bowel preparation adequate to visualize polyps >5mm in size
define complete examination
Complete colonoscopy to cecum, with photo documentation of cecal landmarks, such as the appendiceal orifice, terminal ileum, or ileocecal valve
define high quality examination
Examination complete to cecum with adequate bowel preparation performed by colonoscopist with adequate
adenoma detection rate and attention to complete polyp excision
which patient population does this guideline not apply to?
This article does not include recommendations for follow-up for individuals with hereditary CRC syndromes (eg, Lynch syndrome and familial adenomatous polyposis), IBD, a personal history of CRC (including malignant polyps), family history of CRC or colorectal neoplasia, or serrated polyposis syndrome.
why are sessile serrated polyps and hyperplastic polyps >10 mm not included in the definition of low risk adenoma?
Evidence for these two types of lesions is still evolving
what are some colonoscopy quality metrics?
proportion of colonoscopies with adequate preparation: >85%
proportion of exams complete to cecum >95%
good documentation for polyp size:
for polyps >=10mm, include an endoscopic photo of the polyp with an open snare or open biopsy forceps next to it for comparison
a normal colonoscopy is associated w/ what hazard ratio for reduced risk of CRC?
HR 0.44
What are thoughts of repeat colonoscopies for CRC detection after a normal initial colo?
insufficient evidence, but current recommendation is still the same: if you’ve had a normal colo, repeat in 10 yrs
what is the risk of incident and fatal CRC after baseline adenoma removal?
uncertain (low qual ev)
what is the impact of surveillance colo after baseline removal of adenoma w/ high risk features (e.g. size >= 10 mm)?
may reduce risk for incident CRC, but impact on fatal CRC is uncertain (low qual ev)
what is the impact of surveillance colo after baseline removal of adenoma w/ low risk features (e.g. 1-2 adenomas <10mm size)?
the effect of surveillance colo after baseline removal of adenoma with low risk features on the detection of incident and fatal CRC is uncertain (low qual ev)
Recommended interval for surveillance colo for: normal colo
10 yrs (strong rec; high qual ev)
pts w/ normal colo have lower than average risk of CRC
Recommended interval for surveillance colo for: pts w/ 1-2 TA’s <10mm size, completely resected
7-10 yrs (strong rec; mod qual ev)
previous rec was 5-10 yrs
if pt w/ this profile had the 5-10 yr rec given prior to this guideline, can keep that recommendation or adjust prn
Recommended interval for surveillance colo for: patients w/ 3-4 TA’s <10mm, completely removed
repeat colo in 3-5 yrs (weak rec; very low qual ev)
Recommended interval for surveillance colo for:
pts w/ 5-10 TA’s <10mm, completely removed
repeat colo at 3 yrs (strong rec; mod qual ev)
Recommended interval for surveillance colo for:
pts w/ 1 or more adenomas >=10mm, completely removed
repeat colo in 3 yrs (strong rec; high qual ev)
Recommended interval for surveillance colo for:
pts w/ adenomas containing villous histology completely removed
repeat colo in 3 yrs (strong rec; mod qual ev)
Recommended interval for surveillance colo for:
pts w/ adenoma containing high-grade dysplasia completely removed
repeat colo in 3 yrs (strong rec; mod qual ev)
Recommended interval for surveillance colo for:
pts w/ >10 adenomas completely resected
repeat colo in 1 yr (weak rec; very low qual ev)
since the last update (2012), there was only one cohort study of 214 Korean pts w />10 adenomas where 26^ had metachronous advanced adenoma.
these pts may be at increased risk of hereditary polyposis syndrome, and multiple groups have suggested that pts w/ >10 cumulative lifetime adenomas get genetic testing.
Recommended interval for surveillance colo for:
pts w/ <=20 hyperplastic polyps <10mm in size in the rectum or sigmoid, removed
repeat colo in 10 yrs (strong rec; mod qual ev)
Recommended interval for surveillance colo for:
pts w/ <=20 hyperplastic polyps <10mm in size, located proximal to sigmoid colo, removed
repeat colo 10 yrs (weak rec; very low qual ev)
Recommended interval for surveillance colo for:
pts w/ 1-2 sessile serrated polyps <10mm, completely resected
repeat colo in 5-10 yrs (weak rec; very low qual ev)
despite the lack of good evidence, since there’s uncertainty as to impact of large serrated polyp at repeat colo, and the difficulty of complete resection of SSP’s, task force recommends 5-10 yr follow-up colo
Recommended interval for surveillance colo for:
pts w/ traditional serrated polyp completely removed
repeat colo in 3 yrs (weak rec; very low qual ev)
there isn’t much new evidence since the 2012 guideline
Recommended interval for surveillance colo for:
for pts w/ 3-4 SSP’s <10mm
repeat colo in 3-5 yrs (weak rec; very low qual ev)
Recommended interval for surveillance colo for:
for pts w/ any combo of 5-10 SSPs <10mm
repeat colo in 3 yrs (weak rec; very low qual ev)
Recommended interval for surveillance colo for:
pts w/ SSP >=10mm
repeat colo in 3 yrs (weak rec; very low qual ev)
Recommended interval for surveillance colo for:
pts w/ hyperplastic polyp >=10mm
repeat colo in 3-5 yrs (weak rec; very low qual ev)
favor 3 yr f/u if there’s concern about pathologist’s consistency in distinguishing SSPs from HPs, quality of bowel prep, or complete polyp excision
Recommended interval for surveillance colo for:
pts w/ sessile serrated polyp containing dysplasia
repeat colo in 3 yrs (weak rec; very low qual ev)
Recommended interval for surveillance colo for:
pts w/ piece resection of adenoma or sessile serrated polyp >20mm
repeat colo in 6 mo (strong rec; mod qual ev)
piecemeal resection of polyp (vs en bloc resection) increases risk of metachronous neoplasia
it’s suggested that this is because incomplete resection is more common in piecemal resection.
Endoscopists should consider strategies for verifing complete polyp excision at baseline.
what is the recommended surveillance scope schedule for piecemeal resection of polyps >=20mm?
1st surveillance: 6 mo
2nd surveillance: 1 yr from 1st surveillance.
3rd surveillance: 3 yrs from 2nd surveillance
what are some risk factors for metachronous neoplasia?
MAYBE the following, but the evidence is scant:
- smoking
- metabolic syndrome
- obesity
- sedentary lifestyle
- maybe metformin use
- ASA, NSAIDs may reduce risk of adenoma recurrence
though there is evidence that black pts have higher age-adjusted incidence and mortality from CRC, and develop CRC at younger age than other ethnic/racial groups, once screened, there is no robust evidence that black race modifies the risk for recurrent adenoma or advanced neoplasia
what is hte USPSTF’s stance on low dose aspirin for CRC primary prevention?
for pts age 50-59y w/ >=10% risk of CVD and life expectancy >=10 yrs w/o increased risk of bleeding, ASA 81mg once daily is recommended for primary prevention of both CVD and CRC (grade B rec)
may also consider for pts 60-69y/o based on shared decision making (Grade C rec)
summary of key updates since the 2012 recommendations
- New evidence based on risk of colorectal cancer outcomes, rather than based only on risk of advanced adenoma during surveillance, is provided to strengthen polyp surveillance recommendations
- 7- to 10-y rather than 5- to 10-y follow-up is recommended after removal of 1–2 tubular adenomas <10 mm in size (Table 4)
- More detailed recommendations for follow-up after removal of serrated polyps have been provided (Table 5)
- Importance of high-quality baseline examination has been emphasized
- 1 y rather than <3-y follow-up is recommended after removal of >10 adenomas
- Option to recommend 3–5 y instead of 3-y follow-up after removal of 3–4 adenomas <10 mm in size
