2020 CRC Screening Guidelines

Question 1

define a pt who is average risk for CRC

Answer 1

Absence of inflammatory bowel disease, family history of CRC, hereditary syndrome associated with increased risk, serrated polyposis syndrome, personal history of CRC

Question 2

define normal colo

Answer 2

normal colo:

A colonoscopy where no adenoma, sessile serrated polyp, traditional serrated adenoma, hyperplastic polyp >10 mm, or CRC is found

Question 3

define low risk adenoma

Answer 3

1–2 nonadvanced adenomas <10 mm in size

Question 4

define advanced adenoma

Answer 4

1 or more of the following findings:

• Adenoma >= 10 mm in size
• Adenoma with tubulovillous/villous histology
• Adenoma with high-grade dysplasia

Question 5

define advanced neoplasia

Answer 5

1 or more of the following findings:

• Adenoma >= 10 mm in size
• Adenoma with tubulovillous/villous histology
• Adenoma with high-grade dysplasia
• CRC

Question 6

define high risk adenoma

Answer 6

1 or more of the following findings:

• Advanced neoplasia
• 3 or more adenomas

Question 7

define adequate adenoma detection rate (ADR)

Answer 7

ADR >= 30% in men and >= 20% in women

Question 8

define adequate bowel preparation

Answer 8

bowel preparation adequate to visualize polyps >5mm in size

Question 9

define complete examination

Answer 9

Complete colonoscopy to cecum, with photo documentation of cecal landmarks, such as the appendiceal orifice, terminal ileum, or ileocecal valve

Question 10

define high quality examination

Answer 10

Examination complete to cecum with adequate bowel preparation performed by colonoscopist with adequate
adenoma detection rate and attention to complete polyp excision

Question 11

which patient population does this guideline not apply to?

Answer 11

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.

Question 12

why are sessile serrated polyps and hyperplastic polyps >10 mm not included in the definition of low risk adenoma?

Answer 12

Evidence for these two types of lesions is still evolving

Question 13

what are some colonoscopy quality metrics?

Answer 13

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

Question 14

a normal colonoscopy is associated w/ what hazard ratio for reduced risk of CRC?

Answer 14

HR 0.44

Question 15

What are thoughts of repeat colonoscopies for CRC detection after a normal initial colo?

Answer 15

insufficient evidence, but current recommendation is still the same: if you’ve had a normal colo, repeat in 10 yrs

Question 16

what is the risk of incident and fatal CRC after baseline adenoma removal?

Answer 16

uncertain (low qual ev)

Question 17

what is the impact of surveillance colo after baseline removal of adenoma w/ high risk features (e.g. size >= 10 mm)?

Answer 17

may reduce risk for incident CRC, but impact on fatal CRC is uncertain (low qual ev)

Question 18

what is the impact of surveillance colo after baseline removal of adenoma w/ low risk features (e.g. 1-2 adenomas <10mm size)?

Answer 18

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)

Question 19

Recommended interval for surveillance colo for: normal colo

Answer 19

10 yrs (strong rec; high qual ev)

pts w/ normal colo have lower than average risk of CRC

Question 20

Recommended interval for surveillance colo for: pts w/ 1-2 TA’s <10mm size, completely resected

Answer 20

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

Question 21

Recommended interval for surveillance colo for: patients w/ 3-4 TA’s <10mm, completely removed

Answer 21

repeat colo in 3-5 yrs (weak rec; very low qual ev)

Question 22

Recommended interval for surveillance colo for:

pts w/ 5-10 TA’s <10mm, completely removed

Answer 22

repeat colo at 3 yrs (strong rec; mod qual ev)

Question 23

Recommended interval for surveillance colo for:

pts w/ 1 or more adenomas >=10mm, completely removed

Answer 23

repeat colo in 3 yrs (strong rec; high qual ev)

Question 24

Recommended interval for surveillance colo for:

pts w/ adenomas containing villous histology completely removed

Answer 24

repeat colo in 3 yrs (strong rec; mod qual ev)

Question 25

Recommended interval for surveillance colo for: pts w/ adenoma containing high-grade dysplasia completely removed

Answer 25

repeat colo in 3 yrs (strong rec; mod qual ev)

Question 26

Recommended interval for surveillance colo for: pts w/ >10 adenomas completely resected

Answer 26

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.

Question 27

Recommended interval for surveillance colo for: pts w/ <=20 hyperplastic polyps <10mm in size in the rectum or sigmoid, removed

Answer 27

repeat colo in 10 yrs (strong rec; mod qual ev)

Question 28

Recommended interval for surveillance colo for: pts w/ <=20 hyperplastic polyps <10mm in size, located proximal to sigmoid colo, removed

Answer 28

repeat colo 10 yrs (weak rec; very low qual ev)

Question 29

Recommended interval for surveillance colo for: pts w/ 1-2 sessile serrated polyps <10mm, completely resected

Answer 29

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

Question 30

Recommended interval for surveillance colo for: pts w/ traditional serrated polyp completely removed

Answer 30

repeat colo in 3 yrs (weak rec; very low qual ev) there isn't much new evidence since the 2012 guideline

Question 31

Recommended interval for surveillance colo for: for pts w/ 3-4 SSP's <10mm

Answer 31

repeat colo in 3-5 yrs (weak rec; very low qual ev)

Question 32

Recommended interval for surveillance colo for: for pts w/ any combo of 5-10 SSPs <10mm

Answer 32

repeat colo in 3 yrs (weak rec; very low qual ev)

Question 33

Recommended interval for surveillance colo for: pts w/ SSP >=10mm

Answer 33

repeat colo in 3 yrs (weak rec; very low qual ev)

Question 34

Recommended interval for surveillance colo for: pts w/ hyperplastic polyp >=10mm

Answer 34

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

Question 35

Recommended interval for surveillance colo for: pts w/ sessile serrated polyp containing dysplasia

Answer 35

repeat colo in 3 yrs (weak rec; very low qual ev)

Question 36

Recommended interval for surveillance colo for: pts w/ piece resection of adenoma or sessile serrated polyp >20mm

Answer 36

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.

Question 37

what is the recommended surveillance scope schedule for piecemeal resection of polyps >=20mm?

Answer 37

1st surveillance: 6 mo 2nd surveillance: 1 yr from 1st surveillance. 3rd surveillance: 3 yrs from 2nd surveillance

Question 38

what are some risk factors for metachronous neoplasia?

Answer 38

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

Question 39

what is hte USPSTF's stance on low dose aspirin for CRC primary prevention?

Answer 39

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)

Question 40

summary of key updates since the 2012 recommendations

Answer 40

- 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