2016-06-22 16:10:25 UTC

USPSTF CRC Guidelines Are Incomplete

June 23, 2016

New report includes an unranked menu of screening options and is silent on the importance of patient adherence and test quality. Article written by AGA VP Dr. David Lieberman.

By David A. Lieberman, AGAF, AGA vice president

Last week, the U.S. Preventive Services Task Force (USPSTF) published updated recommendations for colorectal cancer (CRC) screening of average-risk, asymptomatic individuals (JAMA 2016; 315:2564-75; login required).

The new recommendations include a menu of screening options, with no stated preference for average-risk and asymptomatic individuals. Higher-risk individuals (based on family history of CRC) and those with lower GI symptoms should have colonoscopy as the preferred diagnostic test. The report includes a decision model that provides some insight into the potential benefits, harms and rates of each program. Unfortunately, USPSTF was silent on the importance of patient adherence and test quality. 

Here are some key things to know about the guidelines: 

  • USPSTF does not express a preference for any specific program, acknowledging that each has advantages and limitations. While the potential of each program to prevent CRC death is presented in the decision model, the potential to reduce incidence is not discussed. We believe that many patients and health-care providers would like to know if a screening program might prevent the development of and avert the care for CRC in some individuals. Many would consider a reduction in CRC incidence to be an important factor in informed decision making.
  • At this time in the U.S., two programs are used most commonly: a fecal occult blood test or colonoscopy. It is not known which program would result in greater reduction in CRC mortality and incidence. Three ongoing studies (one in the U.S. and two in Europe) will compare these programs, but results will not be available for many years. Some patients may prefer an invasive screening test, like colonoscopy, which may be more likely to prevent cancer, while others may prefer a non-invasive stool-based test that can be performed at home.  

Ultimately, effective screening depends on two important factors, which are not discussed in detail in the guideline: patient adherence and quality. AGA feels strongly that whatever program is used, quality monitoring and adherence should be an integral part of the program measurements.  

  • An effective fecal testing program may depend on three elements of adherence: 1) the test completed and returned; 2) if the test is positive, the patient receives colonoscopy; and 3) if the test is negative, is it repeated at the appropriate interval. Adherence failure of any of these steps may impact the effectiveness of a fecal testing program. These elements should be monitored as part of a quality assurance program for fecal-based testing.  
  • In a colonoscopy program, adherence is just as important. A recent study in Europe found that among subjects offered screening with colonoscopy at no cost and at a convenient location, only 40 percent completed the exam (NordICC study: Bretthauer et al; JAMA Int Med, published online May 23, 2016, login required). Quality is also important, and AGA has strongly advocated for measurement of quality metrics (bowel prep quality, cecal intubation and adenoma detection rate) as part of any colonoscopy screening program.   

Brief summary of recommendations

1. Age of screening:

a. Screening should begin at age 50 years for average-risk individuals and continue until age 75 years (Grade A recommendation).
b. From age 76 to 85, screening should be individualized based on past screening history and co-morbidity, which might limit benefit and increase risk. Although not clearly stated, the implication is that if patients have negative screening before age 75 years, that screening can be stopped. There may be benefit to screening after age 75 years if there has not been prior screening.
c. Screening should not continue after age 85 years, because risk may outweigh any potential benefit. 

2. The USPSTF supports any of seven screening programs, including:

a. Sensitive gFOBT — annual.
b. FIT — annual.
c. Multi-target stool DNA (DNA + FIT) — every one to three years.
d. Sigmoidoscopy — every five years.
e. Sigmoidoscopy — every 10 years + annual FIT.
f. CT colonography — every five years.
g. Colonoscopy — every 10 years.

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