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CA Cancer J Clin. 2018 Jul;68(4):250-281. doi: 10.3322/caac.21457. Epub 2018 May 30.

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society.

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Associate Professor and Attending Physician, University of Virginia School of Medicine, Charlottesville, VA.
Emeritus Professor, Louisiana State University School of Public Health, New Orleans, LA.
Professor, University of Minnesota and Masonic Cancer Center, Minneapolis, MN.
Professor and Attending Physician, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA.
Associate Professor of Medicine of the Perelman School of Medicine and Attending Physician, University of Pennsylvania Medical Center, Philadelphia, PA.
Independent retired physician and patient advocate, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA.
Biostatistician, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA.
Professor and Director, Division of Preventive Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA.
Professor and Director of the Duke Center for Onco-Primary Care, Durham, NC.
Professor, Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX.
Professor and Attending Physician, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA.
Director, Cancer Control Department, American Cancer Society, Atlanta, GA.
Chief Medical and Scientific Officer and Executive Vice President-Research, American Cancer Society, Atlanta, GA.
Vice President, Cancer Control Interventions, Cancer Control Department, American Cancer Society, Atlanta, GA.
Strategic Director for Risk Factor Screening and Surveillance, American Cancer Society, Atlanta, GA.
Strategic Director, Surveillance Information Services, American Cancer Society, Atlanta, GA.
Chief Cancer Control Officer, American Cancer Society, Atlanta, GA.
Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA.


In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281.


adenoma, colonoscopy; colorectal and rectal neoplasms; computed tomography colonoscopy; mass screening and early detection; mortality; occult blood; radiography; sigmoidoscopy; stool testing

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