[Skip to Content]
[Skip to Content Landing]

Screening for Colorectal Cancer and Evolving Issues for Physicians and PatientsA Review

Educational Objective To understand the various recommendations for colorectal cancer (CRC) screening, the modalities available, and how to best communicate CRC screening options to patients.
1 Credit CME

Importance  Colorectal cancer (CRC) is the second-leading cause of cancer death in the United States. Screening can reduce CRC mortality and incidence, and numerous screening options, although available, complicate informed decision making. This review provides evidence-based tools for primary care physicians to identify patients with higher-than-average-risk and engage patients in informed decision making about CRC screening options.

Observations  Recently, the US Preventive Services Task Force recommended any of 8 CRC screening approaches for average-risk individuals, beginning at age 50 years. Only 2 methods have been shown in randomized clinical trials to reduce mortality: fecal occult blood testing and flexible sigmoidoscopy. Of the 8 programs, screenings using the fecal immunochemical test annually and colonoscopy every 10 years are now the most commonly used tests in the United States and among the most effective in reducing CRC mortality as determined by decision models. With the exception of primary screening using colonoscopy, all of the other screening approaches have multiple steps. Adherence to each phase of a multistep program is critical to achieving maximal effectiveness of the screening program. It is likely that each of the recommended programs can reduce CRC mortality, but other key outcomes may differ such as lifetime burden of colonoscopy, complications, patient acceptance, and cost. Decisions about the timing of screening cessation should be individualized.

Conclusions and Relevance  CRC screening is effective if patients adhere to the steps in each screening program. There is no evidence that one program is superior to another. Informed decision-making tools are provided to assist patients and clinicians with the goal of improving adherence to effective screening.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: David Lieberman MD, Division of Gastroenterology and Hepatology, Oregon Health and Science University-L 461, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (lieberma@ohsu.edu).

Author Contributions: Dr Lieberman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acquisition, analysis, or interpretation of data: Lieberman, Ladabaum, Inadomi, Giardiello, Cruz-Correa, Wender.

Drafting of the manuscript: all authors.

Critical revision of the manuscript for important intellectual content: all authors.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

American Cancer Society.  Cancer Facts & Figures 2016. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf. Accessed August 19, 2016.
Hardcastle  JD, Chamberlain  JO, Robinson  MHE,  et al.  Randomised controlled trial of faecal-occult-blood screening for colorectal cancer.  Lancet. 1996;348(9040):1472-1477.PubMedGoogle ScholarCrossref
Kronborg  O, Fenger  C, Olsen  J, Jørgensen  OD, Søndergaard  O.  Randomised study of screening for colorectal cancer with faecal-occult-blood test.  Lancet. 1996;348(9040):1467-1471.PubMedGoogle ScholarCrossref
Mandel  JS, Bond  JH, Church  TR,  et al.  Reducing mortality from colorectal cancer by screening for fecal occult blood: Minnesota Colon Cancer Control Study.  N Engl J Med. 1993;328(19):1365-1371.PubMedGoogle ScholarCrossref
Mandel  JS, Church  TR, Bond  JH,  et al.  The effect of fecal occult-blood screening on the incidence of colorectal cancer.  N Engl J Med. 2000;343(22):1603-1607.PubMedGoogle ScholarCrossref
Shaukat  A, Mongin  SJ, Geisser  MS,  et al.  Long-term mortality after screening for colorectal cancer.  N Engl J Med. 2013;369(12):1106-1114.PubMedGoogle ScholarCrossref
Segnan  N, Armaroli  P, Bonelli  L,  et al; SCORE Working Group.  Once-only sigmoidoscopy in colorectal cancer screening: follow-up findings of the Italian Randomized Controlled Trial—SCORE.  J Natl Cancer Inst. 2011;103(17):1310-1322.PubMedGoogle ScholarCrossref
Schoen  RE, Pinsky  PF, Weissfeld  JL,  et al; PLCO Project Team.  Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy.  N Engl J Med. 2012;366(25):2345-2357.PubMedGoogle ScholarCrossref
Atkin  WS, Edwards  R, Kralj-Hans  I,  et al; UK Flexible Sigmoidoscopy Trial Investigators.  Once only flexible sigmoidsocopy screening in prevention of colorectal cancer: a multicentre randomized controlled trial.  Lancet. 2010;375:1624-1633.PubMedGoogle ScholarCrossref
Holme  Ø, Løberg  M, Kalager  M,  et al.  Effect of flexible sigmoidoscopy screening on colorectal cancer screening on colorectal cancer incidence and mortality: a randomized clinical trial.  JAMA. 2014;312:606-615.PubMedGoogle ScholarCrossref
Zauber  AG, Winawer  SJ, O’Brien  MJ,  et al.  Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.  N Engl J Med. 2012;366(8):687-696.PubMedGoogle ScholarCrossref
Klabunde  C, Brown  M, Ballard-Barbash  R,  et al; Centers for Disease Control and Prevention (CDC).  Cancer screening—United States, 2010.  MMWR Morb Mortal Wkly Rep. 2012;61(3):41-45.PubMedGoogle Scholar
Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force.  Screening for colorectal cancer: US Preventive Services Task Force Recommendation Statement.  JAMA. 2016;315(23):2564-2575.PubMedGoogle ScholarCrossref
Knudsen  AB, Zauber  AG, Rutter  CM,  et al.  Estimation of benefits, burden and harms for colorectal cancer screening strategies: modeling study for the US Preventive Services Task Force.  JAMA. 2016;315(23):2595-2609.PubMedGoogle ScholarCrossref
Levin  B, Lieberman  DA, McFarland  B,  et al; American Cancer Society Colorectal Cancer Advisory Group; US Multi-Society Task Force; American College of Radiology Colon Cancer Committee.  Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology.  Gastroenterology. 2008;134(5):1570-1595.PubMedGoogle ScholarCrossref
Qaseem  A, Denberg  TD, Hopkins  RH  Jr,  et al; Clinical Guidelines Committee of the American College of Physicians.  Screening for colorectal cancer: a guidance statement from the American College of Physicians.  Ann Intern Med. 2012;156(5):378-386.PubMedGoogle ScholarCrossref
Inadomi  JM, Vijan  S, Janz  NK,  et al.  Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies.  Arch Intern Med. 2012;172(7):575-582.PubMedGoogle ScholarCrossref
Brett  AS.  Flexible sigmoidoscopy for colorectal cancer screening: more evidence, persistent ironies.  JAMA. 2014;312(6):601-602.PubMedGoogle ScholarCrossref
Steinwachs  D, Allen  JD, Barlow  WE,  et al.  National Institutes of Health State-of-the-Science Conference Statement: Enhancing Use and Quality of Colorectal Cancer Screening.  Ann Intern Med. 2010;152(10):663-667.PubMedGoogle ScholarCrossref
Subramanian  S, Klosterman  M. Amonkar  MM, Hunt  TL.  Adherence with colorectal cancer screening guidelines: a review.  Prev Med. 2004;38:536-550.PubMedGoogle ScholarCrossref
US Preventive Services Task Force.  Screening for colorectal cancer: US Preventive Services Task Force recommendation statement.  Ann Intern Med. 2008;149(9):627-637.PubMedGoogle ScholarCrossref
Henley  SJ, Singh  SD, King  J, Wilson  R, O’Neil  ME, Ryerson  AB; Centers for Disease Control and Prevention.  Invasive cancer incidence and survival—United States, 2011.  MMWR Morb Mortal Wkly Rep. 2015;64(9):237-242.PubMedGoogle Scholar
Carethers  JM.  Screening for colorectal cancer in African Americans: determinants and rationale for an earlier age to commence screening.  Dig Dis Sci. 2015;60(3):711-721.PubMedGoogle ScholarCrossref
Zauber  AG.  The impact of screening on colorectal cancer mortality and incidence: has it really made a difference?  Dig Dis Sci. 2015;60(3):681-691.PubMedGoogle ScholarCrossref
Nishihara  R, Wu  K, Lochhead  P,  et al.  Long-term colorectal-cancer incidence and mortality after lower endoscopy.  N Engl J Med. 2013;369(12):1095-1105.PubMedGoogle ScholarCrossref
Løberg  M, Kalager  M, Holme  Ø, Hoff  G, Adami  HO, Bretthauer  M.  Long-term colorectal-cancer mortality after adenoma removal.  N Engl J Med. 2014;371(9):799-807.PubMedGoogle ScholarCrossref
Chan  AT, Giovannucci  EL.  Primary prevention of colorectal cancer.  Gastroenterology. 2010;138(6):2029-2043.e10.PubMedGoogle ScholarCrossref
Kahi  CJ, Boland  CR, Dominitz  JA,  et al; United States Multi-Society Task Force on Colorectal Cancer.  Colonoscopy surveillance after colorectal cancer resection: recommendations of the US Multi-Society Task Force on Colorectal Cancer.  Gastroenterology. 2016;150(3):758-768.e11.PubMedGoogle ScholarCrossref
Lieberman  DA, Rex  DK, Winawer  SJ, Giardiello  FM, Johnson  DA, Levin  TR; United States Multi-Society Task Force on Colorectal Cancer.  Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.  Gastroenterology. 2012;143(3):844-857.PubMedGoogle ScholarCrossref
Farraye  FA, Odze  RD, Eaden  J,  et al; AGA Institute Medical Position Panel on Diagnosis and Management of Colorectal Neoplasia in Inflammatory Bowel Disease.  AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease.  Gastroenterology. 2010;138(2):738-745.PubMedGoogle ScholarCrossref
Giardiello  FM, Allen  JI, Axilbund  JE,  et al; US Multi-Society Task Force on Colorectal Cancer.  Guidelines on genetic evaluation and management of Lynch syndrome: a consensus statement by the US Multi-Society Task Force on colorectal cancer.  Gastroenterology. 2014;147(2):502-526.PubMedGoogle ScholarCrossref
Lowery  JT, Ahnen  DJ, Schroy  PC  III,  et al Understanding the contribution of family history to colorectal cancer risk and its clinical implications: a state of the science review.  Cancer2016;122(17):2633-2645..PubMedGoogle ScholarCrossref
Lee  JK, Liles  EG, Bent  S, Levin  TR, Corley  DA.  Accuracy of fecal immunochemical tests for colorectal cancer: systematic review and meta-analysis.  Ann Intern Med. 2014;160(3):171-181.PubMedGoogle ScholarCrossref
van Rossum  LG, van Rijn  AF, Laheij  RJ,  et al.  Random comparison of guaiac and immunochemical fecal occult blood tests for colorectal cancer in a screening population.  Gastroenterology. 2008;135(1):82-90.PubMedGoogle ScholarCrossref
Segnan  N, Senore  C, Andreoni  B,  et al; SCORE3 Working Group-Italy.  Comparing attendance and detection rate of colonoscopy with sigmoidoscopy and FIT for colorectal cancer screening.  Gastroenterology. 2007;132(7):2304-2312.PubMedGoogle ScholarCrossref
Quintero  E, Castells  A, Bujanda  L,  et al; COLONPREV Study Investigators.  Colonoscopy versus fecal immunochemical testing in colorectal-cancer screening.  N Engl J Med. 2012;366(8):697-706.PubMedGoogle ScholarCrossref
Hubbard  RA, Johnson  E, Hsia  R, Rutter  CM.  The cumulative risk of false-positive fecal occult blood test after 10 years of colorectal cancer screening.  Cancer Epidemiol Biomarkers Prev. 2013;22(9):1612-1619.PubMedGoogle ScholarCrossref
Moss  SM, Campbell  C, Melia  J,  et al.  Performance measures in three rounds of the English bowel cancer screening pilot.  Gut. 2012;61(1):101-107.PubMedGoogle ScholarCrossref
Lo  SH, Halloran  S, Snowball  J, Seaman  H, Wardle  J, von Wagner  C.  Colorectal cancer screening uptake over three biennial invitation rounds in the English bowel cancer screening programme.  Gut. 2015;64(2):282-291.PubMedGoogle ScholarCrossref
Jensen  CD, Corley  DA, Quinn  VP,  et al.  Fecal immunochemical test program performance over 4 rounds of annual screening: a retrospective cohort study.  Ann Intern Med. 2016;164(7):456-463.PubMedGoogle ScholarCrossref
Imperiale  TF, Ransohoff  DF, Itzkowitz  SH,  et al.  Multitarget stool DNA testing for colorectal-cancer screening.  N Engl J Med. 2014;370(14):1287-1297.PubMedGoogle ScholarCrossref
Johnson  CD, Chen  M-H, Toledano  AY,  et al.  Accuracy of CT colonography for detection of large adenomas and cancers.  N Engl J Med. 2008;359(12):1207-1217.PubMedGoogle ScholarCrossref
Heresbach  D, Djabbari  M, Riou  F,  et al.  Accuracy of computed tomographic colonography in a nationwide multicentre trial, and its relation to radiologist expertise.  Gut. 2011;60(5):658-665.PubMedGoogle ScholarCrossref
Knudsen  AB, Lansdorp-Vogelaar  I, Rutter  CM,  et al.  Cost-effectiveness of computed tomographic colonography screening for colorectal cancer in the medicare population.  J Natl Cancer Inst. 2010;102(16):1238-1252.PubMedGoogle ScholarCrossref
Leggett  B, Whitehall  V.  Role of the serrated pathway in colorectal cancer pathogenesis.  Gastroenterology. 2010;138(6):2088-2100.PubMedGoogle ScholarCrossref
Zalis  ME, Barish  MA, Choi  JR,  et al; Working Group on Virtual Colonoscopy.  CT colonography reporting and data system: a consensus proposal.  Radiology. 2005;236(1):3-9.PubMedGoogle ScholarCrossref
Brenner  DJ, Hall  EJ.  Computed tomography—an increasing source of radiation exposure.  N Engl J Med. 2007;357(22):2277-2284.PubMedGoogle ScholarCrossref
Baxter  NN, Goldwasser  MA, Paszat  LF, Saskin  R, Urbach  DR, Rabeneck  L.  Association of colonoscopy and death from colorectal cancer.  Ann Intern Med. 2009;150(1):1-8.PubMedGoogle ScholarCrossref
Doubeni  CA, Weinmann  S, Adams  K,  et al.  Screening colonoscopy and risk for incident late-stage colorectal cancer diagnosis in average-risk adults: a nested case-control study.  Ann Intern Med. 2013;158(5 Pt 1):312-320.PubMedGoogle ScholarCrossref
Kahi  CJ, Myers  LJ, Slaven  JE,  et al.  Lower endoscopy reduces colorectal cancer incidence in older individuals.  Gastroenterology. 2014;146(3):718-725.e3.PubMedGoogle ScholarCrossref
Brenner  H, Chang-Claude  J, Jansen  L, Knebel  P, Stock  C, Hoffmeister  M.  Reduced risk of colorectal cancer up to 10 years after screening, surveillance, or diagnostic colonoscopy.  Gastroenterology. 2014;146(3):709-717.PubMedGoogle ScholarCrossref
Bretthauer  M, Kaminski  MF, Loberg  M,  et al.  Population-based colonoscopy screening for colorectal cancer: a randomized clinical trial.  JAMA Intern Med. 2016;176(7):894-902.PubMedGoogle ScholarCrossref
Ko  CW, Riffle  S, Michaels  L,  et al.  Serious complications within 30 days of screening and surveillance colonoscopy are uncommon.  Clin Gastroenterol Hepatol. 2010;8(2):166-173.PubMedGoogle ScholarCrossref
Warren  JL, Klabunde  CN, Mariotto  AB,  et al.  Adverse events after outpatient colonoscopy in the Medicare population.  Ann Intern Med. 2009;150(12):849-857, W152.PubMedGoogle ScholarCrossref
Ranasinghe  I, Parzynski  CS, Searfoss  R,  et al.  Difference in colonoscopy quality among facilities: development of a post-colonoscopy risk-standardized rate of unplanned hospital visits.  Gastroenterology. 2016;150(1):103-113.PubMedGoogle ScholarCrossref
Lieberman  D, Nadel  M, Smith  RA,  et al.  Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable.  Gastrointest Endosc. 2007;65(6):757-766.PubMedGoogle ScholarCrossref
Rex  DK, Schoenfeld  PS, Cohen  J,  et al.  Quality indicators for colonoscopy.  Am J Gastroenterol. 2015;110(1):72-90.PubMedGoogle ScholarCrossref
Lieberman  D, Williams  JL, Holub  J, Morris  C, Logan  J, Carney  P.  Race, ethnicity and gender differences in risk of colorectal neoplasia in average-risk men and women: Implications for initiation age of colorectal cancer screening.  Gastroenterology. 2014;147:351-358.PubMedGoogle ScholarCrossref
Regula  J, Rupinski  M, Kraszewska  E,  et al.  Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia.  N Engl J Med. 2006;355(18):1863-1872.PubMedGoogle ScholarCrossref
Ferlitsch  M, Reinhart  K, Pramhas  S,  et al.  Sex-specific prevalence of adenomas, advanced adenomas, and colorectal cancer in individuals undergoing screening colonoscopy.  JAMA. 2011;306(12):1352-1358.PubMedGoogle ScholarCrossref
Rex  DK, Johnson  DA, Anderson  JC, Schoenfeld  PS, Burke  CA, Inadomi  JM; American College of Gastroenterology.  American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected].  Am J Gastroenterol. 2009;104(3):739-750.PubMedGoogle ScholarCrossref
Lieberman  DA, Holub  JL, Morris  CD, Logan  J, Williams  JL, Carney  P.  Low rate of large polyps (>9 mm) within 10 years after an adequate baseline colonoscopy with no polyps.  Gastroenterology. 2014;147(2):343-350.PubMedGoogle ScholarCrossref
Acosta  RD, Abraham  NS, Chandrasekhara  V,  et al; ASGE Standards of Practice Committee.  The management of antithrombotic agents for patients undergoing GI endoscopy.  Gastrointest Endosc. 2016;83(1):3-16.PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
State Requirements