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Screening for colorectal cancer: Strategies in patients at average risk

Chyke Doubeni, MD, FRCS, MPH
Section Editors
J Thomas Lamont, MD
Joann G Elmore, MD, MPH
Deputy Editor
Judith A Melin, MA, MD, FACP


Colorectal cancer (CRC) is a common and lethal cancer. Screening provides benefit because removal of premalignant adenomas can prevent CRC and removal of localized cancer may prevent CRC-related death. CRC is infrequent before age 40; the incidence rises progressively thereafter to 3.7/1000 per year by age 80 (figure 1). The lifetime incidence for patients at average risk in the United States is 4.4 percent [1,2], with 90 percent of cases occurring after age 50.

Worldwide, CRC is the second most commonly diagnosed cancer in women and third most common in men, accounting for over 694,000 deaths in 2012 [3]. In the United States, CRC is the second leading cause of cancer death and accounts for approximately 8.3 percent of cancer deaths overall [4]. Approximately one in three people who develop CRC die of this disease.

Both the incidence of and mortality rates from CRC have been declining in the United States [5-7], with death rates from CRC declining on average 2.7 percent each year between 2004 and 2013 [1]. One microsimulation model, MISCAN-Colon, suggests that screening may account for 53 percent of the observed reduction in CRC mortality [8]. A study of temporal trends in CRC incidence and screening rates in the United States reported that approximately 250,000 to 500,000 CRC cases may have been prevented from 1987 to 2010, along with a shift from late- to early-stage disease [7]. There are many contributing factors to this changing epidemiology, including prevention of some cancers from detection and removal of adenomatous polyps during screening. (See "Colorectal cancer: Epidemiology, risk factors, and protective factors".)

Screening rates for CRC, although rising in the United States over the past few years, are generally below national targets [9]. In 2013 in the United States, 61.2 percent of adults between ages 50 and 75 years were up-to-date with CRC screening [10,11]. Colonoscopy was the most commonly used screening test (nearly 61 percent). Screening rates rose between 2002 and 2010 from 52.3 to 65.4 percent [5] and appear stable subsequently. Screening rates are higher in adults who are insured, better educated, higher income earners, Asians and non-Hispanic whites, or have a usual source of medical care [12-14]. Approximately one-half of the cases of CRC diagnosed in the United States between 2004 and 2006 were late-stage, particularly in older adults and in black men and women [15].

This topic addresses the rationale and modalities recommended for CRC screening in patients who are at average risk for the disease. Screening recommendations for patients at increased risk, as well as surveillance for CRC in patients with colon polyps, are addressed separately (see "Screening for colorectal cancer in patients with a family history of colorectal cancer" and "Familial adenomatous polyposis: Screening and management of patients and families" and "Approach to the patient with colonic polyps" and "Lynch syndrome (hereditary nonpolyposis colorectal cancer): Screening and management", section on 'Cancer screening' and "Juvenile polyposis syndrome", section on 'Cancer screening'). Additionally, characteristics of specific tests used for screening for colorectal cancer are discussed separately. (See "Tests for screening for colorectal cancer: Stool tests, radiologic imaging and endoscopy".)


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