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. 1994 Jun 15;150(12):1961–1970.

Periodic health examination, 1994 update: 2. Screening strategies for colorectal cancer. Canadian Task Force on the Periodic Health Examination.

M J Solomon 1, R S McLeod 1
PMCID: PMC1337008  PMID: 7980760

Abstract

OBJECTIVE: To make recommendations on the effectiveness of screening for colorectal cancer in asymptomatic patients over 40 years of age. OPTIONS: Multiphase screening that begins with test for fecal occult blood, uniphase screening with sigmoidoscopy and uniphase screening with colonoscopy. Options included screening repeated at different intervals and different procedures for patients with selected risk factors. OUTCOMES: Rates of death, death from cancer and cancer detection; compliance, feasibility and accuracy of each manoeuvre. EVIDENCE: A MEDLINE search for articles published between January 1966 and June 1993 with the use of MeSH terms "screening" and "colorectal neoplasia," a check with the reference sections of review articles published before June 1993 and a survey of content experts. Articles were weighted according to the Canadian Task Force on the Periodic Health Examination levels of evidence. VALUES: The highest value was assigned to manoeuvres that lowered the rate of death from cancer and had a low rate of false-positive results and acceptable cost and compliance. Recommendations were determined by consensus of the authors, members of the task force and colorectal cancer experts. BENEFITS, HARMS AND COSTS: There is evidence that annual fecal occult blood testing with the use of the rehydrated Hemoccult test has a small but significant benefit in lowering the rate of death from cancer after more than 10 years of screening; however, the high rate of false-positive results (9.8%) and the poor sensitivity of annual (49%) and biennial (38%) screening make this a poor method for detecting colorectal cancer. There is fair evidence that screening with sigmoidoscopy may improve survival rates; however, this may be due to volunteer bias. The high cost of and poor compliance with colonoscopic screening make this an unfeasible strategy.

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Selected References

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  1. Ahlquist D. A., McGill D. B., Schwartz S., Taylor W. F., Owen R. A. Fecal blood levels in health and disease. A study using HemoQuant. N Engl J Med. 1985 May 30;312(22):1422–1428. doi: 10.1056/NEJM198505303122204. [DOI] [PubMed] [Google Scholar]
  2. Ahlquist D. A., Wieand H. S., Moertel C. G., McGill D. B., Loprinzi C. L., O'Connell M. J., Mailliard J. A., Gerstner J. B., Pandya K., Ellefson R. D. Accuracy of fecal occult blood screening for colorectal neoplasia. A prospective study using Hemoccult and HemoQuant tests. JAMA. 1993 Mar 10;269(10):1262–1267. [PubMed] [Google Scholar]
  3. Atkin W. S., Morson B. C., Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N Engl J Med. 1992 Mar 5;326(10):658–662. doi: 10.1056/NEJM199203053261002. [DOI] [PubMed] [Google Scholar]
  4. Baker J. W., Gathright J. B., Jr, Timmcke A. E., Hicks T. C., Ferrari B. T., Ray J. E. Colonoscopic screening of asymptomatic patients with a family history of colon cancer. Dis Colon Rectum. 1990 Nov;33(11):926–930. doi: 10.1007/BF02139100. [DOI] [PubMed] [Google Scholar]
  5. Bolt R. J. Sigmoidoscopy in detection and diagnosis in the asymptomatic individual. Cancer. 1971 Jul;28(1):121–122. doi: 10.1002/1097-0142(197107)28:1<121::aid-cncr2820280122>3.0.co;2-s. [DOI] [PubMed] [Google Scholar]
  6. Bonelli L., Martines H., Conio M., Bruzzi P., Aste H. Family history of colorectal cancer as a risk factor for benign and malignant tumours of the large bowel. A case-control study. Int J Cancer. 1988 Apr 15;41(4):513–517. doi: 10.1002/ijc.2910410407. [DOI] [PubMed] [Google Scholar]
  7. Burt R. W., Bishop D. T., Lynch H. T., Rozen P., Winawer S. J. Risk and surveillance of individuals with heritable factors for colorectal cancer. WHO Collaborating Centre for the Prevention of Colorectal Cancer. Bull World Health Organ. 1990;68(5):655–665. [PMC free article] [PubMed] [Google Scholar]
  8. Cannon-Albright L. A., Skolnick M. H., Bishop D. T., Lee R. G., Burt R. W. Common inheritance of susceptibility to colonic adenomatous polyps and associated colorectal cancers. N Engl J Med. 1988 Sep 1;319(9):533–537. doi: 10.1056/NEJM198809013190902. [DOI] [PubMed] [Google Scholar]
  9. Castiglione G., Grazzini G., Ciatto S. Guaiac and immunochemical tests for faecal occult blood in colorectal cancer screening. Br J Cancer. 1992 Jun;65(6):942–944. doi: 10.1038/bjc.1992.197. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Eckardt V. F., Fuchs M., Kanzler G., Remmele W., Stienen U. Follow-up of patients with colonic polyps containing severe atypia and invasive carcinoma. Compliance, recurrence, and survival. Cancer. 1988 Jun 15;61(12):2552–2557. doi: 10.1002/1097-0142(19880615)61:12<2552::aid-cncr2820611227>3.0.co;2-6. [DOI] [PubMed] [Google Scholar]
  11. Ekbom A., Helmick C., Zack M., Adami H. O. Ulcerative colitis and colorectal cancer. A population-based study. N Engl J Med. 1990 Nov 1;323(18):1228–1233. doi: 10.1056/NEJM199011013231802. [DOI] [PubMed] [Google Scholar]
  12. Friedman G. D., Collen M. F., Fireman B. H. Multiphasic Health Checkup Evaluation: a 16-year follow-up. J Chronic Dis. 1986;39(6):453–463. doi: 10.1016/0021-9681(86)90112-8. [DOI] [PubMed] [Google Scholar]
  13. Frühmorgen P., Demling L. Complications of diagnostic and therapeutic colonoscopy in the Federal Republic of Germany. Results of an inquiry. Endoscopy. 1979 May;11(2):146–150. doi: 10.1055/s-0028-1098341. [DOI] [PubMed] [Google Scholar]
  14. Gilbertsen V. A., McHugh R., Schuman L., Williams S. E. The earlier detection of colorectal cancers: a preliminary report of the results of the Occult Blood Study. Cancer. 1980 Jun 1;45(11):2899–2901. doi: 10.1002/1097-0142(19800601)45:11<2899::aid-cncr2820451132>3.0.co;2-m. [DOI] [PubMed] [Google Scholar]
  15. Gilbertsen V. A., Nelms J. M. The prevention of invasive cancer of the rectum. Cancer. 1978 Mar;41(3):1137–1139. doi: 10.1002/1097-0142(197803)41:3<1137::aid-cncr2820410350>3.0.co;2-g. [DOI] [PubMed] [Google Scholar]
  16. Gilbertsen V. A. Proctosigmoidoscopy and polypectomy in reducing the incidence of rectal cancer. Cancer. 1974 Sep;34(3):suppl–suppl:939. doi: 10.1002/1097-0142(197409)34:3+<936::aid-cncr2820340722>3.0.co;2-5. [DOI] [PubMed] [Google Scholar]
  17. Grobe J. L., Kozarek R. A., Sanowski R. A. Flexible versus rigid sigmoidoscopy: a comparison using an inexpensive 35-cm flexible proctosigmoidoscope. Am J Gastroenterol. 1983 Sep;78(9):569–571. [PubMed] [Google Scholar]
  18. Grossman S., Milos M. L. Colonoscopic screening of persons with suspected risk factors for colon cancer. I. Family history. Gastroenterology. 1988 Feb;94(2):395–400. doi: 10.1016/0016-5085(88)90427-1. [DOI] [PubMed] [Google Scholar]
  19. Grossman S., Milos M. L., Tekawa I. S., Jewell N. P. Colonoscopic screening of persons with suspected risk factors for colon cancer: II. Past history of colorectal neoplasms. Gastroenterology. 1989 Feb;96(2 Pt 1):299–306. doi: 10.1016/0016-5085(89)91551-5. [DOI] [PubMed] [Google Scholar]
  20. HERTZ R. E., DEDDISH M. R., DAY E. Value of periodic examinations in detecting cancer of the rectum and colon. Postgrad Med. 1960 Mar;27:290–294. doi: 10.1080/00325481.1960.11712835. [DOI] [PubMed] [Google Scholar]
  21. Hardcastle J. D., Thomas W. M., Chamberlain J., Pye G., Sheffield J., James P. D., Balfour T. W., Amar S. S., Armitage N. C., Moss S. M. Randomised, controlled trial of faecal occult blood screening for colorectal cancer. Results for first 107,349 subjects. Lancet. 1989 May 27;1(8648):1160–1164. doi: 10.1016/s0140-6736(89)92750-5. [DOI] [PubMed] [Google Scholar]
  22. Jensen B. M., Kronborg O., Fenger C. Interval cancers in screening with fecal occult blood test for colorectal cancer. Scand J Gastroenterol. 1992 Sep;27(9):779–782. doi: 10.3109/00365529209011183. [DOI] [PubMed] [Google Scholar]
  23. Johnson D. A., Gurney M. S., Volpe R. J., Jones D. M., VanNess M. M., Chobanian S. J., Avalos J. C., Buck J. L., Kooyman G., Cattau E. L., Jr A prospective study of the prevalence of colonic neoplasms in asymptomatic patients with an age-related risk. Am J Gastroenterol. 1990 Aug;85(8):969–974. [PubMed] [Google Scholar]
  24. Kewenter J., Björk S., Haglind E., Smith L., Svanvik J., Ahrén C. Screening and rescreening for colorectal cancer. A controlled trial of fecal occult blood testing in 27,700 subjects. Cancer. 1988 Aug 1;62(3):645–651. doi: 10.1002/1097-0142(19880801)62:3<645::aid-cncr2820620333>3.0.co;2-#. [DOI] [PubMed] [Google Scholar]
  25. Kronborg O., Fenger C., Olsen J., Bech K., Søndergaard O. Repeated screening for colorectal cancer with fecal occult blood test. A prospective randomized study at Funen, Denmark. Scand J Gastroenterol. 1989 Jun;24(5):599–606. doi: 10.3109/00365528909093096. [DOI] [PubMed] [Google Scholar]
  26. Levin B., Murphy G. P. Revision in American Cancer Society recommendations for the early detection of colorectal cancer. CA Cancer J Clin. 1992 Sep-Oct;42(5):296–299. doi: 10.3322/canjclin.42.5.296. [DOI] [PubMed] [Google Scholar]
  27. Love R. R., Morrissey J. F. Colonoscopy in asymptomatic individuals with a family history of colorectal cancer. Arch Intern Med. 1984 Nov;144(11):2209–2211. [PubMed] [Google Scholar]
  28. Lovett E. Family studies in cancer of the colon and rectum. Br J Surg. 1976 Jan;63(1):13–18. doi: 10.1002/bjs.1800630103. [DOI] [PubMed] [Google Scholar]
  29. Lynch H. T., Rozen P., Schuelke G. S. Hereditary colon cancer: polyposis and nonpolyposis variants. CA Cancer J Clin. 1985 Mar-Apr;35(2):95–114. doi: 10.3322/canjclin.35.2.95. [DOI] [PubMed] [Google Scholar]
  30. Macrae F. A., St John D. J. Relationship between patterns of bleeding and Hemoccult sensitivity in patients with colorectal cancers or adenomas. Gastroenterology. 1982 May;82(5 Pt 1):891–898. [PubMed] [Google Scholar]
  31. Mandel J. S., Bond J. H., Bradley M., Snover D. C., Church T. R., Williams S., Watt G., Schuman L. M., Ederer F., Gilbertsen V. Sensitivity, specificity, and positive predictivity of the Hemoccult test in screening for colorectal cancers. The University of Minnesota's Colon Cancer Control Study. Gastroenterology. 1989 Sep;97(3):597–600. doi: 10.1016/0016-5085(89)90629-x. [DOI] [PubMed] [Google Scholar]
  32. Mandel J. S., Bond J. H., Church T. R., Snover D. C., Bradley G. M., Schuman L. M., Ederer F. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med. 1993 May 13;328(19):1365–1371. doi: 10.1056/NEJM199305133281901. [DOI] [PubMed] [Google Scholar]
  33. Ponz de Leon M., Antonioli A., Ascari A., Zanghieri G., Sacchetti C. Incidence and familial occurrence of colorectal cancer and polyps in a health-care district of northern Italy. Cancer. 1987 Dec 1;60(11):2848–2859. doi: 10.1002/1097-0142(19871201)60:11<2848::aid-cncr2820601141>3.0.co;2-f. [DOI] [PubMed] [Google Scholar]
  34. Pye G., Marks C. G., Martin S., Marks V., Jackson J., Hardcastle J. D. An evaluation of Fecatwin/Feca EIA; a faecal occult blood test for detecting colonic neoplasia. Eur J Surg Oncol. 1989 Oct;15(5):446–448. [PubMed] [Google Scholar]
  35. Ransohoff D. F., Lang C. A. Screening for colorectal cancer. N Engl J Med. 1991 Jul 4;325(1):37–41. doi: 10.1056/NEJM199107043250107. [DOI] [PubMed] [Google Scholar]
  36. Rex D. K., Lehman G. A., Hawes R. H., Ulbright T. M., Smith J. J. Screening colonoscopy in asymptomatic average-risk persons with negative fecal occult blood tests. Gastroenterology. 1991 Jan;100(1):64–67. doi: 10.1016/0016-5085(91)90583-7. [DOI] [PubMed] [Google Scholar]
  37. Rogers B. H., Silvis S. E., Nebel O. T., Sugawa C., Mandelstam P. Complications of flexible fiberoptic colonoscopy and polypectomy. Gastrointest Endosc. 1975 Nov;22(2):73–77. doi: 10.1016/s0016-5107(75)73705-7. [DOI] [PubMed] [Google Scholar]
  38. Rozen P., Fireman Z., Figer A., Legum C., Ron E., Lynch H. T. Family history of colorectal cancer as a marker of potential malignancy within a screening program. Cancer. 1987 Jul 15;60(2):248–254. doi: 10.1002/1097-0142(19870715)60:2<248::aid-cncr2820600223>3.0.co;2-g. [DOI] [PubMed] [Google Scholar]
  39. Sackett D. L. Bias in analytic research. J Chronic Dis. 1979;32(1-2):51–63. doi: 10.1016/0021-9681(79)90012-2. [DOI] [PubMed] [Google Scholar]
  40. Schull W. J., Cobb S. The intrafamilial transmission of rheumatoid arthritis. 3. The lack of support for a genetic hypothesis. J Chronic Dis. 1969 Sep;22(4):217–222. doi: 10.1016/0021-9681(69)90015-0. [DOI] [PubMed] [Google Scholar]
  41. Selby J. V., Friedman G. D., Quesenberry C. P., Jr, Weiss N. S. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med. 1992 Mar 5;326(10):653–657. doi: 10.1056/NEJM199203053261001. [DOI] [PubMed] [Google Scholar]
  42. Selby J. V., Friedman G. D. US Preventive Services Task Force. Sigmoidoscopy in the periodic health examination of asymptomatic adults. JAMA. 1989 Jan 27;261(4):594–601. [PubMed] [Google Scholar]
  43. Shahmir M., Schuman B. M. Complications of fiberoptic endoscopy. Gastrointest Endosc. 1980 Aug;26(3):86–91. doi: 10.1016/s0016-5107(80)73282-0. [DOI] [PubMed] [Google Scholar]
  44. Silverberg E., Boring C. C., Squires T. S. Cancer statistics, 1990. CA Cancer J Clin. 1990 Jan-Feb;40(1):9–26. [PubMed] [Google Scholar]
  45. Simon J. B. Occult blood screening for colorectal carcinoma: a critical review. Gastroenterology. 1985 Mar;88(3):820–837. doi: 10.1016/0016-5085(85)90158-1. [DOI] [PubMed] [Google Scholar]
  46. Smith L. E. Fiberoptic colonoscopy: complications of colonoscopy and polypectomy. Dis Colon Rectum. 1976 Jul-Aug;19(5):407–412. doi: 10.1007/BF02590825. [DOI] [PubMed] [Google Scholar]
  47. Songster C. L., Barrows G. H., Jarrett D. D. Immunochemical detection of fecal occult blood--the fecal smear punch-disc test: a new non-invasive screening test for colorectal cancer. Cancer. 1980 Mar 15;45(5 Suppl):1099–1102. doi: 10.1002/1097-0142(19800315)45:5+<1099::aid-cncr2820451312>3.0.co;2-t. [DOI] [PubMed] [Google Scholar]
  48. Spencer R. J., Melton L. J., 3rd, Ready R. L., Ilstrup D. M. Treatment of small colorectal polyps: a population-based study of the risk of subsequent carcinoma. Mayo Clin Proc. 1984 May;59(5):305–310. doi: 10.1016/s0025-6196(12)61425-6. [DOI] [PubMed] [Google Scholar]
  49. St John D. J., Young G. P., Alexeyeff M. A., Deacon M. C., Cuthbertson A. M., Macrae F. A., Penfold J. C. Evaluation of new occult blood tests for detection of colorectal neoplasia. Gastroenterology. 1993 Jun;104(6):1661–1668. doi: 10.1016/0016-5085(93)90643-q. [DOI] [PubMed] [Google Scholar]
  50. Vasen H. F., Griffioen G., Offerhaus G. J., Den Hartog Jager F. C., Van Leeuwen-Cornelisse I. S., Meera Khan P., Lamers C. B., Van Slooten E. A. The value of screening and central registration of families with familial adenomatous polyposis. A study of 82 families in The Netherlands. Dis Colon Rectum. 1990 Mar;33(3):227–230. doi: 10.1007/BF02134185. [DOI] [PubMed] [Google Scholar]
  51. Winawer S. J., Andrews M., Flehinger B., Sherlock P., Schottenfeld D., Miller D. G. Progress report on controlled trial of fecal occult blood testing for the detection of colorectal neoplasia. Cancer. 1980 Jun 15;45(12):2959–2964. doi: 10.1002/1097-0142(19800615)45:12<2959::aid-cncr2820451212>3.0.co;2-e. [DOI] [PubMed] [Google Scholar]
  52. Winawer S. J., Fleisher M., Baldwin M., Sherlock P. Current status of fecal occult blood testing in screening for colorectal cancer. CA Cancer J Clin. 1982 Mar-Apr;32(2):100–112. doi: 10.3322/canjclin.32.2.100. [DOI] [PubMed] [Google Scholar]
  53. Winawer S. J., Miller C., Lightdale C., Herbert E., Ephram R. C., Gordon L., Miller D. Patient response to sigmoidoscopy. A randomized, controlled trial of rigid and flexible sigmoidoscopy. Cancer. 1987 Oct 15;60(8):1905–1908. doi: 10.1002/1097-0142(19871015)60:8<1905::aid-cncr2820600839>3.0.co;2-k. [DOI] [PubMed] [Google Scholar]
  54. Winawer S. J., Schottenfeld D., Flehinger B. J. Colorectal cancer screening. J Natl Cancer Inst. 1991 Feb 20;83(4):243–253. doi: 10.1093/jnci/83.4.243. [DOI] [PubMed] [Google Scholar]
  55. Winawer S. J., Zauber A. G., O'Brien M. J., Ho M. N., Gottlieb L., Sternberg S. S., Waye J. D., Bond J., Schapiro M., Stewart E. T. Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup. N Engl J Med. 1993 Apr 1;328(13):901–906. doi: 10.1056/NEJM199304013281301. [DOI] [PubMed] [Google Scholar]

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