ACS Announces its Revised Colorectal Screening Guidelines

WASHINGTON--Myles Cunningham, MD, president of the American Cancer Society(ACS), announced new ACS guidelines for screening and surveillance forearly detection of colorectal polyps and cancer. The announcement cameat a press briefing held during Digestive Disease Week.

For years, Dr. Cunningham said, the medical and scientific communitywas skeptical about the effectiveness of screening for colorectal cancer."That," he said, "is no longer true." Current testingprocedures, he said, are widely available, accurate, and underutilized.The latest ACS update is meant to be clear and simple so that both patientsand physicians can understand them.

The previous 1992 ACS recommendations called for everyone over age 50and not at high risk to be screened with annual fecal occult blood testing(FOBT) and sigmoidoscopy every three to five years. Those considered athigher risk were advised simply to seek the advice of their physicians.

The new guidelines divide the population into three categories--average,moderate, and high risk--with specific recommendations for each.

Average risk--Men and women at average risk should begin screeningby age 50 with an annual FOBT plus either sigmoidoscopy (every five years)or a total colon examination either by colon-oscopy (every 10 years) orby double-contrast barium enema (every five to 10 years). Digital rectalexamination should be performed at the time of the sigmoid-oscopy or thetotal colon exam.

The ACS decision to include periodic sigmoidoscopy is an important differencebetween the ACS and the AHCPR Task Force recommendations.

Moderate risk--Because colorectal adenomas are clearly precursorlesions for almost all colorectal cancers, and because adenomas are usuallypresent for several years before they develop into cancer, persons diagnosedas having adeno-matous polyps are considered to be at moderate risk.

The ACS guidelines recommend that such persons have a colonoscopy atthe time of diagnosis and total colon examination within three years ofpolyp removal. If the colon exam proves normal, the patient can then beconsidered as being average risk.

High risk--High-risk patients, those with a family history ofadenomatous polyposis or with nonpolyposis colon cancer, are advised tohave much more intensive supervision at an earlier age. The guidelinessuggest surveillance with endoscopy beginning at puberty and counselingto consider genetic testing.

Those with a personal history of inflammatory bowel disease are alsoconsidered to be at high risk, but a somewhat less intensive screeningschedule is recommended for these patients.

If genetic testing proves positive or if polyposis is confirmed, thepatient is advised to consider colectomy. If genetic testing is negative,the ACS recommends endoscopy at one- to two-year intervals.

Physician Cooperation Needed

Fewer than 30% of eligible adults have had colorectal cancer screening.Dr. Cunningham called upon physicians for their cooperation in applyingthe guidelines. "We have a unique opportunity to use medical screeningtools for a prevention strategy," he said.

Dr. Cunningham described the current situation with colorectal canceras "analogous to that of breast cancer a decade ago." A majorityof women aged 40 and older have had at least one mammo-gram, and a growingproportion of women now participate in periodic screening. "It istime," he said, " that we begin making similar progress in ourfight against colorectal cancer."

Senator Bob Graham (D-Fla), sponsor of new preventive health benefitslegislation, joined Dr. Cunningham at the briefing to discuss the effortsin Congress to improve Medicare coverage of cancer prevention measures,including colorectal and prostate cancer screening.

In an interview with Oncology News International, Dr. Cunningham saidthat different versions of this legislation are being considered in theHouse and Senate, and that some bill to improve preventive coverage hasa high probability of passage, perhaps by August.

"We hope the coverage will conform to the ACS guidelines, but thefinal form of the legislation is not yet known," he commented.