ACS Colorectal Cancer Screening Guideline for Average Risk Adults - - PowerPoint PPT Presentation

ACS Colorectal Cancer Screening Guideline for Average Risk Adults 2018

1

2

Publication

External Review (Experts and Stakeholder Organizations) ACS Board of Directors Mission Outcomes Committee Guideline Development Group (GDG) & GDG CRC Sub- group Staff

Systematic Evidence Review & Modeling Reports [existing (and supplemented) or Commissioned]

External Expert Advisors

ACS Guideline Development Process

How are Cancer Screening Guidelines Developed?

3

• The ACS recommends that adults aged 45 years and older

with an average risk of colorectal cancer undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) exam, depending on patient preference and test availability.

• As a part of the screening process, all positive results on non-

colonoscopy screening tests should be followed up with timely colonoscopy.

ACS 2018 Recommendations for CRC Screening

4

• Age to start screening

The recommendation is based on the preponderance of benefits of CRC screening over harms, the overall quality of the evidence on screening outcomes, and the high value individuals place on preventing and avoiding death from CRC. ü Start at age 45 y (Qualified) ü Aged 50 and older (Strong)

ACS 2018 Recommendations for CRC Screening

5

• The ACS recommends that average-risk adults in good health with a life

expectancy of greater than 10 years continue colorectal cancer screening through the age of 75 years. (qualified recommendation)

• The ACS recommends that clinicians individualize colorectal cancer

screening decisions for individuals aged 76 through 85 years, based on patient preferences, life expectancy, health status, and prior screening

• history. (qualified recommendation)
• The ACS recommends that clinicians discourage individuals over age 85

years from continuing colorectal cancer screening. (qualified recommendation)

ACS 2018 Recommendations for CRC Screening

6

Options for CRC screening

Stool-based tests:

• Fecal immunochemical test (FIT) every year
• High sensitivity guaiac-based fecal occult blood test (HS-gFOBT) every year
• Multi-target stool DNA test (mt-sDNA) every 3 years

Structural (visual) exams:

• Colonoscopy (CSY) every 10 years
• CT Colonography (CTC) every 5 years
• Flexible sigmoidoscopy (FS) every 5 years

As a part of the screening process, all positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy.

ACS 2018 Recommendations for CRC Screening

7

• Change in age to start screening to 45y from 50y
• A General Recommendation vs. Specific Test Recommendations
• Emphasis on choice

ü The recommendation for CRC screening includes offering patients the

• pportunity to select either a structural (visual) exam or a high-

sensitivity stool-based test, depending on patient preference and test availability. ü Barium enema no longer recommended

• Guidance on when to stop screening
• Reinforce importance of follow up colonoscopy as part of the screening

process

What h has c s changed? ( (2018 v 2018 vs 2008) s 2008)

8

GRADE (Grading of Recommendations, Assessment, Development and Evaluation) criteria

• Quality of evidence - high-quality studies of test performance

and effectiveness of screening

• Evidence on the burden of disease by age and race
• Modeling studies
• Balance between desirable and undesirable effects - benefits of

each of the included screening modalities are significantly greater than the harms.

• Values and preferences –Since there is no single test that is

consistently preferred by adults in the U.S., the GDG emphasized the importance of offering choice, rather than ranking tests based solely on quality of evidence for individual tests.

What informed the GDG decisions?

Source: Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974-2013. JNCI 2017;109;djw322.

Trends in CRC incidence by age and year of birth

10

Rationale – Disease Burden of CRC

5 10 15 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008 2011 2014 Colorectal cancer cases per 100,000 persons <50years Year or diagnosis

Figure 1. Trends in Colorectal Cancer Incidence Rates in Adults Younger than Aged 50 years by Race, 1975-2014

White Black

Source: Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J

• Clin. 2018; 68: 000-000 [epub ahead of print]. URL to be: https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21457

11

Rationale – Disease Burden of CRC

2 4 6 8 10 12 14

1975-76 1977-78 1979-80 1981-82 1983-84 1985-86 1987-88 1989-90 1991-92 1993-94 1995-96 1997-98 1999-00 2001-02 2003-04 2005-06 2007-08 2009-10 2011-12 2013-14 Colorectal cancer cases per 100,000 persons aged 20-49 years

Year of diagnosis

Aged 20-49 years

Trends in Colorectal Cancer Incidence Rates by Age and Sex, 1975-2014

50 100 150 200 250 300

1 9 7 5

• 7

6 1 9 7 8

• 7

9 1 9 8 1

• 8

2 1 9 8 4

• 8

5 1 9 8 7

• 8

8 1 9 9

• 9

1 1 9 9 3

• 9

4 1 9 9 6

• 9

7 1 9 9 9

• 2

2

• 3

2 5

• 6

2 8

• 9

2 1 1

• 1

2 Colorectal cancer cases per 100,000 persons aged 50+ years

Year of diagnosis

Aged 50+ years

Men Women

Source: Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018; 68: 000-000 [epub ahead of print]. URL to be: https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21457

Pe Percentage of Years of Po Potential Life Lost Due to Death from Co Colorectal Ca Cancer by y Age at Diagnosis (incidence-ba based ed mo mortality 2010-14 14 wit ith follo llow-up up 20 yea ears after er di diagno nosis)

0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 0.2 30-34 years 35-39 years 40-44 years 45-49 years 50-54 years 55-59 years 60-64 years 65-69 years 70-74 years 75-79 years 80-84 years 85+ years

Both sexes

> 10 % of all LYL is due to a diagnosis of CRC between ages 45-49

13

Model-estimated Benefit CRC Screening by Starting Age

50 100 150 200 250 300 350 400 450 500

CSY CTC FS FIT HSgFOBT mt-sDNA

Model-estimated LYG

Screening test

Model-estimated Life Years Gained from CRC Screening Starting at Aged 45y vs 50y, per 1000 Screened Over a Lifetime

LYG 45y-75y LYG 50y-75 y

Source: Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018; 68: 000-000 [epub ahead of print]. URL to be: https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21457

Starting Age of 45: Conclusions

• Modeling convincingly demonstrates that, due to the rising incidence
• f CRC in younger individuals, screening all average-risk persons

between the ages of 45 and 75 reduces mortality from CRC with an acceptable risk (as measured by number of colonoscopies per LYG).

• The previously expected benefit of starting screening at age 45 versus

50 can no longer be considered “modest.”

• The trend of increasing CRC incidence in successively younger birth

cohorts suggests that the recommended starting age of 45 will likely continue to be relevant.

• The benefit-burden balance strongly favors changing the starting age

from 50 to 45.

15

CRC Screening Guidelines for Average Risk Adults: ACS (2018); USPSTF (2016)

Recommendations ACS, 2018 USPSTF, 2016 Age to start screening S-strong Q-qualified Age 45y Starting at 45y (Q) Screening at aged 50y and older - (S) Aged 50y (A) Choice of test High-sensitivity stool-based test or a structural exam. Different methods can accurately detect early stage CRC and adenomatous polyps. Acceptable Test

• ptions
• FIT annually,
• HSgFOBT annually
• mt-sDNA every 3y
• Colonoscopy every 10y
• CTC every 5y
• FS every 5y

All positive non-colonoscopy tests should be followed up with colonoscopy.

• HSgFOBT annually
• FIT annully
• sDNA every 1 or 3 y
• Colonoscopy every 10y
• CTC every 5y
• FS every 5y
• FS every 10y plus FIT every year

Age to stop screening Continue to 75y as long as health is good and life expectancy 10+y (Q) 76-85y individual decision making (Q) >85y discouraged from screening (Q) 76-85 y individual decision making (C)

Guideline Resources

• Visit cancer.org/colonmd to find more information, including:

ü Materials for health professionals ü Materials for patients/consumers ü Tools to facilitate conversations between clinicians and patients about selecting a screening test option that is consistent with patient preferences ü Links to the 2018 guidelines article and modeling papers

Key References

• Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk

adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018; 68: 000-000 [epub ahead of print].

• Peterse EFP, Meester RGS, Siegel , et al. The Impact of the Rising Colorectal Cancer

Incidence in Young Adults on the Optimal Age to Start Screening: Microsimulation Analysis to Inform the American Cancer Society Colorectal Cancer Screening Guideline.

• Cancer. 10.1002/cncr.31543 [epub ahead of print].
• Meester RGS, Peterse EFP, Knudsen AB, et al. Optimizing colorectal cancer screening by

race and sex: microsimulation analysis II to inform the American Cancer Society Colorectal Cancer Screening Guideline. Cancer. 10.1002/cncr.31542 [epub ahead of print].

• Volk RJ, Leal VB, Jacobs LE, et al. From Guideline to Practice: New Shared Decision-

Making Tools for Colorectal Cancer Screening From the American Cancer Society. CA Cancer J Clin. 2018; 68: 000-000 [epub ahead of print].

• Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal Cancer Incidence Patterns in the

United States, 1974-2013. Journal of the National Cancer Institute 2017;109.

• Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for Colorectal Cancer: US

Preventive Services Task Force Recommendation Statement. Jama 2016;315:2564-75.

17

Thank You!