Screening for Colorectal Cancer: A Targeted, Updated Systematic Review for the U.S. Preventive Services Task Force

4 November 2008 | Volume 149 Issue 9 | Pages 638-658

Background: In 2002, the U.S. Preventive Services Task Force (USPSTF) recommended colorectal cancer screening for adults 50 years of age or older but concluded that evidence was insufficient to prioritize among screening tests or evaluate newer tests, such as computed tomographic (CT) colonography.

Purpose: To review evidence related to knowledge gaps identified by the 2002 recommendation and to consider community performance of screening endoscopy, including harms.

Data Sources: MEDLINE, Cochrane Library, expert suggestions, and bibliographic reviews.

Study Selection: Eligible studies reported performance of colorectal cancer screening tests or health outcomes in average-risk populations and were at least of fair quality according to design-specific USPSTF criteria, as determined by 2 reviewers.

Data Extraction: Two reviewers verified extracted data.

Data Synthesis: Four fecal immunochemical tests have superior sensitivity (range, 61% to 91%), and some have similar specificity (97% to 98%), to the Hemoccult II fecal occult blood test (Beckman Coulter, Fullerton, California). Tradeoffs between superior sensitivity and reduced specificity occur with high-sensitivity guaiac tests and fecal DNA, with other important uncertainties for fecal DNA. In settings with sufficient quality control, CT colonography is as sensitive as colonoscopy for large adenomas and colorectal cancer. Uncertainties remain for smaller polyps and frequency of colonoscopy referral. We did not find good estimates of community endoscopy accuracy; serious harms occur in 2.8 per 1000 screening colonoscopies and are 10-fold less common with flexible sigmoidoscopy.

Limitation: The accuracy and harms of screening tests were reviewed after only a single application.

Conclusion: Fecal tests with better sensitivity and similar specificity are reasonable substitutes for traditional fecal occult blood testing, although modeling may be needed to determine all tradeoffs. Computed tomographic colonography seems as likely as colonoscopy to detect lesions 10 mm or greater but may be less sensitive for smaller adenomas. Potential radiation-related harms, the effect of extracolonic findings, and the accuracy of test performance of CT colonography in community settings remain uncertain. Emphasis on quality standards is important for implementing any operator-dependent colorectal cancer screening test.

Author and Article Information

From Kaiser Permanente Center for Health Research, Portland, Oregon.

Acknowledgment: The authors thank the following peer reviewers for the evidence report (alphabetical)James Allison, MD, Carrie Klabunde, PhD, Ted Levin, MD, Perry Pickhardt, MD, Margaret Piper, PhD, MPH, David Ransohoff, MD, Robert Smith, PhD, and Steve Woolf, MD, MPH; Oregon Evidence-based Practice Center staffKevin Lutz, MA, Taryn Cardenas, BA, Rebecca Newton-Thompson, MD, MPH, Elizabeth O'Connor, PhD, Mark Helfand, MD, MS, MPH, and Daphne Plaut, MLS; and Centers for Disease Control and Prevention staffLaura Seeff, MD.

Grant Support: This study was conducted by the Oregon Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (contract HHSA-290-2007-10057-I-EPC3, task order 3).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Reprints are available from the Agency for Healthcare Research and Quality Web site (http://www.ahrq.gov/clinic/uspstfix.htm).

Current Author Addresses: Drs. Whitlock, Lin, and Liles and Ms. Beil: Kaiser Permanente Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227.

Dr. Fu: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239.