ACP Issues CRC Screening “Guidance Statement”; Declines to Endorse Either FIT-Fecal DNA or CT Colonography

ACP Issues CRC Screening “Guidance Statement”; Declines to Endorse Either FIT-Fecal DNA or CT Colonography

Douglas K. Rex, MD, FASGE reviewing Qaseem A, et al. Ann Intern Med 2019 Nov 5.

The American College of Physicians (ACP) has issued a guidance statement on colorectal cancer screening in average-risk adults; the guidance statement is based on a review of other published guidelines and not on its own independent review of original data. The ACP rated the quality of the U.S. Preventive Services Task Force and Canadian Task Force on Preventive Health Care (CTFPHC) guidelines the highest (The CTFPHC declined to recommend screening colonoscopy.). 

Key recommendations include:

  • Screening average-risk adults between ages 50 to 75 is endorsed. 
  • Screening should be stopped in average-risk adults older than 75 years or if life expectancy is 10 years or less.
  • Suggested tests include:
  • The fecal immunochemical test (FIT) or high-sensitivity guaiac-based fecal occult blood test every 2 years.
  • Colonoscopy every 10 years.
  • Flexible sigmoidoscopy every 10 years plus FIT every 2 years.
  • Fecal DNA and CT colonography were evaluated and rejected as recommended screening options.

This guidance statement weighs evidence from randomized controlled trials very heavily and places limited evidence on practical considerations. Thus, the recommendations still include flexible sigmoidoscopy as a first-line option, even though flexible sigmoidoscopy use for screening has all but disappeared. 

The big news here is the ACP is declining to endorse beginning screening at age 45 and is endorsing fecal blood testing every 2 years rather than the annual programs usually used in the U.S. Also, the ACP is declining to endorse either FIT-fecal DNA or CT colonography. This is a good set of recommendations, with the exception of including flexible sigmoidoscopy as a viable first-line strategy. CT colonography, however, is currently not a significant screening player, so it seems reasonable not to endorse it. Discouraging FIT-fecal DNA by not endorsing it is also reasonable, considering that the test is not being driven by either relative effectiveness or cost-effectiveness but, rather, primarily by marketing and the longer interval of protection compared to fecal blood testing.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Douglas K. Rex, MD, FASGE


Qaseem A, Crandall CJ, Mustafa RA, et al. Screening for colorectal cancer in asymptomatic average-risk adults: a guidance statement from the American College of Physicians. Ann Intern Med 2019;171:643-654. (

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