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Practice Rapid Recommendations

Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5515 (Published 02 October 2019) Cite this as: BMJ 2019;367:l5515
Visual summary of recommendation Last updated 19 Jan 2023
No screening FIT Every year FIT Every two years Sigmoidoscopy Single Colonoscopy Single Favours no screening Favours screening We suggest no screening Interventions compared Recommendations Screening options Population We suggest using a tool such as the QCancer® calculator to estimate the risk of colorectal cancer for each person in the next 15 years. This calculates risk, based on: Understanding a person’s risk of cancer can help to determine the benefits and harms of different screening tests for their individual situation. Faecal testing with a faecal immunochemical test (FIT) every year Faecal testing with a faecal immunochemical test (FIT) every two years Endoscopic examination of only the lower part of the colon Endoscopic examination of the entire colon Favours no screening Favours screening Colonoscopy offered if FIT or sigmoidoscopy positive People with an estimated 15 year risk of colorectal cancer below 3% We suggest screening with one of the four screening options People with an estimated 15 year risk of colorectal cancer above 3% Estimating risk Healthy adults with no history of screening Aged 50 to 79 Age Smoking status Medical and family history BMI Sex Ethnicity Link to QCancer® calculator qcancer.org/15yr/colorectal/ Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.
Visit the MAGICapp multiple comparison tool to compare and choose options Evidence summaries Screening options should be chosen in shared decision making, based on a person’s individual risk of cancer

For a person with a 2% risk of colorectal cancer within 15 years

Colorectal cancer mortality No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 6 3 3 3 2 Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low -1 0 -1 0 -1 -3 -3 -3 -4 0 Colorectal cancer incidence No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 20 17 14 19 13 Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer incidence Events per 1000 people -1 -3 -6 -5 -4 -3 -1 -6 -7 -2 One or more colonoscopies No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 300 159 203 1000 Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy One or more colonoscopies Events per 1000 people -841 -141 -797 -44 -700 -300 -203 -159 -1000 -97 Two or more colonoscopies No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 66 57 54 68 Events per 1000 people Evidence quality (GRADE score) Low Two or more colonoscopies Events per 1000 people -11 -9 -14 -3 -2 -66 -54 -57 -68 -12 GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low See all outcomes

For a person with a 3% risk of colorectal cancer within 15 years

No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 9 3 4 4 3 Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low -1 -1 -1 0 0 -6 -5 -5 -6 -1 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 30 26 22 29 20 Colorectal cancer incidence Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer incidence Events per 1000 people Evidence quality (GRADE score) Low -2 -4 -9 -7 -6 -4 -1 -8 -10 -3 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 347 237 246 1000 One or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy One or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy -763 -110 -754 -9 -653 -347 -246 -237 -1000 -101 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 101 86 83 105 Two or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low Two or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low -19 -15 -22 -3 -4 -101 -83 -86 -105 -18 GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low See all outcomes

For a person with a 4% risk of colorectal cancer within 15 years

No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 13 6 6 7 5 Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer mortality Events per 1000 people Evidence quality (GRADE score) Low -1 0 -2 -1 -1 -7 -6 -7 -8 -1 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 40 34 29 38 26 Colorectal cancer incidence Events per 1000 people Evidence quality (GRADE score) Low Colorectal cancer incidence Events per 1000 people Evidence quality (GRADE score) Low -3 -5 -12 -9 -8 -6 -2 -11 -14 -4 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 391 312 288 1000 One or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy One or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low * * High quality for colonoscopy -688 -79 -712 -24 -609 -391 -288 -312 -1000 -103 No screening FIT every year Sigmoidoscopy FIT every two years Colonoscopy 0 138 119 112 144 Two or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low Two or more colonoscopies Events per 1000 people Evidence quality (GRADE score) Low -25 -19 -32 -7 -6 -138 -112 -119 -144 -26 GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low See all outcomes
Key practical issues While most of the evidence relates to people aged 50-79, these recommendations may also apply to those aged below 50. However, as cancer risk is usually very low in this group, few people will have a 15 year colorectal cancer risk over 3% Other ages The panel found convincing evidence that people’s values and preferences on whether to test and what test to have varies considerably, and this is one factor driving a weak recommendation Values and preferences FIT Sigmoidoscopy Done at home every year or every two years for 15 years Done once in 15 years at an outpatient clinic/hospital Stool from one bowel movement is collected with a stick and mailed for analysis Preparation with bowel enema on the day of the procedure. Sometimes combined with oral laxatives Preparation with oral laxatives starting the day before procedure Individuals with a positive test are offered colonoscopy Usually performed with no sedation, so no recovery time necessary after procedure Often performed under conscious sedation. Also performed under general anesthesia or with no sedation Most individuals will experience no or only mild pain during and shortly after the procedure, but some will experience moderate to severe pain If sedation or anesthesia is used, recovery time will be needed after the procedure If performed without sedation, the majority of individuals will experience no or only mild pain during and shortly after the procedure, but some will experience moderate to severe pain Colonoscopy Preparation During theprocess Afterwards Timing

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This article has a correction. Please see:

  1. Lise M Helsingen, methods co-chair, medical doctor1 2 3,
  2. Per Olav Vandvik, general internist, methodologist4 5,
  3. Henriette C Jodal, medical doctor1 2 3,
  4. Thomas Agoritsas, general internist, methodologist6 7,
  5. Lyubov Lytvyn, patient partnership liaison7,
  6. Joseph C Anderson, gastroenterologist8 9 10,
  7. Reto Auer, general practicioner11 12,
  8. Silje Bjerkelund Murphy, registered nurse13,
  9. Majid Abdulrahman Almadi, gastroenterologist14 15,
  10. Douglas A Corley, gastroenterologist16 17,
  11. Casey Quinlan, patient partner18 19 20,
  12. Jonathan M Fuchs, patient partner21,
  13. Annette McKinnon, patient partner22,
  14. Amir Qaseem, medical doctor, methodologist23,
  15. Anja Fog Heen, general internist, methodologist24,
  16. Reed A C Siemieniuk, general internist, methodologist7,
  17. Mette Kalager, surgeon, researcher1 2 3,
  18. Juliet A Usher-Smith, general practitioner25,
  19. Iris Lansdorp-Vogelaar, modeller26,
  20. Michael Bretthauer, gastroenterologist1 2 3,
  21. Gordon Guyatt, chair, general internist, methodologist7
  1. 1Clinical Effectiveness Research Group, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
  2. 2Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
  3. 3Frontier Science Foundation, Boston, Massachusetts, USA
  4. 4Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
  5. 5Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
  6. 6Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
  7. 7Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
  8. 8Veterans Affairs Medical Center, White River Junction, Vermont, USA
  9. 9The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
  10. 10University of Connecticut Health Center, Farmington, USA
  11. 11Institute of Primary Health Care, University of Bern, Bern, Switzerland
  12. 12Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
  13. 13Diakonhjemmet Hospital, Oslo, Norway
  14. 14Division of Gastroenterology, Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
  15. 15Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
  16. 16Division of Research, Kaiser Permanente, Oakland, California, USA
  17. 17Department of Gastroenterology, San Francisco Medical Center, California, USA
  18. 18Cochrane Consumers
  19. 19Society for Participatory Medicine, Boston, Massachusetts, USA
  20. 20Mighty Casey Media, LLC, Richmond, Virginia, USA
  21. 21Population Health and Health Policy Consultant, California, USA
  22. 22Patient Advisors Network, Founding Member, Canada
  23. 23American College of Physicians, Philadelphia, USA
  24. 24Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
  25. 25The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  26. 26Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
  1. Correspondence: L M Helsingen lisemhe{at}medisin.uio.no

Abstract

Update to this article In October 2022, three years after the initial publication of this guideline, the first trial of the effect of colonoscopy screening was published. The implications of this new evidence for the current recommendations were evaluated by the guideline panel in January 2023. The guideline panel judged that this new evidence did not alter the current recommendations, and therefore that an update of the following guideline was not needed (see table 2 for details).

Clinical question Recent 15-year updates of sigmoidoscopy screening trials provide new evidence on the effectiveness of colorectal cancer screening. Prompted by the new evidence, we asked: “Does colorectal cancer screening make an important difference to health outcomes in individuals initiating screening at age 50 to 79? And which screening option is best?”

Current practice Numerous guidelines recommend screening, but vary on recommended test, age and screening frequency. This guideline looks at the evidence and makes recommendations on screening for four screening options: faecal immunochemical test (FIT) every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy.

Recommendations These recommendations apply to adults aged 50-79 years with no prior screening, no symptoms of colorectal cancer, and a life expectancy of at least 15 years. For individuals with an estimated 15-year colorectal cancer risk below 3%, we suggest no screening (weak recommendation). For individuals with an estimated 15-year risk above 3%, we suggest screening with one of the four screening options: FIT every year, FIT every two years, a single sigmoidoscopy, or a single colonoscopy (weak recommendation). With our guidance we publish the linked research, a graphic of the absolute harms and benefits, a clear description of how we reached our value judgments, and linked decision aids.

How this guideline was created A guideline panel including patients, clinicians, content experts and methodologists produced these recommendations using GRADE and in adherence with standards for trustworthy guidelines. A linked systematic review of colorectal cancer screening trials and microsimulation modelling were performed to inform the panel of 15-year screening benefits and harms. The panel also reviewed each screening option’s practical issues and burdens. Based on their own experience, the panel estimated the magnitude of benefit typical members of the population would value to opt for screening and used the benefit thresholds to inform their recommendations.

The evidence Overall there was substantial uncertainty (low certainty evidence) regarding the 15-year benefits, burdens, and harms of screening. Best estimates suggested that all four screening options resulted in similar colorectal cancer mortality reductions. FIT every two years may have little or no effect on cancer incidence over 15 years, while FIT every year, sigmoidoscopy, and colonoscopy may reduce cancer incidence, although for FIT the incidence reduction is small compared with sigmoidoscopy and colonoscopy. Screening related serious gastrointestinal and cardiovascular adverse events are rare. The magnitude of the benefits is dependent on the individual risk, while harms and burdens are less strongly associated with cancer risk.

Understanding the recommendation Based on benefits, harms, and burdens of screening, the panel inferred that most informed individuals with a 15-year risk of colorectal cancer of 3% or higher are likely to choose screening, and most individuals with a risk of below 3% are likely to decline screening. Given varying values and preferences, optimal care will require shared decision making.

Footnotes

  • Research, doi: 10.1136/bmj.l5383

  • This BMJ Rapid Recommendation article is one of a series that provides clinicians with trustworthy recommendations for potentially practice changing evidence. BMJ Rapid Recommendations represent a collaborative effort between the MAGIC group (http://magicproject.org/) and The BMJ. A summary is offered here and the full version including decision aids is on the MAGICapp (https://app.magicapp.org), for all devices in multilayered formats. Those reading and using these recommendations should consider individual patient circumstances, and their values and preferences and may want to use consultation decision aids in MAGICapp to facilitate shared decision making with patients. We encourage adaptation and contextualisation of our recommendations to local or other contexts. Those considering use or adaptation of content may go to MAGICapp to link or extract its content or contact The BMJ for permission to reuse content in this article.

  • Funding: This guideline was not funded.

  • Competing interests: All authors have completed the BMJ Rapid Recommendations interest disclosure form and a detailed, contextualised description of all disclosures is reported in appendix 2. As with all BMJ Rapid Recommendations, the executive team and The BMJ judged that no panel member had any financial conflict of interest. Professional and academic interests were minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions.

  • Disclaimer: Participation in the panel and authorship of this manuscript does not constitute organisational endorsement of the recommendations.

  • Transparency: L M Helsingen and G Guyatt affirm that the manuscript is an honest, accurate, and transparent account of the recommendation being reported; that no important aspects of the recommendation have been omitted; and that any discrepancies from the recommendation as planned have been explained.

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