Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

Andrew M.D. Wolf, Elizabeth T.H. Fontham, Timothy R. Church, Christopher R. Flowers, Carmen E. Guerra, Samuel J. LaMonte, Ruth Etzioni, Matthew T. McKenna, Kevin C. Oeffinger, Ya Chen Tina Shih, Louise C. Walter, Kimberly S. Andrews, Otis W. Brawley, Durado Brooks, Stacey A. Fedewa, Deana Manassaram-Baptiste, Rebecca L. Siegel, Richard C. Wender, Robert A. Smith

Research output: Contribution to journalArticlepeer-review

798 Scopus citations


In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250–281.

Original languageEnglish (US)
Pages (from-to)250-281
Number of pages32
JournalCA Cancer Journal for Clinicians
Issue number4
StatePublished - Jul 1 2018

Bibliographical note

Funding Information:
We thank Amy Allison, MPH, MLS, and Shenita Peterson, MPH (Woodruff Health Sciences Center Library, Emory University), for assistance with literature searches to update and supplement the evidence review. We also thank Michael Bonow (Intern, Emory University Rollins School of Public Health) for assistance with supplemental literature review and evidence synthesis. In addition, we thank the expert advisory panel (listed in the online Supporting Information) for their time and expertise throughout the guideline update and the representatives of stakeholder organizations (listed in the Supporting Information) who reviewed the draft recommendations and rationale. Finally, we thank our colleagues from the Cancer Intervention and Surveillance Modeling Network for their analyses and review of the article (Amy Knudsen, PhD; Iris Lansdorp-Vogelaar, PhD; Reinier Meester, PhD; Elisabeth Peterse, MSc; and Ann Zauber, PhD).

Funding Information:
Disclosures: Timothy R. Church reports grants from Epigenomics and personal fees from GRAIL Bio outside the submitted work; he is a member of the Physician’s Data Query (PDQ) for Screening and Prevention Editorial Board (National Cancer Institute [NCI], National Institutes of Health [NIH], Chair of the CONFIRM trial Data and Safety Monitoring Board (Veterans Affairs), site principal investigator for the Prostate, Lung, Colon, and Ovarian Cancer Screening Trial (funded by the NIH), and site principal investigator for the National Colonoscopy Study (funded by the NIH through Memorial Sloan Kettering Cancer Center). Christopher R. Flowers reports multiple relationships with industry but none directly related to colorectal cancer screening; personal fees from Spectrum, Celgene, Optum Rx, Seattle Genetics, Gilead, Bayer, Karyopharm, Astra Zeneca, and Beigene; unpaid consultant work for Genentech/Biogen-Idec/Roche and Millennium/Takeda; research funding to the Emory University School of Medicine and Winship Cancer Institute from AbbVie, Acerta, Celgene, Gilead Sciences, Infinity Pharmaceuticals, Janssen Pharmaceutical, Millennium/Takeda, Spectrum, Onyx Pharmaceuticals, Phamacyclics, and the NIH (grants R21CA158686, U01CA195568, and K24CA208132), the Burroughs Wellcome Fund, and the V Foundation; and personal fees for developing educational presentations from Clinical Care Options, Educational Concepts, PRIME Oncology, and Research to Practice. Otis W. Brawley and Stacey A. Fedewa are employed by the ACS, which received a grant from Merck Inc for intramural research outside the submitted work; however, their salary is solely funded through ACS. The ACS receives partial funding from the Centers for Disease Control and Prevention (CDC) to support the National Colorectal Cancer Roundtable, of which Richard C. Wender is the Chair, Robert C. Smith is the Co-Chair, and Durado Brooks is a Steering Committee member, to support initiatives related to colorectal cancer screening. The ACS also received contributions from Bracco Diagnostics Inc, Polymedco Inc, Exact Sciences, Medtronic GI Solutions Inc, Quest Diagnostics, Epigenomics Inc, Clinical Genomics, Medial Early Sign, the American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology, the American College of Radiology, and the American Gastroenterological Association to support the annual meeting of the National Colorectal Cancer Roundtable. ACS cancer screening guideline development is supported by ACS operational funds; neither the Roundtables nor the sources of funding described in this disclosure have had any role, involvement, or have made any financial contribution to ACS screening guideline development or approval. All remaining authors report no conflicts of interest.

Publisher Copyright:
© 2018 American Cancer Society


  • adenoma, colonoscopy
  • colorectal and rectal neoplasms
  • computed tomography colonoscopy
  • mass screening and early detection
  • mortality
  • occult blood
  • radiography
  • sigmoidoscopy
  • stool testing


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