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

ACS Colorectal Cancer Screening Guideline for Average Risk Adults 2018 1

How are Cancer Screening Guidelines Developed? ACS Guideline Development Process Systematic Evidence Review & Modeling Reports [existing (and supplemented) or Commissioned] External Review (Experts and Stakeholder External Expert Organizations) Staff Advisors Guideline Development Group (GDG) & Mission ACS Board of GDG CRC Sub- Outcomes Directors Publication group Committee 2

ACS 2018 Recommendations for CRC Screening • 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. 3

ACS 2018 Recommendations for CRC Screening • 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) 4

ACS 2018 Recommendations for CRC Screening 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) 5

ACS 2018 Recommendations for CRC Screening 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. 6

What h has c s changed? ( (2018 v 2018 vs 2008) s 2008) 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 opportunity 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 7

What informed the GDG decisions? 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. 8

Trends in CRC incidence by age and year of birth Source: Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974-2013. JNCI 2017;109;djw322.

Rationale – Disease Burden of CRC Figure 1. Trends in Colorectal Cancer Incidence Rates in Adults Younger than Aged 50 years by Race, 1975-2014 15 Colorectal cancer cases per 100,000 persons <50years 10 5 0 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008 2011 2014 Year or diagnosis 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 10 Clin. 2018; 68: 000-000 [epub ahead of print]. URL to be: https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21457

Rationale – Disease Burden of CRC Trends in Colorectal Cancer Incidence Rates by Age and Sex, 1975-2014 Aged 20-49 years Aged 50+ years Colorectal cancer cases per 100,000 persons 14 300 Colorectal cancer cases per 100,000 12 250 10 persons aged 50+ years 200 8 aged 20-49 years 150 6 100 4 50 2 0 0 6 9 2 5 8 1 4 7 0 3 6 9 2 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 7 7 8 8 8 9 9 9 0 0 0 0 1 - - - - - - - - - - - - - 5 8 1 4 7 0 3 6 9 2 5 8 1 7 7 8 8 8 9 9 9 9 0 0 0 1 9 9 9 9 9 9 9 9 9 0 0 0 0 1 1 1 1 1 1 1 1 1 2 2 2 2 Year of diagnosis Year of diagnosis 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 11 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) Both sexes 85+ years 80-84 years 75-79 years 70-74 years 65-69 years 60-64 years 55-59 years > 10 % of all LYL is due 50-54 years to a diagnosis of CRC 45-49 years 40-44 years between ages 45-49 35-39 years 30-34 years 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 0.2

Model-estimated Benefit CRC Screening by Starting Age Model-estimated Life Years Gained from CRC Screening Starting at Aged 45y vs 50y, per 1000 Screened Over a Lifetime 500 450 400 Model-estimated LYG 350 300 250 200 150 100 50 0 CSY CTC FS FIT HSgFOBT mt-sDNA Screening test 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 13 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 • of 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.

CRC Screening Guidelines for Average Risk Adults: ACS (2018); USPSTF (2016) Recommendations ACS, 2018 USPSTF, 2016 Age to start screening Age 45y Aged 50y (A) Starting at 45y (Q) S-strong Q-qualified Screening at aged 50y and older - (S) 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 • FIT annually, • HSgFOBT annually options • HSgFOBT annually • FIT annully • mt-sDNA every 3y • sDNA every 1 or 3 y • Colonoscopy every 10y • Colonoscopy every 10y • CTC every 5y • CTC every 5y • FS every 5y • FS every 5y All positive non-colonoscopy tests should be followed • FS every 10y plus FIT every year up with colonoscopy. Age to stop screening Continue to 75y as long as health is good and life 76-85 y individual decision making (C) expectancy 10+y (Q) 76-85y individual decision making (Q) >85y discouraged from screening (Q) 15

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