New Colonoscopy recommendations

ACPM 2009: USPSTF Updates Recommendations for Colorectal Cancer Screening

Norra MacReady

Medscape Medical News 2009. © 2009 Medscape

February 17, 2009 (Los Angeles, California) — The US Preventive Services Task Force (USPSTF) no longer recommends colorectal cancer screening for everyone older than 50 years, with no upper age limit.

In 2002, the USPSTF recommended screening for anyone older than 50 years, with no upper limitation on age. That year, the task force also noted that there was, as yet, insufficient evidence to recommend for or against using computed tomography colonography (CTC) as one of the screening modalities.

In the 2009 update, the USPSTF now recommends that adults aged 50 to 74 years be screened in 1 of the following ways: every year with high-sensitivity fecal occult blood testing (FOBT); every 10 years with colonoscopy; or every 5 years with flexible sigmoidoscopy plus interval high-sensitivity FOBT.

The task force also recommended against routine screening of people aged 76 to 85 years, although individual patients might have considerations that support screening. As for CTC, the task force said it is still too early to include it in the screening recommendations.

The recommendation has a rating of A, meaning that the task force urges the clinician to provide the service to eligible patients and that there is good evidence that the service improves health outcomes, with benefits substantially outweighing harms, said USPSTF scientific director Mary Barton, MD, who presented the update here at Preventive Medicine 2009: The Annual Meeting of the American College of Preventive Medicine.

The update was developed based on a review of new data conducted by the Oregon Evidence-Based Practice Center, which analyses clinical studies that federal, state, and private agencies use in making policy and coverage decisions.

To examine the data on CTC, the center analyzed 4 studies it considered to be of good or fair quality, which involved a total of 4312 patients. Depending on whether the scan was read by a gastroenterologist or an experienced radiologist, CTC identified 12 or 13 of a total of 14 colorectal cancers across the 4 studies. Compared with colonoscopy, the sensitivity of CTC ranged from 59% to 94% for detecting adenomas, depending on the size. The specificity ranged from 80% to 96%.

CTC produces "lots of false positives," Dr. Barton said. The result is that doctors might be "sending many people to colonoscopy who [they] were trying to spare colonoscopy," with its "real and moderate-sized procedure-related harms," such as perforation and major bleeding. Noting that Medicare is announcing that it will not cover CTC for colorectal screening, Dr. Barton said that the currently available studies on CTC vary widely in quality, making it hard to determine the true net benefit or harm of the test. The task force concluded that there is not yet enough information to permit an assessment of the benefits and harms of CTC, so it did not mention the procedure at all when updating its recommendations for colorectal cancer screening.

The updated findings show that "we're not ready for CT colonography yet," even though patients are requesting it, said Wayne Dysinger, MD, chair of the Department of Preventive Medicine at Loma Linda University, in California. "This makes it clear that I can tell patients we don't have the science yet to pursue CT colonography." Dr. Dysinger, who was not involved in developing the recommendations, said he was a little surprised that the task force concluded it could not recommend CTC.

Preventive Medicine 2009: The Annual Meeting of the American College of Preventive Medicine (ACPM). Session 30. Presented February 13, 2009.