Colorectal Cancer Screening Guidelines

Screening Options

The American Gastroenterological Association recommends colonoscopy every 10 years or annual FIT as first-tier screening options for average-risk individuals, with Cologuard considered a second-tier option for those who decline both 1, 2
Patients who decline colonoscopy and FIT should be offered Cologuard every 3 years as a second-tier option 1, 2

Cologuard has superior sensitivity compared to FIT for detecting colorectal cancer (92.3% vs 73.8%), advanced precancerous lesions (42.4% vs 23.8%), polyps with high-grade dysplasia (69.2% vs 46.2%), and sessile serrated polyps larger than 1 cm (42.4% vs 5.1%) 3, 4
However, Cologuard has lower specificity than FIT (86.6% vs 94.9%), resulting in more false positives and follow-up colonoscopies 3, 4

The American College of Gastroenterology suggests that Cologuard might be considered for patients with an estimated moderate risk of advanced neoplasia who decline colonoscopy 1
FIT would be more appropriate for low-risk populations, while colonoscopy would be preferred for high-risk populations 1

Cologuard is recommended every 3 years, compared to annual FIT or colonoscopy every 10 years 1, 2
Any positive result on Cologuard requires follow-up with colonoscopy 2, 5

Screening should begin at age 45-50 years for average-risk individuals (45 for African Americans) 6, 7
Screening should generally be discontinued after age 75 or when life expectancy is less than 10 years 6, 8

Cologuard is not appropriate for high-risk individuals who should undergo colonoscopy, including those with a personal history of colorectal cancer or advanced adenomas 1, 6
Cologuard is also not recommended for individuals with a family history of colorectal cancer in a first-degree relative diagnosed before age 60 or multiple affected relatives 1, 6
Additionally, Cologuard is not suitable for individuals with a personal history of inflammatory bowel disease 5, 8
Known or suspected hereditary colorectal cancer syndromes (Lynch syndrome, familial adenomatous polyposis) also require colonoscopy instead of Cologuard 2

Individuals with a personal history of inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, require specialized surveillance colonoscopy with dysplasia assessment, as recommended by the American Gastroenterological Association 9
Multiple affected first-degree relatives with colorectal cancer should undergo genetic screening and colonoscopy, according to the National Comprehensive Cancer Network 9
Other hereditary colorectal cancer syndromes require regular colonoscopy starting at younger ages, as suggested by the American College of Gastroenterology 9

The American College of Gastroenterology approves Cologuard only for average-risk adults aged 45-85 years 10
The European Society for Medical Oncology recommends that Cologuard is not appropriate for individuals under age 45, unless they meet high-risk criteria requiring colonoscopy 10

Clinically evident intestinal obstruction is a contraindication for Cologuard, as bowel preparation may exacerbate obstruction or cause perforation, according to the American Society of Colon and Rectal Surgeons 9
Symptomatic patients with signs of gastrointestinal pathology should undergo diagnostic evaluation with colonoscopy rather than screening, as recommended by the British Society of Gastroenterology 10

The American College of Gastroenterology states that Cologuard is intended for primary screening, not for surveillance after recent colonoscopy, in most guidelines 11, 10
The European Society for Medical Oncology recommends that any deviation from average-risk status mandates colonoscopy as the appropriate screening/surveillance modality rather than stool-based testing 9, 10