Colorectal Cancer Screening Recommendations

When to Start Screening

Average-risk adults should begin colorectal cancer screening at age 45 years, with colonoscopy every 10 years or annual fecal immunochemical testing (FIT) as first-line options, as recommended by the American Cancer Society and other guideline societies 1, 2
The American Cancer Society updated their recommendation to age 45 in recognition of rising colorectal cancer incidence in younger adults and similar rates of advanced neoplasia in 45-49 year-olds compared to historical 50-year-old cohorts, with a moderate strength of evidence 2
African Americans should begin screening at age 45 due to higher disease burden and earlier onset of disease, according to the U.S. Multi-Society Task Force and other guideline societies 1, 3, 4

For patients with a first-degree relative diagnosed with colorectal cancer or advanced adenoma before age 60, or two first-degree relatives at any age, begin colonoscopy at age 40 OR 10 years before the youngest affected relative's diagnosis, whichever comes first, as recommended by the U.S. Multi-Society Task Force 1, 2, 3, 4
Repeat colonoscopy every 5 years in these higher-risk family history patients, with a strong recommendation 2, 3

Colonoscopy every 10 years and annual FIT are the cornerstone screening tests and should be offered first, as recommended by the U.S. Multi-Society Task Force and other guideline societies 1, 2, 3
Annual FIT is preferred in organized screening programs and for patients who decline colonoscopy, with a moderate strength of evidence 1, 2, 3
CT colonography every 5 years, multitarget stool DNA test (FIT-DNA) every 3 years, and flexible sigmoidoscopy every 5-10 years are second-tier options for patients who decline colonoscopy and FIT, as recommended by the U.S. Multi-Society Task Force 1, 2, 5

All positive non-colonoscopy screening tests MUST be followed by timely diagnostic colonoscopy—failure to do so negates the entire benefit of screening, with a strong recommendation 1, 2

Discontinue screening at age 75 in patients who are up-to-date with prior negative screening tests, particularly colonoscopy, as recommended by the U.S. Multi-Society Task Force and other guideline societies 1, 2, 3, 4
Stop screening when life expectancy falls below 10 years regardless of age, with a moderate strength of evidence 1, 2, 3, 4
Discourage screening beyond age 85 as harms outweigh benefits, with a strong recommendation 1, 2

Cecal intubation rates should exceed 90% in screening populations, with a strong recommendation 2
Withdrawal time should be at least 6 minutes, with a moderate strength of evidence 2
Adenoma detection rates should be at least 25% in men and 15% in women over 50, with a strong recommendation 2

Patients under age 50 with colorectal bleeding symptoms require diagnostic colonoscopy, not screening, with a strong recommendation 3
Inadequate bowel preparation reduces colonoscopy effectiveness and should trigger repeat examination, with a moderate strength of evidence 1
Continuing screening in patients over 75 who are up-to-date with negative tests exposes them to unnecessary procedural risks, with a strong recommendation 1, 3