Systematic review of colorectal cancer screening guidelines for average-risk adults: Summarizing the current global recommendations

Table 1 Summarized recommendations for colorectal cancer screening in average-risk individuals, published in North America between 2007 and 2017

Continent	Country/association	Publication year	Age	Screening tests recommended	Recommendation	Note
North America	United States: ACG	2009	≥ 50	Preferred prevention test: Colonoscopy (10 yr). If not possible or refused by individual: FS (5-10 yr) - OR CTC (5 yr) OR detection test	Grade 1B except for FS (2B) and CTC(1C)	Screening starting at age 45 for African American population
				Preferred detection test: FIT (1 yr). If not possible: Annual gFOBT (Hemoccult Sensa) OR- Fecal DNA testing (3 yr)	FIT : Grade 1B
	United States: ACP	2015	50-75	High sensitivity FOBT/FIT (1 year) OR FS (5 years) OR FOBT/FIT (3 yr) + FS (5 yr) OR colonoscopy (10 yr)	-
			≥ 75 and individuals whose life expectancy is estimated to less than 10 years	Screening not recommended	-
	United States: USPSTF	2016	50-75	gFOBT/FIT (1 yr) OR FIT-DNA (1-3 yr) OR FS (10 yr) + FIT (1year) OR FS (5 yr) OR colonoscopy (10 yr) OR CT-colonoscopy (5 yr)	Grade A recommendation
			76-85	Screening is considered an individual decision,	Grade C recommendation
	Canada: CTFPHC	2016	50-59	gFOBT/FIT (2 yr) OR FS (10 yr) OR defer until age 60	Weak recommendation; moderate-quality evidence	Colonoscopy not recommended for screening (weak recommendation; low-quality evidence), but could be discussed
			60-74	gFOBT/FIT (2 years) OR FS (10 yr)	Strong recommendation; moderate-quality evidence
			≥ 75	Screening not recommended, but can be discussed	Weak recommendation; low-quality evidence
	United States: NCCN	2017	50-75	Colonoscopy (10 years) OR gFOBT/FIT (1 yr) OR Fecal DNA test (3 yr) OR FS (5-10 yr) (+/- gFOTB/FIT at year 3) OR CTC (5 yr)	Category 2A except for annual gFOBT and FS every 5-10 years (which are category 1)	FIT is identified as more sensitive than gFOBT
			76-85	Screening should be an individual decision, can be discussed
	United States: US Multi-Society Task Force of Colorectal Cancer	2017	50-75	First-tier (preferred tests): Annual FIT OR colonoscopy (10 yr)	Strong recommendation; moderate-quality evidence	Screening for African American starting at age 45 (weak recommendation; very-low-quality evidence)
				Second-tier: CTC (5 yr) OR FIT-fecal DNA testing (3 yr) OR FS (5-10 yr)	CTC and FIT-DNA : Strong recommendation; low-quality evidence
					FS: Strong recommendation; high-quality evidence
				Third-tier: Capsule colonoscopy (5 yr)	Weak recommendation; low-quality evidence
			76-85	Screening should be considered for individuals without prior screening	Weak recommendation; low-quality evidence

CRC: Colorectal cancer; FS: Flexible sigmoidoscopy; DCBE: Double contrast barium enema; CTC: CT colonography, FOBT: Fecal occult blood test: gFOBT: Guaiac-based fecal occult blood test: FIT: Fecal immunochemical test.

Table 2 Summarized recommendations for colorectal cancer screening in average-risk individuals, published in Europe between 2007 and 2017

Continent	Country/Association	Year	Age	Screening tests recommended	Recommendation	Note
Europe	Scotland: TIS	2011 (revised in 2016)	Age not mentioned	FIT (quantitative) (interval not mentioned)	Grade A recommendation	Performance of FS unsure in the Scottish population. Colonoscopy and CT colonography are not recommended
	Germany: GGPO	2014	≥ 50	Preferred test: Colonoscopy (10 yr) If refused by individual: FS (5 yr) + annual FOBT OR Annual FOBT	Colonoscopy: Grade B recommendation; 3b level of evidence. FS: Grade B recommendation; 2b level of evidence. Adding FOBT to FS: Grade B recommendation; 3b level of evidence. FOBT as a screening test: Good clinical practice	General use of FIT is not recommended, but FIT can be used instead of gFOBT if it has a proven high specificity (> 90%) and sensitivity. Genetic stool tests, CT colonography, MR-colonography and capsule endoscopy are not recommended.
	Spain: SEOM	2014	50-74	FIT every 2 yr OR, depending on available resources, annual or biennial gFOBT OR FS (5 yr) OR colonoscopy (every 10 yr)	Grade B (moderate) quality of evidence, except for FOBT every 2 yr (grade A quality of evidence)	Combination of gFOBT and FS, and CT colonography are not recommended
	European Guidelines	2013	50-74	Recommended test: gFOBT/FIT (1-2 yr)	Recommendation based on good evidence for gFOBT, reasonable evidence for FIT and FS, and limited evidence for colonoscopy	Evidence supports FIT superiority compared to gFOBT
				Other options include colonoscopy (10-20 yr) OR FS (10-20 yr)

CRC: Colorectal cancer; FS: Flexible sigmoidoscopy; FOBT: Fecal occult blood test; gFOBT: Guaiac-based fecal occult blood test; FIT: Fecal immunochemical test.

Table 3 Summarized recommendations for colorectal cancer screening in average risk individuals, published in Asia between 2007 and 2017

Continent	Country/region	Year	Age	Screening tests recommended	Recommendation	Note
Asia	South Korea	2012	≥ 50	Colonoscopy (at least 5 years) is the priority OR FOBT (FIT) OR CTC OR DCBE	Colonoscopy (strong recommendation; low-quality evidence) with 5-year interval (weak recommendation; very low-quality evidence). FOBT (strong recommendation; moderate-quality evidence). CTC (strong recommendation; low-quality evidence). DCBE (weak recommendation; low-quality evidence)	FS efficacy is recognized, but FS not widely used because it doesn't explore entire colon, might need a colonoscopy after, and FS less preferred by individuals and physicians
	China	2014	50-74	FOBT (chemical FOBT or FIT) + Questionnaire every 3 yr	-
	Asia Pacific	2015	50-75	FIT (preferred choice) OR FS OR colonoscopy (intervals not mentioned)	A for FIT; A for FS; B for colonoscopy	FIT is preferred over gFOBT
	Saudi Arabia	2015	45-69	Colonoscopy (10 yr) is the recommended modality; if not possible: FS (5 yr)+ FIT/gFOBT (1 yr) OR FS (3 yr)	Colonoscopy: Strong recommendation; low-quality evidence. FS: Strong recommendation; moderate-quality evidence.	FIT is preferred over gFOBT. FOBT used alone is not recommended, but could be used depending on availability of other modalities.
			≥ 70	Screening not recommended	Conditional recommendation; low-quality evidence	Screening for people over 70 could be beneficial in certain cases (depending on health status)

CRC: Colorectal cancer; FS: Flexible sigmoidoscopy; DCBE: Double contrast barium enema; CTC: CT colonography; FOBT: Fecal occult blood test; gFOBT: Guaiac-based fecal occult blood test; FIT: Fecal immunochemical test.

Table 4 Recommended test in terms of available resources according to World Gastroenterology Organization’s colorectal cancer screening cascade

Level of recommendation	Recommended screening test
1	Colonoscopy every 10 yr
2	Colonoscopy, once in a lifetime
3	FS every 5 yr, followed by a colonoscopy if FS was positive
4	FS, once in a lifetime, followed by a colonoscopy if FS was positive
5	FS, once in a lifetime, followed by a colonoscopy only if advanced neoplasia is detected
6	Fecal blood test annually, followed, if positive, by a colonoscopy or barium enema (depending on colonoscopy’s availability)

FS: Flexible sigmoidoscopy.

Table 5 Screening tests characteristics

Screening test	Specificity/sensitivity for advanced adenoma detection (%)	Specificity/sensitivity for CRC detection (%)	Price (USD)	Participation rates after first-time invitation (%)[56]	Decreased mortality for CRC (%)	Risk of complications (%)[63]
gFOBT	95.4/8.6[64]	97.7/23.8[39]	5[61]-23[60]	47	14[65]-32[7]	0
FIT	96.8-97.4/20.3-25.7[64]	94.0 79.0[66]	23[60]-25[61]	42	59[65]	0
FS	87.0/95.0[67]		169[60]-238[61]	35	33[65] - 50[10]	Perforation: 0.01 Major bleeds: 0.02
Colonoscopy	91.3/92.9 (for adenomas > 10 mm)[68]	100.0/91.2[68]	645[60]-803[61]	28	61[65]- 65[48]	Perforation: 0.04 Major bleeds: 0.08
sDNA test	89.81/42.4[69]	89.81/92.3[69]	150[61]	NR	NR	0
CTC	87.3/91.2 (for adenomas > 10 mm)[68]	99.0/96.8[68]	570[60]	22	NR	Perforation: Less than 0.02

¹Specificity was not defined separately for advanced adenoma detection and colorectal cancer detection. CRC: Colorectal cancer; gFOBT: Guaiac fecal occult blood test; FIT: Fecal immunochemical test; FS: Flexible sigmoidoscopy; sDNA test: Stool DNA test; CTC: CT colonography; NR: Not reported.