Description

This logic path makes recommendations and provides considerations for next steps after a screening colonoscopy, stool test, flexible sigmoidoscopy, or CT colonography.

The path may be triggered when a screening test report/results are available for review, and is intended for use with either individual patient alerts/flagging, or for generating asynchronous reports on any post-colonoscopy follow-up (e.g. documenting next screening due date, any follow-up with endoscopist).

Mid-Level Flow Diagram

Semi-Structured Logic Statements

Inclusions

Name	Description
Patients eligible for screening
See 'Screening Eligible' logic path
Patients at average risk for colorectal cancer
See 'Increased Risk Exclusions' logic path

Exclusions

None.

Events

Name	Description
Most recent screening test is colonoscopy?
'Most recent screening test is colonoscopy' IS TRUE
Colonoscopy finding of colorectal cancer?	Colonoscopy finding of colorectal cancer.
Finding of colorectal cancer' associated with latest 'Colonoscopy' exists
Diagnosis of CRC after a malignant colonoscopy finding?
Date of 'Current colorectal cancer' or 'Personal history of colorectal cancer' is after date of 'Finding of colorectal cancer'
Colonoscopy finding(s) of potentially precancerous polyp(s)?	Finding of adenoma(s), sessile serrated polyps, traditional serrated adenomas, or hyperplastic polyps >= 10 mm in size.
'Finding(s) of potentially precancerous polyp(s)' associated with latest 'Colonoscopy' exists
Endoscopist recommended interval in most recent colonoscopy?	The interval recommended by the endoscopist for the next screening or surveillance colonoscopy.
'Recommended follow-up interval' associated with latest 'Colonoscopy' exists
Most recent screening test is stool-based test?
'Most recent screening test is gFOBT or FIT test' OR 'Most recent screening test is stool DNA-FIT test'
Inconclusive stool-based test?
'Most recent screening test is gFOBT or FIT test' AND latest 'FOBT test' result is (`Inconclusive` OR `Invalid`) OR 'Most recent screening test is stool DNA-FIT test' AND latest 'Stool DNA-FIT test' result is (`Inconclusive` OR `Invalid`)
Positive stool-based test?
'Most recent screening test is gFOBT or FIT test' AND latest 'FOBT test' result is `Positive` OR 'Most recent screening test is stool DNA-FIT test' AND latest 'Stool DNA-FIT test' result is `Positive`
Most recent screening test is flexible sigmoidoscopy?
'Most recent screening test is flexible sigmoidoscopy'
Flexible sigmoidoscopy finding(s) of colorectal cancer or potentially precancerous polyp(s)?
'Finding of colorectal cancer' associated with latest 'Flexible sigmoidoscopy' EXISTS OR 'Finding(s) of potentially precancerous polyp(s)' associated with latest 'Flexible sigmoidoscopy' EXISTS
Most recent screening test is CT colonography?
'Most recent screening test is CT colonography'
CT colonography result inconclusive?
'Finding of inadequate CT Colonography' associated with latest 'CT colonography' EXISTS
CT colonography finding(s) of colorectal cancer or potentially precancerous polyp(s)?
'C-RADS category C4 finding' associated with latest 'CT colonography' exists OR 'C-RADS category C2, C2a, C2a OR C3 finding' associated with latest 'CT colonography' exists

Actions

Recommendation: Repeat screening Description Repeat screening due to inconclusive test results. Pseudocode

Recommendation: Order follow-up colonoscopy Description Order follow-up colonoscopy. Positive stool-based tests or abnormal findings identified by flexible sigmoidoscopy ot CT colonoscopy require follow-up with colonoscopy for the screening benefits to be achieved. Pseudocode

Recommendation: Refer for oncology evaluation Description REFERRAL for Oncology evaluation Pseudocode

Recommendation: Follow-up with endoscopist Description Recommend to follow-up with endoscopist to determine appropriate interval for next screening/surveillance colonoscopy. Pseudocode

References

• USMSTF (2017): Rex, D. K., et al. (2017). Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology, 153(1), 307-323. https://doi.org/10.1053/j.gastro.2017.05.013
• USMSTF (2020): Gupta, S., et al. (2020). Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointestinal Endoscopy, Gastroenterology, The American Journal of Gastroenterology, 91(3), 463-485.e5. https://doi.org/10.1016/j.gie.2020.01.014
• USPSTF (2021): Davidson, K. W., et al. (2021). Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA - Journal of the American Medical Association, 325(19), 1965-1977. https://doi.org/10.1001/jama.2021.6238