Description
This logic path provides colorectal cancer screening recommendations for individuals with a family history of CRC or advanced polyps, according to recommendations from the U.S. Multi-Society Task Force of Colorectal Cancer (MSTF) and the American College of Gastroenterology (ACG).
Mid-Level Flow Diagram
Semi-Structured Logic Statements
Inclusions
| Name | Description |
|---|---|
Family history of colorectal cancer or potentially precancerous polyp(s)? | |
'Family history of colorectal cancer' exists OR 'Family history of potentially precancerous polyp(s)' exists | |
Exclusions
None.
Events
| Name | Description |
|---|---|
Personal history of potentially precancerous polyp(s)? | Patient has potentially precancerous polyps. |
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 | |
Colorectal cancer or confirmed advanced precancerous polyp(s) in first-degree relative(s)? | |
FAMILY HISTORY includes `Colorectal Cancer` AND relationship is `First-degree relative` OR STRUCTURED DOCUMENTATION of `Confirmed Advanced Precancerous Polyp(s) in First-Degree Relative` | |
Relationship to family members with colorectal cancer known? | Whether the relationship is specified when a patient has a family history of colorectal cancer |
FAMILY HISTORY includes `Colorectal Cancer` AND relationship EXISTS | |
Patient age >= 40? | |
Patient age >= 40 | |
>= 2 first-degree relatives affected? | Total number of first-degree relatives affected with either colorectal cancer or confirmed advanced precancerous polyp(s). |
Structured documentation of `Number of affected relatives`value >=2 | |
Relative's age at diagnosis >= 60? | |
Relatives' youngest age at diagnosis >= 50? | |
Patient is >= 10 years younger than relatives' youngest age at diagnosis? | Patient age is <= 10 years younger than relatives' youngest age at diagnosis. |
Patient age >= 'Youngest affected relative age at diagnosis' - 10 years | |
Actions
Recommendation: Follow endoscopist recommendation Description Recommendation: Follow endoscopist-recommended interval for the next colonoscopy. Considerations: * Surveillance intervals should favor the shortest indicated interval based on family history or polyp findings. Source: USMSTF (2020), USMSTF (2017). Pseudocode Next due date = DATE of latest 'Colonoscopy' date + 'Recommended follow-up interval' associated with latest 'Colonoscopy' |
Recommendation: Follow-up with endoscopist Description Recommendation: Follow-up with endoscopist to determine appropriate interval for next colonoscopy. Considerations: * Surveillance intervals should favor the shortest indicated interval based on family history or polyp findings. Source: USMSTF (2020), USMSTF (2017). Pseudocode Next due date = insufficient information to calculate next due date |
Recommendation: Follow average risk recommendations Description Consideration: Patients with a family history of colorectal cancer or advanced polyp(s) in second-degree relatives should be treated as average risk. Source: ACG (2021) Pseudocode Next due date = See "Decision to Screen (USPSTF)" logic path |
Recommendation: Need more comprehensive family history Description Recommendation: A more comprehensive family history is needed to make a recommendation, including: * Whether the relative(s) with a colorectal cancer or confirmed advanced polyp are/were first degree relative(s), i.e., mother, father, sibling or child (blood only). * The age at which relative(s) was/were diagnosed with colorectal cancer or confirmed advanced polyp(s) --- For patients with a single first-degree relative (mother, father, sibling, child) with colorectal cancer or an advanced polyp(s): * If relative diagnosed at >= 60 years: * Start screening at 40 years old. * Modality and interval: tests and intervals are as per the average risk screening recommendations. * If relative diagnosed at < 60 years old: * Start screening 10 years before relative's age at diagnosis or age 40, whichever is earlier. * Modality and interval: colonoscopy every 5 years. * Considerations: If no significant neoplasia appears by age 60 years, can offer expanding the interval between colonoscopies. For patients with 2 or more first-degree relatives with colorectal cancer or an advanced polyp: * Start screening 10 years before the reatives' youngest age at diagnosis or age 40, whichever is earlier. * Modality and interval: colonoscopy every 5 years. Pseudocode Next due date = insufficient information to calculate next due date |
Recommendation: Colonoscopy every 5 years Description Recommendation: * Start screening: Age 40 or 10 years before the youngest affected relative, whichever is earlier * Modality and interval: colonoscopy every 5 years. Considerations: For those with a single first-degree relative with colorectal cancer in whom no significant neoplasia appears by age 60 years, physicians can offer expanding the interval between colonoscopies. Source: USMSTF (2017); ACG (2021) Pseudocode Next due date = today if NOT EXISTS 'Colonoscopy' OR Next due date = DATE of latest 'Colonoscopy' + 5 years |
Recommendation: Modalities and intervals per average risk recommendations Description Recommendation: * Start screening: Age 40 * Modality and interval: same as those for average-risk persons: * Colonoscopy every 10 years * High-sensitivity gFOBT or FIT every year * sDNA-FIT every 1 to 3 years * CT colonography every 5 years * Flexible sigmoidoscopy every 5 years * Flexible sigmoidoscopy every 10 years + FIT every year Source: USMSTF (2017); ACG(2021) Pseudocode Next due date = today if NOT EXISTS 'Previous screening test result' OR Next due date = "See determine next due date" logic path if 'Previous screening test result' exists |
Recommendation: Modality and interval dependent on relative's age at diagnosis Description Recommendation: * If relative diagnosed at < 60, colonoscopy every 5 years. * If relative diagnosed at >= 60, modalities and intervals are the same as for average-risk persons: * Colonoscopy every 10 years * High-sensitivity gFOBT or FIT every year * sDNA-FIT every 1 to 3 years * CT colonography every 5 years * Flexible sigmoidoscopy every 5 years * Flexible sigmoidoscopy every 10 years + FIT every year Source: USMSTF (2017); USMSTF (2020); USPSTF (2021) - for modalities for average risk screening. Pseudocode Next due date = insufficient information to calculate next due date |
Recommendation: Start screening at age 40 Description Recommendation: Start screening: Age 40. Source: USMSTF, 2017; ACG, 2021 Pseudocode Next due date = Patient birthdate + 40 years |
Recommendation: Start screening 10 years prior to relatives' youngest age at diagnosis Description Recommendations: Start screening: 10 years younger than the age at which the youngest first-degree relative was diagnosed. Source: USMSTF(2017); ACG (2021). Pseudocode Next due date = 'Youngest affected relative age at diagnosis' - 10 years |
Recommendation: Start screening at 40 or earlier Description Recommendation: Start screening: age 40 or 10 years younger than the age at which the youngest first-degree relative was diagnosed, whichever is earlier. Source: USMSTF(2017); ACG (2021). Pseudocode Next due date = insufficient information to calculate next due date |
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
- ACG (2021): Shaukat, A., et al. (2021). ACG Clinical Guidelines: Colorectal Cancer Screening 2021. American Journal of Gastroenterology, 116(3), 458-479. https://doi.org/10.14309/ajg.0000000000001122