The high-level flow diagram identifies several different patient populations based on a patient’s symptoms, past medical history and previous screening results. The flow diagram also points to the corresponding guidelines that outline how that patient should be cared for. The mid-level flow diagram (which is divided across several pages) provides a more detailed view of the logic. It describes how population criteria are defined and decision points that identify relevant guidelines and patient-specific recommendations.
Primary Screening Decision Logic Path 3: Increased Risk Screening/Surveillance Care Delivery and Follow-Up Genetic/Familial Risk Referral Logic Path 1 Screening Eligible Logic Path 2 Decision to Screen Logic Path 4 Average Risk Screening Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement (2021) Logic Path 3A Hereditary Syndromes Guidelines on genetic evaluation and management of lynch syndrome: A consensus statement by the US multi-society task force on colorectal cancer (USMSTF, 2014) ACG Clinical Guideline: Genetic Testing and Management of Hereditary Gastrointestinal Cancer Syndromes (ACG, 2015) Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF, 2017) Diagnosis and Management of Cancer Risk in the Gastrointestinal Hamartomatous Polyposis Syndromes: Recommendations From the US Multi-Society Task Force on Colorectal Cancer (USMSTF, 2022) Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update (USMSTF, 2020) NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric V.2.2024 (NCCN, 2024) Logic Path 3B Inflammatory Bowel Disease AGA Clinical Practice Update on Endoscopic Surveillance and Management of Colorectal Dysplasia in Inflammatory Bowel Diseases: Expert Review (AGA, 2021) ACG Clinical Guideline: Primary Sclerosing Cholangitis (ACG, 2015) ACG Clinical Guideline: Management of Crohn’s Disease in Adults (ACG, 2018) ACG Clinical Guideline: Ulcerative Colitis in Adults (ACG, 2019) The role of endoscopy in inflammatory bowel disease (ASGE, 2015) Logic Path 3C Personal History of CRC Colonoscopy Surveillance after Colorectal Cancer Resection (USMSTF, 2016) Logic Path 3D Family History of CRC or Advanced Polyps Colorectal Cancer Screening: Recommendations for Physicians and Patients (USMSTF, 2017) ACG Clinical Guidelines: Colorectal Cancer Screening (ACG, 2021) Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update (USMSTF, 2020) Logic Path 3E Personal History of Neoplastic Polyps Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update (USMSTF, 2020) Logic Path 5 Due for Screening/Surveillance Logic Path 6 Screening Test Incomplete Logic Path 7 Follow-up after Screening Result Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF, 2017) Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement (2021) Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update (USMSTF, 2020) Report Report Test resulted Logic Path 9 Genetic/Familial Risk Referral ACG Clinical Guideline: Genetic Testing and Management of Hereditary Gastrointestinal Cancer Syndromes (ACG, 2015) no yes no yes no yes no yes yes yes no yes yes
Primary Screening Decision Logic Path 1 Screening Eligible Logic Path 2 Decision to Screen Logic Path 4 Average Risk Screening Increased Risk Screening/Surveillance Logic Path 3 Increased Risk Exclusions Logic Path 3A Personal or Family History of Hereditary Syndromes Logic Path 3B Inflammatory Bowel Disease Logic Path 3C Personal History of CRC Logic Path 3D Family History of CRC or Advanced Polyps Logic Path 3E Personal History of Neoplastic Polyps Logic Path 9 Genetic/Familial Risk Referral History of total colectomy Current Colorectal Cancer? Colorectal Signs or Symptoms? Recommendation: Consider diagnostic work up or examination Eligible for screening Age >= 86 years old? Age >= 76 years old? Recommendation: Selectively offer screening Life expectancy <10 years? Recommendation: Discuss decision to continue screening Has risk factor(s) for colorectal cancer? Recommendation: Stop screening Average risk screening Increased risk screening/surveillance Age >= 45 years old? Has prior screening? Recommendation: Start screening at 45 years old Recommendation: Continue routine screening Recommendation: Start screening Most recent CRC screening test is colonoscopy? Most recent CRC screening test is FOBT or FIT? Most recent CRC screening test is sDNA-FIT? Most recent CRC screening test is CT colonography? Most recent CRC screening test is flexible sigmoidoscopy? Update next due date 10 years Update next due date 1 year Update next due date 1 to 3 years Update next due date 5 years Update next due date 5 years Personal history of or at risk for hereditary cancer syndrome? Personal history of inflammatory bowel disease? Personal history of colorectal cancer? Family history of colorectal cancer or advanced polyp(s)? Personal history of potentially precancerous polyp(s)? Hereditary syndromes increased risk screening/surveillance IBD surveillance Post-colorectal cancer resection surveillance Family history increased risk screening/surveillance Post-polypectomy surveillance Average risk screening Personal history of Lynch syndrome, FAP, AFAP, MAP, PJS, JPS, SPS or Cowden syndrome? Genetic marker for Lynch syndrome, FAP, AFAP, MAP, PJS, JPS, SPS or Cowden Syndrome? Family history of genetic marker for Lynch syndrome, FAP, AFAP, MAP, PJS, JPS, or Cowden Syndrome? Family history of SPS or familial colon cancer type X? Recommendation: Refer to GI specialist for colonoscopy surveillance recommendations Recommendation: Colonoscopy surveillance recommendations for patients with confirmed syndrome apply Primary Sclerosing Cholangitis? Indeterminate or microscopic colitis? Recommendation: initial colonoscopy at PSC diagnosis and surveillance colonoscopy every year Patients not at increased risk for colorectal cancer Recommendation: Initial colonoscopy 8-10 years after disease onset and surveillance colonoscopy every 1-5 years Personal history of colorectal cancer resection? Recommendation: Colonoscopy surveillance starting 1 year after surgery or post-operative clearing colonoscopy Personal history of potentially precancerous polyp(s)? Endoscopist recommended interval in most recent colonoscopy? Recommendation: Follow endoscopist recommendation Colorectal cancer or confirmed advanced precancerous polyp(s) in first-degree relative(s)? Relationship to family members with colorectal cancer known? Recommendation: Follow average risk recommendations Patient age >= 40? >= 2 first-degree relatives affected? Relative's age at diagnosis >= 60? Relatives' youngest age at diagnosis >= 50? Patient is >= 10 years younger than relatives' youngest age at diagnosis? Recommendation: Follow-up with endoscopist Recommendation: Need more comprehensive family history Recommendation: Colonoscopy every 5 years Recommendation: Modalities and intervals per average risk recommendations Recommendation: Modality and interval dependent on relative's age at diagnosis Recommendation: Start screening at age 40 Recommendation: Start screening 10 years prior to relatives' youngest age at diagnosis Recommendation: Start screening at 40 or earlier Most recent CRC screening test is colonoscopy? Recommendation: Patient should be under colonoscopy surveillance Endoscopist recommended interval in most recent colonoscopy? Recommendation: Next due date per endoscopist-recommended interval Recommendation: Follow-up with endoscopist Family history of inherited genetic susceptibility to colorectal cancer? Variant status known? Personal history of syndrome-related cancer diagnosed before age 50? Family history of hereditary syndrome-associated cancer? 1 or more first-degree relative diagnosed with hereditary syndrome-associated cancer diagnosed before age 50? 3 or more relatives with a hereditary syndrome-associated cancer? Recommendation: Consider referral to genetic counseling for possible genetic testing Recommendation: Consider referral to genetic counseling for comprehensive cancer risk assessment/genetic evaluation no no yes no no yes no yes yes no no yes no yes yes no yes no yes no yes no yes no yes yes no yes no yes no yes no yes no yes no yes no yes no yes yes no yes no yes yes no yes no yes no yes no yes no yes no yes no unknown yes no yes no unknown yes no yes no yes no no yes no yes yes no yes
Care Delivery and Follow-up Logic Path 5 Due for Screening/Surveillance Logic Path 6 Screening Test Incomplete Logic Path 7 Follow-up Screening Result Next due date is available? Due for screening? Patient outreach Decision to screen Recommendation: Order screening test Pending order or referral for colorectal screening test? Screening test is pending Screening test is completed Most recent screening test is colonoscopy? Colonoscopy finding of colorectal cancer? Diagnosis of CRC after a malignant colonoscopy finding? Endoscopist recommended interval in most recent colonoscopy? Colonoscopy finding(s) of potentially precancerous polyp(s)? Most recent screening test is stool-based test? Inconclusive stool-based test? Positive stool-based test? Most recent screening test is flexible sigmoidoscopy? Flexible sigmoidoscopy finding(s) of colorectal cancer or potentially precancerous polyp(s)? Most recent screening test is CT colonography? CT colonography result inconclusive? CT colonography finding(s) of colorectal cancer or potentially precancerous polyp(s)? Recommendation: Refer for oncology evaluation Recommendation: Follow-up with endoscopist Recommendation: Repeat screening Recommendation: Order follow-up colonoscopy yes no due overdue yes no yes no yes no no no yes yes no yes no yes yes no yes yes yes no yes
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