Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website http://www.gastrores.org

Review

Volume 13, Number 1, February 2020, pages 1-10

Colon Cancer: A Clinician’s Perspective in 2019

**Table 1.** CRC Screening Recommendations by MSTF in 2017
Average-risk individuals	Family history of CRC
CRC: colorectal cancer; MSTF: Multi-Society Task Force; FIT: fecal immunochemical test; CT: computed tomography.
First tier tests: colonoscopy every 10 years or annual FIT. Colonoscopy should be offered first. If colonoscopy is refused, annual FIT.	Persons with one first-degree relative of CRC or documented advanced adenoma diagnosed < 60 years or two first-degree relatives with those findings at any age - screening colonoscopy every 5 years beginning 10 years before the age at diagnosis of youngest relative or age 40, whichever is earlier.
Second tier tests: CT colonography every 5 years or FIT-fecal DNA test every 3 years or flexible sigmoidoscopy every 5 to 10 years.	Persons with a single first-degree relative diagnosed at ≥ 60 years with CRC or an advanced adenoma - average risk screening options at age 40 years.
Third tier test: capsule colonoscopy every 5 years.
Septin9 serum assay: not recommended for screening CRC.

Table 1. CRC Screening Recommendations by MSTF in 2017

Average-risk individuals

Family history of CRC

CRC: colorectal cancer; MSTF: Multi-Society Task Force; FIT: fecal immunochemical test; CT: computed tomography.

First tier tests: colonoscopy every 10 years or annual FIT. Colonoscopy should be offered first. If colonoscopy is refused, annual FIT.

Persons with one first-degree relative of CRC or documented advanced adenoma diagnosed < 60 years or two first-degree relatives with those findings at any age - screening colonoscopy every 5 years beginning 10 years before the age at diagnosis of youngest relative or age 40, whichever is earlier.

Second tier tests: CT colonography every 5 years or FIT-fecal DNA test every 3 years or flexible sigmoidoscopy every 5 to 10 years.

Persons with a single first-degree relative diagnosed at ≥ 60 years with CRC or an advanced adenoma - average risk screening options at age 40 years.

Third tier test: capsule colonoscopy every 5 years.

Septin9 serum assay: not recommended for screening CRC.

**Table 2.** CRC Screening Recommendations by ACP in 2019
Average-risk individuals
CRC: colorectal cancer; ACP: American College of Physicians; FIT: fecal immunochemical test; gFOBT: guaiac-based fecal occult blood test.
FIT or gFOBT every 2 years.
Colonoscopy every 10 years.
Flexible sigmoidoscopy every 10 years plus FIT every 2 years.

Table 2. CRC Screening Recommendations by ACP in 2019

Average-risk individuals

CRC: colorectal cancer; ACP: American College of Physicians; FIT: fecal immunochemical test; gFOBT: guaiac-based fecal occult blood test.

FIT or gFOBT every 2 years.

Colonoscopy every 10 years.

Flexible sigmoidoscopy every 10 years plus FIT every 2 years.

**Table 3.** BBPS Scores
Score	Colon cleanliness
BBPS: Boston bowel preparation scale.
0	Unprepared colon segment with mucosa not seen due to solid stool that cannot be cleared.
1	Portion of mucosa of the colon segment seen, but other areas of the colon segment not well seen due to staining, residual stool and/or opaque liquid.
2	Minor amount of residual staining, small fragments of stool and/or opaque liquid, but mucosa of colon segment seen well.
3	Entire mucosa of colon segment seen well with no residual staining, small fragments of stool or opaque liquid.

Table 3. BBPS Scores

Score

Colon cleanliness

BBPS: Boston bowel preparation scale.

Unprepared colon segment with mucosa not seen due to solid stool that cannot be cleared.

Portion of mucosa of the colon segment seen, but other areas of the colon segment not well seen due to staining, residual stool and/or opaque liquid.

Minor amount of residual staining, small fragments of stool and/or opaque liquid, but mucosa of colon segment seen well.

Entire mucosa of colon segment seen well with no residual staining, small fragments of stool or opaque liquid.

**Table 4.** Screening for CRC in High-Risk Individuals
High-risk individuals for CRC	Recommendations
CRC: colorectal cancer; FAP: familial adenomatous polyposis; HNPCC: hereditary non-polyposis colorectal cancer; SPS: serrated polyposis syndrome; IBD: inflammatory bowel disease.
1. Family history: single first-degree relative with CRC or advanced adenoma diagnosed below the age of 60 years or two first-degree relatives with CRC or advanced adenomas at any age.	Screening colonoscopy every 5 years beginning at age 40 or 10 years earlier than the youngest index case in the family.
2. Classical FAP	Annual colonoscopy or flexible sigmoidoscopy starting at age 12 to 14 years until the time of colectomy.
3. Attenuated FAP	Colon cancer screening should start at age 20 to 25 and there is no upper limit of stopping the surveillance.
4. HNPCC	All the family members with positive genetic testing should get screening colonoscopy every 2 years starting age 20 to 25 until age 40, then annually.
5. SPS	Surveillance colonoscopy annually.
6. IBD	Screening colonoscopy is recommended 8 to 10 years after the diagnosis of pan-ulcerative colitis, extensive ulcerative colitis and left-sided ulcerative colitis as well as Crohn’s colitis involving at least one third of the colon.

Table 4. Screening for CRC in High-Risk Individuals

High-risk individuals for CRC

Recommendations

CRC: colorectal cancer; FAP: familial adenomatous polyposis; HNPCC: hereditary non-polyposis colorectal cancer; SPS: serrated polyposis syndrome; IBD: inflammatory bowel disease.

1. Family history: single first-degree relative with CRC or advanced adenoma diagnosed below the age of 60 years or two first-degree relatives with CRC or advanced adenomas at any age.

Screening colonoscopy every 5 years beginning at age 40 or 10 years earlier than the youngest index case in the family.

2. Classical FAP

Annual colonoscopy or flexible sigmoidoscopy starting at age 12 to 14 years until the time of colectomy.

3. Attenuated FAP

Colon cancer screening should start at age 20 to 25 and there is no upper limit of stopping the surveillance.

4. HNPCC

All the family members with positive genetic testing should get screening colonoscopy every 2 years starting age 20 to 25 until age 40, then annually.

5. SPS

Surveillance colonoscopy annually.

6. IBD

Screening colonoscopy is recommended 8 to 10 years after the diagnosis of pan-ulcerative colitis, extensive ulcerative colitis and left-sided ulcerative colitis as well as Crohn’s colitis involving at least one third of the colon.

**Table 5.** TNM Staging System and Dukes Class for CRC With 5-Year Survival
Stage	Code	5-year survival	Dukes class
Primary tumor (T): Tis - carcinoma in situ; T1 - tumor invades submucosa; T3 - tumor invades through muscularis propria into subserosal; T4 - tumor directly invades other organs or structures, and/or perforates visceral peritoneum. Regional lymph nodes (N): N0 - no regional lymph node metastasis; N1 - metastasis in one to three regional lymph nodes; N2 - metastasis in four or more regional lymph nodes. Distant metastasis (M): M0 - no metastasis; M1 - distant metastasis. CRC: colorectal cancer.
0	TisN0M0	100
I	T1N0M0	100	A
	T2N0M0	90	B1
II	T3N0M0	75	B2
	T4N0M0	30
III	Any TN1M0	60	C
	Any TN2M	30
IV	Any T, any N, M1	3	D

Table 5. TNM Staging System and Dukes Class for CRC With 5-Year Survival

Stage

Code

5-year survival

Dukes class

Primary tumor (T): Tis - carcinoma in situ; T1 - tumor invades submucosa; T3 - tumor invades through muscularis propria into subserosal; T4 - tumor directly invades other organs or structures, and/or perforates visceral peritoneum. Regional lymph nodes (N): N0 - no regional lymph node metastasis; N1 - metastasis in one to three regional lymph nodes; N2 - metastasis in four or more regional lymph nodes. Distant metastasis (M): M0 - no metastasis; M1 - distant metastasis. CRC: colorectal cancer.

TisN0M0

100

T1N0M0

100

T2N0M0

T3N0M0

T4N0M0

III

Any TN1M0

Any TN2M

Any T, any N, M1

**Table 6.** Treatment of Different Stages of CRC
Stages of CRC	Treatment modalities
CRC: colorectal cancer.
Stage 1	Endoscopic resection of pedunculated malignant polyp or surgical resection of tumor and local lymph nodes.
Stage 2	Surgery alone. Adjuvant chemotherapy only in presence of high risk features.
Stage 3	Surgery plus adjuvant chemotherapy.
Stage 4	Chemotherapy, biologic targeted therapy, immunotherapy, palliative surgery, radiotherapy, radiofrequency ablation and colonic stenting.

Table 6. Treatment of Different Stages of CRC

Stages of CRC

Treatment modalities

CRC: colorectal cancer.

Stage 1

Endoscopic resection of pedunculated malignant polyp or surgical resection of tumor and local lymph nodes.

Stage 2

Surgery alone. Adjuvant chemotherapy only in presence of high risk features.

Stage 3

Surgery plus adjuvant chemotherapy.

Stage 4

Chemotherapy, biologic targeted therapy, immunotherapy, palliative surgery, radiotherapy, radiofrequency ablation and colonic stenting.