Method in Action

 Identify Screening Protocols for Increased Risk Patients

Greenville Family Medicine is a private family medicine practice in a suburban community outside of a large city. Greenville recently went through a process to establish a standardized system for CRC screening across its three locations. In addition to targeting the general population for screening, Greenville also wanted to include specific screening schedules for individuals with a positive family history of CRC or polyps according to guidelines.

The clinical champion physician and office manager started by looking for guidelines from primary care societies, and reviewed the American College of Physicians (ACP) 2012 Guidance Statement on Screening for Colorectal Cancer and American Academy of Family Physicians (AAFP) 2018 guidelines on Colorectal Cancer Screening and Surveillance in Individuals at Increased Risk.^17,19 They evaluated the guidelines focusing on the recommendations for those with a family history. ACP recommends screening with colonoscopy at 40 or 10 years prior to the youngest cancer diagnosis in the family for “high risk” patients, but does not define what family history scenarios meet criteria for high risk. AAFP also recommends colonoscopy at 40 or 10 years prior to the youngest cancer diagnosis in the family, specifying this should be for individuals with a first-degree relative* with CRC or advanced adenoma prior to 60 years of age, with repeat every 5 years. AAFP also recommends specific screening plans for additional family history scenarios, including a single first-degree relative over age 60 (colonoscopy starting at 40), multiple first-degree relatives at any age, and two second degree relatives at any age.

To confirm the population of patients who should be offered earlier screening, the practice team then expanded their review to include additional organizations. They reviewed guidelines from the National Comprehensive Cancer Network (NCCN), updated in 2018, and the Colorectal Cancer Screening Multi-Society Task Force (MSTF; includes the American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy), published in 2017.^22,23 These guidelines were consistent with AAFP in recommending CRC screening at 40 for individuals with a first-degree relative with CRC or advanced adenoma at any age, although the recommended screening modalities vary when CRC occurs > 60 years. For those with a first-degree relative with CRC < 60, all guidelines agree that colonoscopy should begin at 40 or 10 years prior to the youngest cancer diagnosis in the family, whichever is earlier. However, while AAFP and NCCN recommend colonoscopy as the screening test for all patients with a first-degree relative with CRC regardless of age of onset, the MSTF states that individuals with a first-degree relative > 60 could be offered any of CRC screening tests used for average risk patients. The repeat screening intervals were also somewhat discordant between AAFP, NCCN and MSTF for the different risk categories (5-10 years).

After reviewing ACP, AAFP, NCCN, and MSTF, the practice ultimately adopted the AAFP guidelines, which are aligned with the others but with more detailed criteria for at-risk individuals.

*First-degree relatives (FDR): Parents, siblings, children. Second-degree relatives (SDR): Grandparents, aunts, uncles, nieces, nephews, half-siblings, grandchildren.