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Each Patient’s Risk Must be Assessed Individually Consider These Risk Factors When Screening Patients for CRC
The presence of these risk factors alone does not elevate patients beyond the average-risk category CRC: colorectal cancer.
1. Wolf AMD, et al. CA Cancer J Clin. 2018;68(4):250-281. 2. Rex DK, et al. Am J Gastroenterol. 2017;112(7):1016-1030. 3. Davidson KW, et al. JAMA. 2021;325(19):1965-1977. Diabetes1-3 Cigarette smoking1-3 Excess body weight1-3 Increased age1-3 Moderate to high consumption of alcohol1 Lack of physical activity1 Low consumption of fiber, calcium, fruits, and vegetables1 Long-term consumption of red and processed meat1<br>

Summary of Current Guideline Recommendations & Choice of Test *See Rex DK, et al. Am J Gastroenterol. 2017;112(7):1016-1030 for additional MSTF recommendations. The United States Multi-Society Task Force on Colorectal Cancer includes the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE).
†Nomenclature based on different guidelines: mt-sDNA, sDNA-FIT or FIT-FECAL DNA.
CRC: colorectal cancer; CTC: computed tomography colonography; FIT: fecal immunochemical test; FS: flexible sigmoidoscopy; hs-gFOBT: high sensitivity guaiac-based fecal occult blood test; mt-sDNA: multi-target stool DNA test. All Positive Results On Non-colonoscopy Screening Tests Should Be Followed Up with a Timely Colonoscopy1-4 Direct Visual Examination Stool-based Tests 1. Davidson KW, et al. JAMA. 2021;325(19):1965-1977. 2. Wolf AMD, et al. CA Cancer J Clin. 2018;68(4):250-281. 3. Shaukat A, et al. Am J Gastroenterol. 2021;116:458-479. 4. Patel SG, et al. Gastroenterol. 2022;162(1):285-299.<br>

National Guidelines for CRC Screening of Individuals at Average Risk All Positive Results on Non-colonoscopy Screening Tests Should be Followed Up with a Timely Colonoscopy1-4 *See Rex DK, et al. Am J Gastroenterol. 2017;112(7):1016-1030 for additional MSTF recommendations. The United States Multi-Society Task Force on Colorectal Cancer includes the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE). †The USPSTF concludes with moderate certainty that screening for CRC in adults aged 45 to 49 years has moderate net benefit (Grade B).
‡The “qualified” designation indicates that there is clear evidence of benefit (or harm) but some uncertainty on the balance of benefits/harms or patient values/preferences, which can influence individual decisions.
CRC: colorectal cancer; CTC: computed tomography colonography; FIT: fecal immunochemical test; FS: flexible sigmoidoscopy; hs-gFOBT: high sensitivity guaiac-based fecal occult blood test; mt-sDNA: multi-target stool DNA test. 1. Davidson KW, et al. JAMA. 2021;325(19):1965-1977. 2. Wolf AMD, et al. CA Cancer J Clin. 2018;68(4):250-281. 3. Shaukat AK, et al. Am J Gastroenterol. 2021;116(3):458-479. 4. Patel SG, et al. Gastroenterol. 2022;162(1):285-299.<br>

Informed Decision Making 1. Davidson KW, et al. JAMA. 2021;325(19):1965-1977. 2. Wolf AMD, et al. CA Cancer J Clin. 2018;68(4):250-281. 3. Shaukat et al. Am J Gastroenterol. 2021;116:458-479. National Guidelines Recommend Informed Decision Making to Improve Screening Adherence<br>

Guideline Recommendations: Colonoscopy After Positive Stool-Based Test FIT: fecal immunochemical test.
1. Davidson KW, et al. JAMA. 2021;325(19):1965-1977. 2. Wolf AMD, et al. CA Cancer J Clin. 2018;68(4):250-281. 3. Shaukat A, et al. Am J Gastroenterol. 2021;116(3):458-479. Timely follow-up screening of positive stool tests with colonoscopy is recommended by most major screening guidelines.1-3 “When stool-based tests reveal abnormal results, follow-up with colonoscopy is needed for further evaluation.” US Preventive Services Task Force (USPSTF) 20211 “[For non-colonoscopy CRC screening stool tests] positive results require colonoscopy.” American
Cancer Society (ACS)
20182 For non-colonoscopy CRC screening tests, “positive results require colonoscopy.” American College of Gastroenterology
(ACG) 20213<br>

Colonoscopy After a Positive Stool-Based Test: New Coverage Requirements for Colonoscopies After Positive Stool-Based Tests ACA: Affordable Care Act; CRC: colorectal cancer.
1. DOL. FAQs About Affordable Care Act Implementation Part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation. Published January 10, 2022. Accessed September 30, 2025. https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf 2. Centers for Medicare & Medicaid Services. HHS Finalizes Physician Payment Rule Strengthening Access to Behavioral Health Services and Whole-Person Care. [Press Release]. Published November 1, 2022. Accessed September 30, 2025. https://www.cms.gov/newsroom/press-releases/hhs-finalizes-physician-payment-rule-strengthening-access-behavioral-health-services-and-whole 3. American Cancer Society. Insurance Coverage for Colorectal Cancer Screening. Updated February 27, 2025. Accessed September 30, 2025. https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/screening-coverage-laws.html Federal guidance requires commercial health plans under the Affordable Care Act (ACA) to cover follow-up colonoscopy after a positive, noninvasive CRC screening test without patient cost share2 Effective January 1, 2023, Medicare covers as a preventive service, a screening colonoscopy after a positive non-invasive stool test, with no out-of-pocket costs3 Patients and providers are encouraged to ask their individual insurers about coverage4
Some commercial plans may have exceptions4
Polyp removal or other services may be subject to separate charges, regardless of a positive stool-based test4
Plan and benefit designs are different, and the rules may differ if a provider is out-of-network4<br>

What Makes Clinical Guidelines Trustworthy? 1. Graham R, et al. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. Accessed September 30, 2025. https://www.ncbi.nlm.nih.gov/books/NBK209539/pdf/Bookshelf_NBK209539.pdf 2. GRADE Working Group. December 2024. Accessed September 30, 2025. www.gradeworkinggroup.org 3. Guyatt G, et al. J Clin Epidemiol. 2011;64(4):383-394. Institute of Medicine Recommendations for Trustworthy Guidelines1 GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) 2,3 Based on systematic evidence review
Developed by panel of multidisciplinary experts
Transparent to minimize bias
Provide ratings of quality of evidence
Provide ratings of strength of recommendations Provides a common, sensible, and transparent approach for grading the quality/certainty of evidence and the strength of recommendations in clinical guidelines2
Specifies an approach for3:
Framing questions
Choosing and rating outcomes of interest
Evaluating the evidence
Incorporating evidence with values of patients and society
Providing guidance on using recommendations in clinical practice [The proposed standards] have the capacity to increase quality and trustworthiness of clinical practice guidelines and ultimately enhance healthcare quality and patient outcomes.
– Institute of Medicine, 2011<br>

2021 United States Preventive Services Task Force (USPSTF) Final Recommendation Statement 1. Davidson KW, et al. JAMA. 2021;325(19):1965-1977. 2. US Preventive Services Task Force. Grade definitions. Current as of June 2018. Accessed September 30, 2025. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions<br>

2018 American Cancer Society (ACS) Recommendation Summary CRC: colorectal cancer.
Wolf A, et al. CA Cancer J Clin. 2018;68:250-281.<br>

2021 American College of Gastroenterology (ACG) Recommendation Statement Shaukat A, et al. Am J Gastroenterol. 2021;116:458-479.<br>

2021 US Multi-Society Task Force (MSTF)* Recommendation Statement *The United States Multi-Society Task Force on Colorectal Cancer includes the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE).
Patel SG, et al. Gastroenterol. 2022;162(1):285-299.<br>

ACP 2023: American College of Physicians ACP: American College of Physicians; CRC: colorectal cancer; FIT: fecal immunochemical test; FS: flexible sigmoidoscopy. hs-gFOBT: high-sensitivity guaiac-based fecal occult blood test;
Qaseem A, et al. Ann Intern Med. 2023;176:1092-1100.<br>

AAFP 2021: American Academy of Family Physicians †A recommendation indicates the AAFP recommends the service. There is high certainty that the net benefit is substantial.
‡C recommendation indicates the AAFP recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.
††D recommendation indicates the AAFP recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
§I statement indicates the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
AAFP: American Academy of Family Physicians; CRC: colorectal cancer; FIT: fecal immunochemical test.
American Academy of Family Physicians. Colorectal Cancer Screening, Adults. Accessed September 30, 2025. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/colorectal-cancer-adults.html<br>

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