Approach to the use of noninvasive colorectal cancer (CRC) screening options

Ideal CRC screening would use precision medicine to identify lower-risk individuals within the average-risk cohort who may benefit from noninvasive screening. These tools include clinical factors (eg, age, sex, race, and family history), lifestyle factors (eg, smoking, obesity, physical activity, and medications), and genomic factors (eg, single nucleotide polymorphisms). Current risk-stratification schemes may improve our ability to provide customized screening based on risk of advanced neoplasia, particularly in young screenees. Strong evidence demonstrates CRC risk increased in 45- to 49-year-olds over the past 20 years, justifying new recommendations to initiate screening at age 45 years, yet risk remains relatively low for most individuals before age 50 years. Noninvasive screening may be appropriate for these younger individuals with use of colonoscopy as patients age into higher-risk states. However, based on risk-scoring schemes, current smoking, obesity, and low levels of physical activity may identify younger individuals at higher risk for advanced adenomas who may benefit from colonoscopy. Further research is needed to determine effective risk-stratification schemes that reduce CRC incidence and mortality. Clinicians should be able to inform patients of available screening options, including advantages, disadvantages, and test accuracy. Patients should be informed that a positive noninvasive test is an indicator of CRC risk and should be followed by a timely, high-quality colonoscopy to complete the screening spectrum. Quality metrics for noninvasive screening programs should be set and program performance should be measured and ideally reported publicly. Poor adherence at any level should trigger review of established protocols and facilitate change to ensure high-quality screening.