Any of 4 screening options suggested for screen-naive adults 59 to 70 y with ≥ 3% 15-y risk for colorectal cancer
To balance shared decision making and population health in colorectal cancer screening, as called for in a recent guideline, a viable strategy could include universal, opt-out fecal immunochemical testing starting at age 50 years, a commentary in ACP Journal Club noted.
A guideline developed by the BMJ Rapid Recommendations project suggested that screening for colorectal cancer (CRC) may not be necessary in low-risk individuals ages 50 to 79 years. It recommended that most fully informed patients may choose screening when their 15-year CRC risk is 3% or greater, whereas most with a lower risk may decide that benefits do not outweigh burdens and risks. However, one's informed choice to screen or not should depend on his or her values and preferences, regardless of baseline risk, the guideline said.
The guideline was published online on Oct. 2, 2019, by The BMJ and was summarized in the Oct. 25, 2019, ACP Gastroenterology Monthly. The following commentary, by Lenard Lesser, MD, MSHS, appeared in the ACP Journal Club section of the March 17 Annals of Internal Medicine.
This guideline confirms that CRC screening results in a small, but significant, mortality benefit; that people at higher risk are more likely to benefit; and that several reasonable screening choices exist. Studies have shown that costs are relatively equal among the options. The guideline recommends shared decision making (SDM) when selecting a screening method.
Using a calculator to estimate the risk for CRC and offering screening to persons with ≥3% risk is recommended. The cutpoint of 3% is based on opinion, not clinical trial data, and so it is reasonable to offer screening to patients at lower risk. However, the calculator may not be universally applicable because it was developed using patient data from England and its utility is limited by a lack of integration into electronic health records.
It is impractical to apply SDM for every clinical decision; SDM is most useful when benefits and harms need to be balanced (e.g., starting a blood thinner for atrial fibrillation) using adequate tools to quantify and discuss risk. With the small risk for harm with [fecal immunochemical test] FIT, SDM for CRC screening should be a lower priority than discussions for other preventive services. Individual autonomy needs to be balanced with population health. For CRC screening, universal FIT programs have higher screening rates than endoscopic methods. Requiring a shared decision for every FIT screening will probably reduce uptake.
To balance SDM and population health in CRC screening, a viable strategy would have a universal, opt-out FIT screening program starting at age 50 years. Clinicians could engage with patients who do not get screened or who opt out of FIT. At perhaps 5-year intervals, SDM could be part of an annual wellness visit where a clinician discusses opting out of an annual FIT program for another screening option. Meanwhile, clinical decision-support tools using electronic health records could identify patients with higher risk who could benefit from colonoscopy.
Combining a technology-enhanced, universal FIT screening program with opportunistic SDM will probably strike a balance of reducing CRC mortality with patient autonomy.