NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Colorectal Cancer Screening Version 1.2015 NCCN.org Continue Version 1.2015, 06/01/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN® NCCN Guidelines Version 1.2015 Panel Members NCCN Guidelines Index Colorectal Screening TOC Colorectal Cancer Screening Discussion * Dawn Provenzale, MD, MS/Chair ¤ Þ Francis M. Giardiello, MD, MBA ¤ Patrick M. Lynch, MD, JD ¤ Duke Cancer Institute The Sidney Kimmel Comprehensive The University of Texas Cancer Center at Johns Hopkins MD Anderson Cancer Center * Kory Jasperson, MS, CGC/Vice-chair/Lead ∆ Huntsman Cancer Institute Samir Gupta, MD ¤ Robert J. Mayer, MD † Þ at the University of Utah UC San Diego Moores Cancer Center Dana-Farber/Brigham and Women’s Cancer Center Dennis J. Ahnen, MD ¤ Amy L. Halverson, MD ¶ University of Colorado Cancer Center Robert H. Lurie Comprehensive Cancer Reid M. Ness, MD, MPH ¤ Center of Northwestern University Vanderbilt-Ingram Cancer Center Harry Aslanian, MD ¤ Yale Cancer Center/ Stanley R. Hamilton, MD ≠ M. Sambasiva Rao, MD ≠ ¤ Smilow Cancer Hospital The University of Texas Robert H. Lurie Comprehensive Cancer MD Anderson Cancer Center Center of Northwestern University Travis Bray, PhD ¥ Hereditary Colon Cancer Foundation Heather Hampel, MS, CGC ∆ Scott E. Regenbogen, MD ¶ The Ohio State University Comprehensive University of Michigan Jamie A. Cannon, MD ¶ Cancer Center - James Cancer Hospital Comprehensive Cancer Center University of Alabama at Birmingham and Solove Research Institute Comprehensive Cancer Center Moshe Shike, MD ¤ Þ Mohammad K. Ismail, MD ¤ Memorial Sloan Kettering Cancer Center Donald S. David, MD ¤ St. Jude Children’s Research Hospital/ City of Hope Comprehensive The University of Tennessee Gideon Steinbach, MD, PhD ¤ Þ Cancer Center Health Science Center Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance Dayna S. Early, MD ¤ Jason B. Klapman, MD ¤ Siteman Cancer Center at Barnes- Moffitt Cancer Center David Weinberg, MD, MSc ¤ Jewish Hospital and Washington Fox Chase Cancer Center University School of Medicine David W. Larson, MD, MBA¶ NCCN Mayo Clinic Cancer Center Susan Darlow, PhD Deborah Erwin, PhD Mary Dwyer, MS Roswell Park Cancer Institute Audrey J. Lazenby, MD ≠ Deborah Freedman-Cass, PhD Fred & Pamela Buffett Cancer Center James M. Ford, MD † Þ ∆ ¤ Gastroenterology Stanford Cancer Institute ∆ Cancer genetics Þ Internal medicine † Medical oncology Continue ≠ Pathology ¶ Surgery/Surgical oncology ¥ Patient advocacy NCCN Guidelines Panel Disclosures * Discussion Writing Committee Member Version 1.2015, 06/01/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN® NCCN Guidelines Version 1.2015 Table of Contents NCCN Guidelines Index Colorectal Screening TOC Colorectal Cancer Screening Discussion NCCN Colorectal Cancer Screening Panel Members Clinical Trials: NCCN believes that Summary of the Guidelines Updates the best management for any cancer patient is in a clinical trial. • Risk Assessment for Colorectal Cancer (CSCR-1) Participation in clinical trials is especially encouraged. Average Risk To find clinical trials online at NCCN Member Institutions, click here: • Average Risk (CSCR-2) nccn.org/clinical_trials/physician.html. Increased Risk NCCN Categories of Evidence and • Personal History of Adenomatous or Sessile Serrated Polyps (CSCR-3) Consensus: All recommendations • Personal History of Colorectal Cancer (CSCR-4) are category 2A unless otherwise • Personal History of Inflammatory Bowel Disease (CSCR-5) specified. • Increased Risk Based on Positive Family History (CSCR-6) See NCCN Categories of Evidence and Consensus. • Screening Modality and Schedule (CSCR-A) • Definitions of Common Colorectal Resections (CSCR-B) For High-Risk Colorectal Cancer Syndromes, see NCCN Genetic/Familial High-Risk Assessment: Colorectal The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2015. Version 1.2015, 06/01/15 © National Comprehensive Cancer Network, Inc. 2015, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN® NCCN Guidelines Version 1.2015 Updates NCCN Guidelines Index Colorectal Screening TOC Colorectal Cancer Screening Discussion Updates in Version 1.2015 of the NCCN Guidelines for Colorectal Cancer Screening from Version 1.2014 include: CSCR-1 • Footnote “b” was changed from “There is controversy over whether SSPs should be called ‘sessile serrated adenomas.’ These terms are equivalent and these guidelines will use ‘SSPs.’ SSPs are a type of serrated polyp and should be managed the same as adenomas. However, any serrated lesions in the proximal to sigmoid colon should be followed similarly to adenomatous polyps.” to “The terms sessile serrated polyp (SSP) and sessile serrated adenoma are synonymous; SSPs are a type of serrated polyp that are not dysplastic but they can develop foci of dysplasia and are then termed SSP with cytologic dysplasia (SSP-cd). These guidelines will use ‘SSP’ for SSPs without dysplasia and ‘SSP-cd’ for SSPs with dysplasia. In general SSPs are managed like tubular adenomas and SSP-cd are managed like high-risk adenomas but may need even more frequent surveillance. In addition, any serrated lesions proximal to the sigmoid colon should be followed similarly to adenomatous polyps.” CSCR-2 Average Risk Screening • Evaluation of Screening Findings After biopsy or polypectomy, the findings option was revised: “Hyperplastic, non-SSP, and <1 cmin rectum and sigmoid only.” • Footnotes Footnote “d” was revised as, “Currently there is not a consensus on the use of CT colonography (CTC) as a primary screening modality... Also unclear is what follow-up is required for a patient with a positive CTC and a negative colonoscopy. CTC may also not be as sensitive as colonoscopy to detect clinically significant lateral spreading tumors (Togashi K, et al. World J Gastroenterol 2014 Dec;20:17552-7). Despite these uncertainties, CTC is being utilized in clinical practice However. The current data available suggest that if CTC is negative/no polyps, then repeat CTC in 5 y, and if positive/polyps lesions, colonoscopy should be performed.” Footnote “e” was added: “CRC screening should be performed as part of a program that includes a systematic method for identifying those who are eligible for and wish to undergo screening, standard methods for administering the screening tests at agreed upon intervals, standardized reporting of the results, and a mechanism for follow-up of those with a positive test.” Footnote “f” was modified as, “If colonoscopy is incomplete or preparation is suboptimal, consider other screening modality or repeat colonoscopy in 1 y (Johnson D, et al. Gastroenterology 2014;147:903–924) a shorter interval at discretion of physician.” Footnote “g” was revised as, “Emerging technologies such as stool DNA have shown increasing evidence as a reasonably accurate screening modality, but Stool DNA testing has recently been approved by the FDA as a primary screening modality for colorectal cancer (Imperiale TF, et al. N Engl J Med 2014;370:1287-97). At this time, there are limited data available to determine an appropriate interval between screening. At present, stool DNA is not considered a primary screening modality. Footnote “i” was revised as, “SSPs are managed the same as adenomas SSPs without dysplasia are generally managed like adenomas; SSP-cd are managed like high-risk adenomas and may need even more frequent surveillance.” (Also for CSCR-3) Footnote “e” text was moved to CSCR-A, ◊ There is direct evidence from randomized controlled trials that fecal occult blood testing (Mandel JS, et al. N Engl J Med 1993;328:1365-71; Hardcastle JD, et al. Lancet 1996; 348:1472-77; Kronborg O, et al. Lancet 1996; 348:1467-71) and flexible sigmoidoscopy (Atkin WS, et al. Lancet 2010;375:1624-33; Schoen RE, et al. N Eng J Med 2012;366:2345-57; Nishihara R, et al. N Eng J Med; 2013;369:1095-105) will reduce mortality from colorectal cancer. There is evidence from case control and cohort studies that colonoscopy has the potential ability to prevent colorectal cancer (with its associated morbidity) and cancer deaths (Kahi CJ, et al. Clin Gastroenterol Hepatol 2009;7:770-5; Baxter NN, et al. Ann Intern Med 2009;150:1-8). ◊ “Winawer S, et al. J Natl Cancer Inst 1993;85:1311-8 and Zauber AG, et al. Ann Intern Med 2008;149:659-69.” Continued on next page Version 1.2015, 06/01/15 © National Comprehensive Cancer Network, Inc.