Dr Shaukat discusses risk stratification for colorectal cancer screening and surveillance for low- and high-risk patients. 

Aasma Shaukat, MD, is professor of medicine and population health at the NYU-Grossman School of Medicine and a physician at the New York Harbor Veterans Administration Medical Center in New York City.

Hello, my name is Aasma Shaukat, I'm a professor of medicine and population health at NYU Grossman School of Medicine and a physician at the New York Harbor VA Medical Center. I'm very excited to be talking to you about risk stratification for colorectal cancer screening as well as surveillance.

We've had some really great evidence recently accumulate in the literature that has informed our guidelines and this is an area that is often confusing for physicians, so I'm going to walk you through it. For individuals that have no family history of colorectal cancer or advanced adenomas either personally or in their family, also don't have a high-risk condition such as inflammatory bowel disease, hereditary colorectal cancer syndrome, or polyposis, we consider them average risk and screening should begin at age 45 for both men and women and it should continue until age 75.

Between 76 and 85 the decision can be based on several factors including the patient's screening history, their baseline risk, their health status and their expected life expectancy. After age 85, screening is generally not recommended because the harms outweigh the benefits. So we really need to be selective in that population and generally consider not screening after the age of 85.

In terms of family history, having a family history of a first-degree relative with a colon cancer, the most important thing to ask is, was that first-degree relative younger or older than age 60 at the time of diagnosis? Often our patients don't know, so it's a best guess situation. So, after we determine that information, in general, screening should begin at age 40 or 10 years younger than that first-degree relative's age of diagnosis. So if the first-degree relative that developed cancer, but their age at diagnosis was younger than 60, then we would recommend our patients start colorectal cancer screening at age 40. Only use colonoscopy because we consider them increased risk and repeat screening every 5 years if that colonoscopy is negative.

However, if the first-degree relative was older than age 60 at diagnosis, then we recommend that colon cancer screening start at age 40. However, any modality can be used, either a colonoscopy or a stool-based test. And if, say, the colonoscopy is done and it's negative, we would follow regular repeat intervals, which is 10 years. So really, that stratification is important and it's supported by data.

The other question that often comes up is second-degree relatives. Second-degree relatives do not confer an increased risk of colorectal cancer. So a second-degree relative would be grandparent, either one or more, aunts or uncles or cousins, that does not constitute high risk for colon cancer, screening can start at the recommended age, which is 45, and follow average risk screening strategies.

The next thing I wanted to address was surveillance. So after our patients have a colonoscopy, when should the next colonoscopy be? It's based on the findings of the colonoscopy and the biggest change is that with findings of 1 to 2 small tubular adenomas that are nonadvanced, meaning no advanced villus or high -grade dysplasia features, we would bring them back in 7 to 10 years. For individuals with 3 to 4 small nonadvanced tubular adenomas, we would recommend that they have a repeat colonoscopy in 3 to 5 years. Only when a patient has an advanced adenoma or more than 5 nonadvanced adenomas, the recommended interval for repeat colonoscopy is 3 years. So these are really important, so we maximize the use of our colonoscopy capacity and we're not over surveying our patients or performing undersurveillance and freeing up resources so that we can use them for a lot of other appropriate indications. This is also a quality metric that is tracked for most practices and even can be submitted to pairs as part of MIPS or other quality improvement programs. Thank you so much for your attention.