March is Colorectal Cancer Awareness Month
American Cancer Society Recommendations for Colorectal Cancer Early Detection
People at average risk
The American Cancer Society believes that preventing colorectal cancer (and not just finding it early) should be a major reason for getting tested. Having polyps found and removed keeps some people from getting colorectal cancer. You are encouraged to have tests that have the best chance of finding both polyps and cancer if these tests are available to you and you are willing to have them. But the most important thing is to get tested, no matter which test you choose.
Starting at age 50, men and women at average risk for developing colorectal cancer should use one of the screening tests below:
Tests that find polyps and cancer
- Colonoscopy every 10 years
- CT colonography (virtual colonoscopy) every 5 years*
- Flexible sigmoidoscopy every 5 years*
- Double-contrast barium enema every 5 years*
Tests that mainly find cancer
- Fecal immunochemical test (FIT) every year*,**
- Guaiac-based fecal occult blood test (gFOBT) every year*,**
- Stool DNA test every 3 years*
Is a rectal exam enough to screen for colorectal cancer?
In a digital rectal examination (DRE), a health care provider examines your rectum with a lubricated, gloved finger. Although a DRE is often included as part of a routine physical exam, it’s not recommended as a stand-alone test for colorectal cancer. This simple test, which is not usually painful, can find masses in the anal canal or lower rectum. But by itself, it’s not a good test for detecting colorectal cancer because it only checks the lower rectum.
Doctors often find a small amount of stool in the rectum when doing a DRE. But testing this stool for blood with a gFOBT or FIT is not an acceptable way to screen for colorectal cancer. Research has shown that this type of stool exam will miss more than 90% of colon abnormalities, including most cancers.
People at increased or high risk
If you are at an increased or high risk of colorectal cancer, you might need to start colorectal cancer screening before age 50 and/or be screened more often. The following conditions make your risk higher than average:
- A personal history of colorectal cancer or adenomatous polyps
- A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
- A strong family history of colorectal cancer or polyps (see Colorectal Cancer Risk Factors)
- A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC)
The table below suggests screening guidelines for people with increased or high risk of colorectal cancer based on specific risk factors. Some people may have more than one risk factor. Refer to the table below and discuss these recommendations with your health care provider. Your provider can suggest the best screening option for you, as well as any changes in the schedule based on your individual risk.
| American Cancer Society Guidelines on Screening and Surveillance for the Early Detection of Colorectal Adenomas and Cancer in People at Increased Risk or High Risk | |||
| INCREASED RISK – People who have a history of polyps on prior colonoscopy | |||
| Risk category | When to test | Recommended test(s) | Comment |
| People with small rectal hyperplastic polyps | Same age as those at average risk | Colonoscopy, or other screening options at same intervals as for those at average risk | Those with hyperplastic polyposis syndrome are at increased risk for adenomatous polyps and cancer and should have more intensive follow-up. |
| People with 1 or 2 small (no more than 1 cm) tubular adenomas with low-grade dysplasia | 5 to 10 years after the polyps are removed | Colonoscopy | Time between tests should be based on other factors such as prior colonoscopy findings, family history, and patient and doctor preferences. |
| People with 3 to 10 adenomas, or a large (at least 1 cm) adenoma, or any adenomas with high-grade dysplasia or villous features | 3 years after the polyps are removed | Colonoscopy | Adenomas must have been completely removed. If colonoscopy is normal or shows only 1 or 2 small tubular adenomas with low-grade dysplasia, future colonoscopies can be done every 5 years. |
| People with more than 10 adenomas on a single exam | Within 3 yearsafter the polyps are removed | Colonoscopy | Doctor should consider possible genetic syndrome (such as FAP or Lynch syndrome). |
| People with sessile adenomas that are removed in pieces | 2 to 6 months after adenoma removal | Colonoscopy | If entire adenoma has been removed, further testing should be based on doctor’s judgment. |
| INCREASED RISK – People who have had colorectal cancer | |||
| Risk category | When to test | Recommended test(s) | Comment |
| People diagnosed with colon or rectal cancer | At time of colorectal surgery, or can be 3 to 6 months later if person doesn’t have cancer spread that can’t be removed | Colonoscopy to look at the entire colon and remove all polyps | If the tumor presses on the colon/rectum and prevents colonoscopy, CT colonoscopy (with IV contrast) or DCBE may be done to look at the rest of the colon. |
| People who have had colon or rectal cancer removed by surgery | Within 1 yearafter cancer resection (or 1 year after colonoscopy to make sure the rest of the colon/rectum was clear) | Colonoscopy | If normal, repeat in 3 years. If normal then, repeat test every 5 years. Time between tests may be shorter if polyps are found or there’s reason to suspect Lynch syndrome. After low anterior resection for rectal cancer, exams of the rectum may be done every 3 to 6 months for the first 2 to 3 years to look for signs of recurrence. |
| INCREASED RISK – People with a family history | |||
| Risk category | Age to start testing | Recommended test(s) | Comment |
| Colorectal cancer or adenomatous polyps in any first-degree relative before age 60, or in 2 or more first-degree relatives at any age (if not a hereditary syndrome). | Age 40, or 10 years before the youngest case in the immediate family, whichever is earlier | Colonoscopy | Every 5 years. |
| Colorectal cancer or adenomatous polyps in any first-degree relative aged 60 or older, or in at least 2 second-degree relatives at any age | Age 40 | Same test options as for those at average risk. | Same test intervals as for those at average risk. |
| HIGH RISK | |||
| Risk category | Age to start testing | Recommended test(s) | Comment |
| Familial adenomatous polyposis (FAP) diagnosed by genetic testing, or suspected FAP without genetic testing | Age 10 to 12 | Yearly flexible sigmoidoscopy to look for signs of FAP; counseling to consider genetic testing if it hasn’t been done | If genetic test is positive, removal of colon (colectomy) should be considered. |
| Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC), or at increased risk of Lynch syndrome based on family history without genetic testing |
Age 20 to 25 years, or 10 years before the youngest case in the immediate family | Colonoscopy every 1 to 2 years; counseling to consider genetic testing if it hasn’t been done | Genetic testing should be offered to first-degree relatives of people found to have Lynch syndrome mutations by genetic tests. It should also be offered if 1 of the first 3 of the modified Bethesda criteria is met.* |
| Inflammatory bowel disease:
-Chronic ulcerative colitis -Crohn’s disease |
Cancer risk begins to be significant 8 years after the onset of pancolitis (involvement of entire large intestine), or 12-15 years after the onset of left-sided colitis | Colonoscopy every 1 to 2 years with biopsies for dysplasia | These people are best referred to a center with experience in the surveillance and management of inflammatory bowel disease. |
Colorectal Cancer Screening: Insurance Coverage
The American Cancer Society believes that all people should have access to cancer screenings, without regard to health insurance coverage. Limitations on coverage should not keep someone from the benefits of early detection of cancer. The Society supports policies that give all people access to and coverage of early detection tests for cancer. Such policies should be age- and risk-appropriate and based on current scientific evidence as outlined in the American Cancer Society’s Early Detection Guidelines.
Federal law
Coverage of colorectal cancer screening tests is required by the Affordable Care Act (ACA), but the ACA doesn’t apply to health plans that were in place before it was passed (called “grandfathered plans”). You can find out your insurance plan’s grandfathered status by contacting your health insurance company or your employer’s human resources department. If your plan started on or after September 23, 2010, it must cover colonoscopies and other colorectal cancer screening tests. If a plan started before September 23, 2010, it may still have coverage requirements from state laws, which vary, and other federal laws.
Private health insurance coverage for colorectal cancer screening
The Affordable Care Act requires health plans that started on or after September 23, 2010 to cover colorectal cancer screening tests.
Although many private insurance plans cover the costs for colonoscopy as a screening test, you still might be charged for some services. Review your health insurance plan for specific details, including if your doctor is on your insurance company’s list of “in-network” providers. If the doctor is not in the plan’s network, you may have to pay more out-of-pocket.
Colonoscopies that are done to evaluate specific problems, such as belly (abdominal) pain, intestinal bleeding, or low red blood cell counts (anemia), are usually classified as diagnostic– and not screening – procedures. If that’s the case, you may have to pay any required deductible and co-pay. The same is true if colonoscopy is done after a positive stool test (such as the gFOBT or FIT) or an abnormal double-contrast barium enema or CT colonography. Some insurance plans also consider a colonoscopy diagnostic if something is found (like a polyp) during the procedure that needs to be removed or biopsied.
Before you get a screening colonoscopy, ask your insurance company how much (if anything) you should expect to pay for it. Find out if this amount could change based on what’s found during the test. This can help you avoid surprise costs. If you do have large bills afterward, you may be able to appeal the insurance company’s decision.
Medicare coverage for colorectal cancer screening
Medicare covers an initial preventive physical exam for all new Medicare beneficiaries. It must be done within one year of enrolling in Medicare. The “Welcome to Medicare” physical includes referrals for preventive services already covered under Medicare, including colon cancer screening tests.
If you’ve had Medicare Part B for longer than 12 months, a yearly “wellness” visit is covered without any cost. This visit is used to develop or update a personalized prevention plan to prevent disease and disability. Your provider should discuss a screening schedule (like a checklist) with you for preventive services you should have, including colon cancer screening.
What colorectal cancer screening tests does Medicare cover?
Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year for all Medicare beneficiaries 50 years and older.Stool DNA test (Cologuard) every 3 years for Medicare beneficiaries 50 to 85 years old who do not have symptoms of colorectal cancer and who do not have an increased risk of colorectal cancer.
Flexible sigmoidoscopy every 4 years for those 50 years and older, but not within 10 years of a previous colonoscopy.
Colonoscopy
- Every 2 years for those at high risk (regardless of age)
- Every 10 years for those who are at average risk
- 4 years after a flexible sigmoidoscopy for those who are at average risk
Double-contrast barium enema if a doctor determines that its screening value is equal to or better than flexible sigmoidoscopy or colonoscopy:
- Once every 2 years for those 50 years and older who are at high risk
- Once every 4 years for those 50 years and older who are at average risk
At this time, Medicare does not cover the cost of virtual colonoscopy (CT colonography).
If you have questions about your costs, including deductibles or co-pays, it’s best to speak with your insurance company.
What would someone on Medicare expect to pay for a colorectal cancer screening test?
- FOBT/FIT: Covered at no cost* for those age 50 years or older (no co-insurance or Part B deductible).
- Stool DNA test (Cologuard): Covered at no cost* for those age 50 to 85 as long as they are not at increased risk of colorectal cancer and don’t have symptoms of colorectal cancer (no co-insurance or Part B deductible).
- Flexible sigmoidoscopy: Covered at no cost* for those age 50 or older (no co-insurance, co-payment, or Part B deductible) when the test is done for screening. If because of the test results, you need a biopsy or removal of a growth, it’s no longer a “screening” test, and you will be charged co-insurance and/or a co-pay (although your deductible is waived).
- Colonoscopy: Covered at no cost* at any age (no co-insurance, co-payment, or Part B deductible) when the test is done for screening. If the test results in the biopsy or removal of a growth it’s no longer a “screening” test, and you will be charged co-insurance and/or a co-pay (although you still don’t have to pay the deductible).
- Double-contrast barium enema: Beneficiary pays 20% of the Medicare approved amount for the doctor services. If the test is done in an outpatient hospital department or ambulatory surgical center, the beneficiary also pays the hospital co-payment.
If you’re getting a screening colonoscopy, be sure to find out how much you might have to pay for it. This can help you avoid surprise costs. Patients may still have to pay for the bowel prep kit, anesthesia or sedation, pathology costs, and facility fee. Patients may get one or more bills for different parts of the procedure from different practices and hospital providers.
Tests including colonoscopy are not classified by Medicare as screening procedures if they are done to evaluate specific problems, such as belly (abdominal) pain, intestinal bleeding, or low red blood cell counts (anemia). If you are getting a test for such a reason, you may have to pay the usual deductible and co-pay.
Medicaid coverage for colorectal cancer screening
States are authorized to cover colorectal screening under their Medicaid programs. But unlike Medicare, there’s no federal assurance that all state Medicaid programs must cover colorectal cancer screening in people without symptoms. Medicaid coverage for colorectal cancer screening varies by state. Some states cover fecal occult blood testing (FOBT), while others cover colorectal cancer screening if a doctor determines the test is medically necessary. In some states, coverage varies according to which Medicaid managed care plan a person is enrolled in.