Mayo Clinic Arizona Guidelines for Prevention and Surveillance of Colorectal Cancer

Division of Gastroenterology  Colorectal Neoplasia Clinic


Screening/Prevention (Table 1)


Patient Category                     First Step                            Next Step    Reference

Average risk patient, no risk

factors for colorectal cancer

except age 50 years


Begin screening

colonoscopy at age 50


If normal repeat

every 10 years





Average risk patient, no risk

factors for colorectal cancer

except race (African



Begin screening

colonoscopy at age 45


If normal repeat

every 10 years




Single 1st-degree relative*

with colorectal cancer

dx  age 60 or two 2nd

degree* relatives dx with

colorectal cancer


Begin screening

colonoscopy at age 40.1,3


If normal, repeat

every 5-10 years3,4


AGA1, ACG³,4


Single 1st-degree relative with colorectal cancer or tubular adenoma 60 years or two 1st-degree relatives of any age

Colonoscopy at age 40, or 10 years before the youngest case in the 1st-degree relative, whichever comes first


If normal, repeat

every 5 years


AGA1, ACG³,4


Inflammatory bowel

disease, chronic UC or

Crohn’s disease


Screening colonoscopy

8 years after onset of

pancolitis, or 12-15

years after onset of left



Every 1-2 years





For patients with colorectal

cancer before age 50,

multiple polyps before age

40 or with a family hx of

colorectal or other cancers,

consider a hereditary

colorectal cancer syndrome

Call Genetic Counseling

@ (480) 301-4585 or

any member of the

Colorectal Interest

Group: Drs. Heigh,

Leighton, Efron, Heppell,

and Young Fadok







Discontinuation of surveillance

colonoscopy should

be considered in patients

with serious co-morbidities

with less than 10 years of

life expectancy, according to

the clinician’s judgment.


Consider alternative to

colonoscopy for

colorectal cancer

prevention or



Follow up is

dependent on

results of











Surveillance (Table2)


Patient Category                                           First Step                    Next Step     Reference           

1 to 2 adenomas, < 1cm


5–10 years; precise timing within this

interval should be based on other

clinical factors such as prior colonoscopy findings, family hx etc.


If normal, repeat every

10 years




• 3 adenomas

•Adenoma with villous or serrated


•1 adenoma> 1 cm

•Hyperplastic polyp >1 cm is treated

as adenoma


Repeat in 3 years if confident all

adenomas have been found and



If normal, repeat in 5



AGA1,7, ACG4


Large sessile (no stalk) adenoma

>2 cm


Repeat in 3 months5


If residual polyp

removed, repeat in 6mos.4 If either of previous exams are normal, repeat in 1 year. If normal after 1 year,

repeat every 3 years.5  If not normal after 2-3

exams then surgery.4,5






Adenoma with high grade dysplasia or

malignant polyp completely resected

with clear margins of excision and no

invasion of stalk.  Adjust for individual

patient characteristics including fitness for and interest in considering additional treatment


If polyp is pedunculated, strongly consider GI or colorectal surgery

consultation. Repeat colonoscopy in 3 years.


If normal, repeat in 5 years if it is the only polyp.




If polyp is sessile, strongly consider GI or colorectal surgery consultation for further diagnosis and treatment

or consider repeating colonoscopy or flex-sig in 3 months 4


Follow up based on consultation or consider repeat colonoscopy or flexsig at 3-6 mos.




Personal history of curative intent

resection of colorectal cancer and surveillance after curative intent

treatment for colorectal cancer:


•Repeat colonoscopy six months to   one year after cancer resection.

•H&P every 3-6 months x 3 years

•Annual CT chest, abdomen and pelvis x 3 years

•CEA every 3 months for 3 years

•Flex-sig every 6 months for rectal cancers not treated with XRT


•H&P every 6 months years 4 and 5




If conflict between table 1 and table 2, choose the earlier time. Individual

situations may dictate a course of management at variance from these guidelines.





Preferred Procedure

Colonoscopy 1, 2, 6 particularly in African Americans


Alternative Strategies:

Fecal occult blood testing (FOBT) plus flexible sigmoidoscopy with

contrast barium enema

1. Three stool samples collected by patient after a bowel movement 1

2. Strict instructions regarding diet/medications prior to stool



Indications for Colonoscopy:

Colon cancer screening and surveillance of colonic neoplasia 9

Evaluation of unexplained gastrointestinal bleeding e.g.

hematochezia, melena after upper GI source has been ruled out,

positive FOBT and treatment of known GI bleeding lesion 9

Abnormality of the colon on imaging study e.g. filling defect on

barium enema 9

Unexplained iron deficiency anemia 9

Patients with significant family history i.e. hereditary non polyposis

colorectal cancer

History of inflammatory bowel disease 9

Foreign body removal 9

Balloon dilation of stenotic lesion 9

Decompression of acute nontoxic megacolon or sigmoid volvulus 9

Marking neoplasm for localization 9

Clinically significant diarrhea of unexplained origin 9

Excision of colonic polyp 9

Change in bowel habits


Colonoscopy Generally Not Indicated for These Symptoms and


Chronic, stable irritable bowel syndrome 9

Chronic abdominal pain; 9 consider contrast barium enema if


Acute diarrhea i.e. diarrhea for less than 3 weeks 9

Metastatic adenocarcinoma of unknown primary site in the absence

of colonic signs & symptoms when it will not influence management9

Upper GI bleeding or melena with a demonstrated upper GI source 9

Chronic constipation; consider contrast barium enema if warranted

Cancer other than colon cancer e.g. prostate cancer, breast cancer

which does not apply if Lynch Syndrome suspected















Mayo Clinic Arizona Standard Preps: 4 liter lavage with balanced electrolyte solutions & PEG:

TriLyte, NuLytely, Colyte, Go-Lytely. Studies show absence of Na sulfate in Trilyte and NuLytely

have better taste.

Optional 2 Liter Lavage: Half-Lytely (balanced electrolytes & PEG plus 4 bisacodyl tablets, Na

sulfate free). Requires a RX from referring MD.

Available Sodium Phosphate Preparations: Fleets Phospho Soda, or OsmoPrep Tablets

Warning for Sodium Phosphate Preps: Extreme caution in renal insufficiency

(CCr<30ml/min), underlying electrolyte disorders, ascites, CHF, unstable angina, arrhythmias,

post GI bypass. Rare reports of renal failure, acute phosphate nephropathy, and seizures

exist. Consider baseline and post colonoscopy labs in those at risk of electrolyte disorders

or complications from electrolyte disorders. Not for use in evaluating diarrhea or IBD.

Patients taking sodium phosphate preps must obtain referring MD’s consent and a RX for


Contraindications for all Preps: obstruction, ileus, gastric retention, possible perforation,

toxic colitis, megacolon.

Prep Timing: For AM exam: 4:00 PM afternoon prior; for PM exam: Morning of exam

preferred, 4:00 PM afternoon prior acceptable if necessary.

Directions for all Preps: Day prior to exam – Clear liquids all day until 3 hours prior to exam.

4 LITER LAVAGE Directions: 4:00 PM day prior drink 8oz prep every 10 minutes until prep is


2 LITER LAVAGE Directions: 12:00 PM day prior take 4 bisocodyl tablets. After bowel

movement, but no later than 6:00 PM, drink 8oz prep every 10 minutes until prep is


PHOSPHO SODA Directions: 4:00 PM day prior - mix 1 1⁄2 oz of prep in 12oz water and drink,

followed immediately by 12oz water. Drink an additional minimum 24oz water that evening.

4:00 AM day of procedure mix 1oz prep in 12oz water and drink. Follow immediately with

12oz water.

OSMOPREP Directions: 4:00 PM day prior take 4 tablets with 8 oz clear liquid every 15

minutes until 20 tablets are consumed. 4:00 AM day of procedure take 4 tablets every 15

minutes until the remaining 12 tablets are consumed.


1 Winawer S,et al; Gastrointestinal Consortium Panel. Colorectal cancer screening and

surveillance: clinical guidelines and rationale-update based on new evidence.

Gastroenterology. 2003 Feb;124(2):544-60

2 ACS-American Cancer Society

3 ACG-American College of Gastroenterology on Colorectal Cancer Screening for

Average and Higher Risk Patients in Clinical Practice. 2000

4 Bond JH. Polyp guideline: diagnosis, treatment, and surveillance for patients with

colorectal polyps. Am J Gastroenterol. 2000 Nov;95(11):3053-63

5 Brooker JC, et al; Treatment with argon plasma coagulation reduces recurrence after

piecemeal resection of large sessile colonic polyps: a randomized trial and

recommendations. Gastrointest Endosc. 2002 Mar;55(3):371-75

6 Agrawal S, Bhupinderjit A, Bhutani MS, Boardman L, Nguyen C,et al; Committee of Minority

Affairs and Cultural Diversity, American College of Gastroenterology. Colorectal cancer in

African Americans. Am J Gastorenterol. 2005 Mar;100(3):515-23

7 Winawer S, et al; American Gastroenterological Association. Guidelines for colonoscopy

surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on

colorectal cancer and the American Cancer Society. Gastroenterology


8 Desch CE, et al; Colorectal cancer surveillance: 2005 update of an American

Society of Clinical Oncology practice guideline. J Clin Oncol. 2005


9 ASGE-American Society for Gastrointestinal Endoscopy

• 1st-degree relative is parent, sibling, or child. 2nd-degree relative is grandparent,

uncle/aunt, or cousin

Revised 7-2006  ITCFranklinGothicStd-Book



Mayo Clinic Arizona Standardized Colon Prep Grading For All Colonoscopies


Excellent: minimal amount of debris not hindering proper adequate



Good: some liquid debris not significantly interfering with the exam.


Fair Adequate: moderate amount of liquid debris, or minimal amount of

solid debris to prevent a completely reliable exam. After adequate

intraprocedure cleansing, endoscopist confident that lesions over 1 cm

have been detected.


Fair Inadequate: large amounts of liquid, or moderate to large amounts

of solid debris with inadequate visualization of colon. After adequate

intraprocedure cleansing, endoscopist not confident that lesions over

1 cm have been detected.


Poor: solid debris limits nearly entire exam.



Suggested Standard Clinical Recommendations For Prevention/

Screening and Most Surveillance Examinations Based on Prep



Excellent: Standard published guidelines


Good: Standard published guidelines


Fair Adequate: standard published guidelines


Fair Inadequate: For appropriate patients who have never had a prior

colon colorectal cancer prevention examination, the examination should

be repeated without delay. Otherwise, for appropriate patients without

signs or symptoms, follow up colonoscopy may be deferred for 1 to 2



Poor: Colon insufficiently evaluated; reexamination by some method

should be considered based on clinical circumstances and patient/referring

physician preferences




1.Only excellent or good prep ratings are acceptable for patients

with signs or symptoms who are scheduled for Diagnostic

Examinations. Other prep grades warrant individual decision making

based on clinical circumstances.

2.Patients who have significant problems with constipation, motility

issues, or a prior history of inadequate colonoscopy preparation, will

require a minimum two days of clear liquids in preparation for the

exam. Please call or consult GI for patients with difficult problems.