Smile By Andrew Lightfoot

National Medical Policy
Subject:
Colonoscopy
Policy Number:
NMP105
Effective Date:
February 2004
Updated:
February 2014
This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE
at the end of this document
For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for
coverage guidelines prior to applying Health Net Medical Policies
The Centers for Medicare & Medicaid Services (CMS)
For Medicare Advantage members please refer to the following for coverage
guidelines first:
Use
X
X
Source
National Coverage Determination
(NCD)
National Coverage Manual Citation
Local Coverage Determination (LCD)*
Reference/Website Link
Colorectal Cancer Screening Tests:
http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx
Colonoscopy and Sigmoidoscopy-Diagnostic;
Diagnostic Colonoscopy:
http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx
X
Article (Local)*
Other
Medicare Claims Processing Manual, Chapter 18 Preventive and Screening Services:
https://www.cms.gov/manuals/downloads/clm104c18
.pdf
Medicare Learning Matters Network. Medicare Guide
to Preventive Services. March 2011:
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/mps_guide_web061305.pdf
Medicare Learning Matters Network. MLN Matters
Colonoscopy Feb 14
1
Number: MM7012 Revised. Related Change Request
(CR) #: 7012. Release Date: March 2, 2011. Waiver
of Coinsurance and Deductible for Preventive
Services, Section 4104 of The Affordable Care Act,
Removal of Barriers to Preventive Services in
Medicare: http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/mm7012.pdf
Medicare Learning Matters Network. MLN Matters
Number: SE0613. Updated October 2012.
Colorectal Cancer: Preventable, Treatable, and
Beatable: Medicare Coverage and Billing for
Colorectal Cancer Screening:
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE0613.pdf
None
Use Health Net Policy
Instructions
 Medicare NCDs and National Coverage Manuals apply to ALL Medicare members
in ALL regions.
 Medicare LCDs and Articles apply to members in specific regions. To access your
specific region, select the link provided under “Reference/Website” and follow the
search instructions. Enter the topic and your specific state to find the coverage
determinations for your region. *Note: Health Net must follow local coverage
determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their
service area when those MACs have exclusive coverage of an item or service. (CMS
Manual Chapter 4 Section 90.2)


If more than one source is checked, you need to access all sources as, on
occasion, an LCD or article contains additional coverage information than
contained in the NCD or National Coverage Manual.
If there is no NCD, National Coverage Manual or region specific LCD/Article,
follow the Health Net Hierarchy of Medical Resources for guidance.
Current Policy Statement
Health Net, Inc. considers colonoscopy medically necessary according to the revised
guidelines set forth by the American Gastroenterological Association, the American
Society of Colon & Rectal Surgeons, the American Cancer Society, the U.S. MultiSociety Task Force on Colorectal Cancer, the American College of Radiology, the
National Comprehensive Cancer Network, the American College of Gastroenterology,
and the American Society for Gastrointestinal Endoscopy for patients who meet any
of the following indications:
Diagnostic Colonoscopy
1. Evaluation of an abnormality on barium enema or other imaging study, which
is likely to be clinically significant, such as a filling defect or stricture.
2. Evaluation of unexplained gastrointestinal bleeding, such as:

Hematochezia not thought to be from rectum or perianal source,
especially if the patient is > 40 years old.
Colonoscopy Feb 14
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
Melena of unknown origin after an upper GI source has been excluded.

Presence of fecal occult blood.
3. Unexplained iron deficiency anemia.
4. Chronic inflammatory bowel disease of the colon if more precise diagnosis or
determination of the extent of activity of disease will influence immediate
management.
5. Clinically significant diarrhea of unexplained origin with additional symptoms
(e.g., dehydration, weight loss).
6. Evaluation of acute colonic ischemia/ischemic bowel disease.
7. Evaluation of cytomegaloviral colitis in a patient with HIV infection
8. Evaluation of patient with Streptococcus bovis endocarditis.
9. Intraoperative identification of the site of a lesion that cannot be detected by
palpation or gross inspection at surgery (e.g., polypectomy site or location of
a bleeding source).
10. Marking a neoplasm for surgical localization.
11. Constipation with involuntary weight loss of > 10 lbs within 12 weeks, or
continued constipation following 2 weeks of treatment with fiber,
hyperosmotic agents or stool softeners.
Therapeutic Colonoscopy
1. Excision of colonic polyp(s).
2. Treatment of bleeding from such lesions as vascular malformation, ulceration,
neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser
or injection therapy).
3. Foreign body removal.
4. Decompression of pseudo-obstruction of the colon (Ogilvie's syndrome).
5. Decompression of acute nontoxic megacolon.
6. Treatment of sigmoid volvulus.
7. Balloon dilation of stenotic lesions (e.g., anastomotic strictures).
8. Palliative treatment of stenosing or bleeding neoplasms (e.g., laser,
electrocoagulation, stenting).
Screening Colonoscopy
Initial screening for colorectal cancer at 50 years of age for asymptomatic, average
risk men and women with follow-up colonoscopy every 10 years if the exam is
normal. Note: Screening may begin age 45 for African Americans because of the
higher incidence of colorectal cancer.
Surveillance Colonoscopy
Colonoscopy Feb 14
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Low-risk Patients With No Family
History of Colorectal Cancer
Treatments
Removal of small, hyperplastic polyps
would be considered normal
colonoscopy.
Subsequent colonoscopy is recommended at
10 years.
Complete removal of 1 or 2 small
tubular adenomas (< 1 cm) in low
risk patients with no family history of
colorectal cancer.
Colonoscopy in 5 years after the initial
polypectomy - if the next exam is normal,
then the colonoscopy will be in 5-10 years,
the patient can thereafter be screened as
per average risk guidelines.
High-risk Patients with a
Personal History of Colorectal
Cancer
Treatments
This refers to patients with colon or
rectal cancer that has been resected
with curative intent. These patients
should undergo high quality perioperative clearing.
Colonoscopy should be done around the
time of initial diagnosis to rule out
synchronous* neoplasms, or synchronous
disease.
At the time of diagnosis of colon
cancer
Presurgical evaluation for additional
synchronous cancer or neoplastic polyps – if
not possible due to obstruction from the
carcinoma or for other technical reasons,
options include intraoperative colonoscopy
or colonoscopy within 3 - 6 months of
resection. If abnormal repeat in 1 year.
Post treatment surveillance: For stage I
disease, colonoscopy at 1 year. Repeat at 3
years, and then at 5 years thereafter,
unless advanced adenoma (villous polyp,
polyp >1 cm or high-grade dysplasia) is
found. In this case, repeat colonoscopy in 1
year.
After resection of colorectal cancer or
neoplastic polyp
Post treatment surveillance stage II/III
disease with no known residual disease,
colonoscopy 1 year after resection, or 3-6
months post resection if not performed
preoperatively due to obstructing lesion.
Repeat in 3 years and then every 5 years
thereafter, follow-up colonoscopy indicated
advanced adenoma (villous polyp, polyp >1
cm or high-grade dysplasia) is found. In
this case, repeat colonoscopy in 1 year.
More frequent colonoscopies may be
indicated in patients with colon cancer
before 50 years of age.
Colonoscopy Feb 14
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Low anterior resection of rectal
cancer
Colonoscopy usually done within 3-6 month
intervals for the first 2-3 years, to identify
local recurrence. NCCN: every 3-6 mo for 2
yrs following LAR then every 6months for a
total of 5 yrs
Pedunculated polyp containing
invasive carcinoma
Colonoscopic removal is adequate
treatment in the uniform presence of
favorable prognostic indicators.** A followup examination within 3 months is
mandatory to confirm the presence or
absence of residual or recurrent disease
Note* - Synchronous neoplasms refers to two or more abnormal growths of tissue
occurring simultaneously and presumed to be of separate origin. The neoplasms may
be histologically the same or different, and may be found in the same or different
sites. Preoperative or intraoperative diagnosis of the presence of synchronous
colorectal carcinomas is very important because once they are over looked, they
present as early metachronous carcinomas with advanced stages and usually require
re-operation. Synchronous adenocarcinomas from large bowel could metastasize to
the liver.
Note** - Favorable prognostic indicators include all of the following:

Complete excision

No vascular or lymphatic invasion

Clear margins

Well-differentiated histology (Grade I or II).
High-risk Patients
Treatments
Individuals with 3 or more adenomas
(3-10)
3 years after initial polypectomy,
subsequent surveillance are recommended
within 5 years, depending on colonoscopic
findings. Longer intrvals are recommended
for persons with normal follow-up
colonoscopies.
Patients with >10 adenomas on a
single examination
<3 years after initial polypectomy. Consider
the possibility of familial polyposis
syndrome.
Individual with a personal history of
attenuated familial adenomatous
polyposis (AFAP)
Varies depending on the individual’s age
and adenoma burden. For young patients
under the age of 21 with small adenoma
burden, colonoscopy and polypectomy are
recommended every 1-2 years with
appropriate surgical evaluation and
counseling. Age 21 and older with small
adenomatous polyp burden, colectomy and
IRA are alternative treatment options to
colonoscopy and polypectomy. When
polposis is too significant to be managed by
polypectomy, (i.e., polyps >20 at any
Colonoscopy Feb 14
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individual exam or when polyp >1 cm in
diameter or advanced histology is
identified), surgery is recommended.
Piece meal resection of a large sessile
adenoma
Colonoscopy at 2 - 6 month intervals until
complete polyp removal is verified.* After
one negative result examination, standard
surveillance is performed as for patients
with benign adenomas.
Crohn's colitis and chronic ulcerative
pancolitis
Screening every 1-2 years should be
initiated 8-10 years at onset of symptoms
of pancolitis or 12 years after onset of leftsided colitis
Note* - Surgical resection is recommended for residual abnormal tissue at the
polypectomy site after two or three attempts at colonoscopic removal.
High-risk Patients With
Significant Family History
Advanced, large adenomas (>1cm),
or multiple adenomas (>3) of any
size, or adenomas with villous
histology, high-grade dysplasia or a
family history of colorectal cancer.
Genetic diagnosis of familial
adenomatous polyposis (FAP)/
attenuated familial adenomatous
polyposis (AFAP), or are at risk of
having FAP but genetic testing has
not been performed or is not feasible
Treatments
Colonoscopy at 3 years after the initial
polypectomy - if normal, repeat in 3 years if normal then, repeat colonoscopy in 5
years. The patient can thereafter be
screened as per average risk guidelines.
Family history of Classical FAP/Genetic
testing done: If an individual at risk is
found not to carry APC gene mutation
responsible for FAP, screen as an average
risk individual. If positive for APC gene
mutation, flexible sigmoidoscopy or
colonocscopy every 12 months, beginning
at 10-15 years of age. Once adenomas
develop, surgical options should be
reviewed.
If no genetic testing has been done, offer
annual flexible sigmoidoscopy or
colonoscopy beginning at age 10 -15 years
until the age of 24. Then if results
continues to be negative, screening is
scaled down to every 2 years until age 34,
every 3 years until age 44 and every 3-5
years thereafter. Consider substituting
colonoscopy every 5 years beginning at age
20 for a chance that an individual may have
attenuated familial adenomatous polyposis
(AFAP).
Family history of AFAP:
Similar genetic counseling, testing and
surveillance considerations for individuals
with FAP apply to patients with AFAP,
except for the endoscopy approach.
Colonoscopy Feb 14
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Individuals with AFAP may not present until
a later age and may have fewer polyps than
those with classical FAP. In the absence of
a true negative genetic test, an individual
with a family history of AFAP, should begin
colonoscopy screening in late teens, with
repeat exam every 2-3 years.
Genetic or clinical diagnosis of
Hereditary Non-polyposis Colon
Cancer (HNPCC)/Lynch Syndrome or
who are at increased risk for HNPCC
Colonoscopy every 1 - 2 years beginning at
age 20 - 25 years, or 2-5 years younger
than the youngest diagnosis age in the
family, whichever comes first, to be
repeated every 1-2 years.
A 1st degree relative (parent, sibling,
or child) with sporadic colorectal
cancer or adenomatous polyps
diagnosed at age < 60 years or 2 or
more 1st degree relatives diagnosed
with colorectal cancer at any age
*Screening colonoscopy starting at age 40
years or 10 years younger than the earliest
diagnosis in their family, whichever comes
first, and repeated every 5 years if
negative.
A first-degree relative ≥age 60 years
or 2 second-degree relatives with
either colorectal cancer or
adenomatous polyps.
Colonoscopy should be done at age 40
years. Screening options at intervals
recommended for average-risk individuals
after this initial colonoscopy.
Note* - Colorectal cancer in relatives more distant than first-degree does not
increase risk substantially above the average risk group.
Health Net, Inc. considers colonoscopy not medically necessary for any of the
following circumstances:
1. Chronic, stable, irritable bowel syndrome or chronic abdominal pain; there are
unusual exceptions in which colonoscopy may be done once to rule out
disease, especially if symptoms are unresponsive to therapy.
2. Acute limited diarrhea.
3. Hemorrhoids.
4. Bright red rectal bleeding in patients with a convincing anorectal source on
sigmoidoscopy and no other symptoms suggestive of a more proximal
bleeding source
5. Metastatic adenocarcinoma of unknown primary site in the absence of colonic
signs or symptoms when it will not influence management.
6. Routine follow-up of inflammatory bowel disease (except for cancer
surveillance in chronic ulcerative colitis and Crohn's colitis).
7. Upper GI bleeding or melena with a demonstrated upper GI source.
8. Routine examination of the colon in patients about to undergo elective
abdominal surgery for non-colonic disease.
Relative contraindications to colonoscopy are
Colonoscopy Feb 14
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1. Toxic megacolon and fulminant colitis.
2. Peritonitis
3. Known or suspected colonic necrosis.
4. Documented acute severe diverticulitis / diverticular abscess.
5. Possible perforated viscus.
6. Severe coagulopathy, severe thrombocytopenia, severe neutropenia
7. History of radiation therapy for abdominal or pelvic cancer
8. History of abdominal or pelvic malignancy
9. Extensive adhesions from prior abdominal surgery
10. Pregnancy *
Note* - Colonoscopy is currently contraindicated during pregnancy because of
inadequate data on safety but may be strongly considered for severe life-threatening
colonic conditions such as suspected colon cancer, evaluation of a right-sided colonic
mass, and uncontrolled severe right-colonic hemorrhage, and to guide segmental
colectomy for urgent colonic surgery.
Codes Related To This Policy
NOTE:
The codes listed in this policy are for reference purposes only. Listing of a code in
this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and
medical necessity criteria. This list of codes may not be all inclusive.
On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and
inpatient procedures will be replaced by ICD-10 code sets. Health Net National
Medical Policies will now include the preliminary ICD-10 codes in preparation for this
transition. Please note that these may not be the final versions of the codes and
that will not be accepted for billing or payment purposes until the October 1, 2014
implementation date.
ICD-9 Codes
V10.00
V10.05
V10.06
V12.70
V12.72
V16.0
V18.51
V76.51
009.0
009.1
009.2
009.3
153.1-153.9
154.0-154.8
195.3
196.2
Colonoscopy Feb 14
Personal history of malignant neoplasm, gastrointestinal, tract,
unspecified
Personal history of malignant neoplasm, large intestine
Personal history of malignant neoplasm, rectum, rectosigmoid
junction, and anus
Personal history of unspecified digestive disease
Personal history of colonic polyps
Family history of malignant neoplasm, gastrointestinal tract
Family history of colonic polyps
Special screening for malignant neoplasms of colon
Infectious colitis, enteritis and gastroenteritis
Colitis, enteritis, and gastroenteritis of presumed infectious
origin
Infectious diarrhea
Diarrhea of presumed infectious origin
Malignant neoplasm of colon
Malignant neoplasm of rectum, rectosigmoid junction, and anus
Malignant neoplasm of the pelvic region
Secondary and unspecified malignant neoplasm of intraabdominal lymph nodes
8
197.5
197.6
197.7
199.0
211.3
211.4
230.3
230.4
230.5
230.6
235.2
235.5
280.0
280.9
285.1
421.0
555.0-555.9
556.0-556.9
557.0
557.1
557.9
558.1
558.2
558.9
560.0
560.1
560.2
560.81
560.89
560.9
562.10
562.12
562.13
564.4
564.5
564.7
564.81
564.89
569.0
569.3
569.41
569.81
569.82
569.83
569.84
569.85
569.86
569.89
578.1
578.9
Colonoscopy Feb 14
Secondary malignant neoplasm of large intestine and rectum
Secondary malignant neoplasm of the retroperitoneum and
peritoneum
Secondary malignant neoplasm of liver, specified as secondary
Disseminated malignant neoplasm without specification of site
Benign neoplasm of colon
Benign neoplasm of rectum and anal canal
Carcinoma in situ of colon
Carcinoma in situ of rectum
Carcinoma in situ of anal canal
Carcinoma in situ of anus, unspecified
Neoplasm of uncertain behavior of stomach, intestines and
rectum
Other and unspecified neoplasm of digestive organs
Iron deficiency anemia secondary to blood loss (chronic)
Iron deficiency anemia, unspecified
Acute posthemorrhagic anemia
Acute and subacute bacterial endocarditis
Regional enteritis
Ulcerative colitis
Acute vascular insufficiency of intestine
Chronic vascular insufficiency of intestine
Unspecified vascular insufficiency of intestine
Gastroenteritis and colitis due to radiation
Toxic gastroenteritis and colitis
Other and unspecified noninfectious gastroenteritis and colitis
Intussusception
Paralytic ileus
Volvulus
Intestinal or peritoneal adhesions with obstruction
(postoperative) (postinfection)
Other specified intestinal obstruction, Other
Unspecified intestinal obstruction
Diverticulosis of colon (without mention of hemorrhage)
Diverticulosis of colon with hemorrhage
Diverticulitis of colon with hemorrhage
Other postoperative functional disorders
Functional diarrhea
Megacolon, other than Hirschsprung's
Neurogenic bowel
Other functional disorders of intestine
Anal and rectal polyp
Hemorrhage of rectum and anus
Ulcer of anus and rectum
Fistula of intestine, excluding rectum and anus
Ulceration of intestine
Perforation of intestine
Angiodysplasia of intestine (without mention of hemorrhage)
Angiodysplasia of intestine with hemorrhage
Dieulafoy lesion (hemorrhagic) of intestine
Other specified disorder of intestine, Other
Blood in stool
Hemorrhage of gastrointestinal tract, unspecified
9
787.9
787.99
792.1
793.4
936
Diarrhea
Other symptoms involving digestive system,
Nonspecific abnormal findings in stool contents
Nonspecific abnormal findings on radiological and other
examination; gastrointestinal tract
Foreign body in intestine and colon
ICD -10 Codes
AØ9
C17-C21.8
C76.3
C77.2
D01.0-D01.49
D12.Ø
D12.6
D5Ø.Ø-D50.9
D62
I33.Ø-I33.9
K50-K50.919
K51-K51.319
K51.4-K51.419
K51.5-K519
K51.8-K51.919
K52-K52.9
K55-K55.9
K56-K56.7
K57-K57.93
K58-K58.9
K59-K59.9
K62-K62.9
K63-K63.9
K63.5
K91.8-K91.89
K92-K92.9
R19.4
R19.5
R93.3
T18.3XXA
T18.4XXA
Z12.I-Z12.3
Z12.11
Z8Ø.Ø
Z83.71
Z85.00
Z86.Ø1Ø
Colonoscopy Feb 14
Infectious gastroenteritis and colitis, unspecified
Malignant neoplasm of small intestine, colon, rectosigmoid
junction, rectum, anus and anal canal
Malignant neoplasm of pelvis
Secondary and unspecified malignant neoplasm of intraabdominal lymph nodes
Carcinoma in situ of colon, rectosigmoid junction, rectum, anal
canal and anus and intestine
Benign neoplasm of cecum
Benign neoplasm of colon, unspecified
Iron deficiency anemia secondary to blood loss (chronic)
Acute posthemorrhagic anemia
Acute and subacute infective endocarditis
Crohn’s disease
Ulcerative colitis
Inflammatory polyps of colon
Left sided colitis
Ulcerative colitis, unspecified
Other and unspecified noninfective gastroenteritis and colitis
Vascular disorders of intestine
Paralytic ileus
Diverticular disease of intestine
Irritable bowel syndrome
Other functional disorders
Other diseases of anus and rectum
Other diseases of intestine
Polyp of colon
Other intraoperative and postprocedural complications and
disorders of digestive system
Other diseases of digestive system
Change in bowel habits
Other fecal abnormalities
Abnormal findings on diagnostic imaging of other parts of
digestive tract
Foreign body in small intestine, initial encounter
Foreign body in colon, initial encounter
Encounter for screening for malignant neoplasm of intestinal
tract
Encounter for screening for malignant neoplasm of colon
Family history of malignant neoplasm of digestive organs
Family history of colonic polyps
Personal history of malignant neoplasm of unspecified digestive
organ
Personal history of colonic polyps
10
Z87.19
Z85.03-Z85.048
Z85.06-Z85.068
Personal history of other diseases of the digestive system
Personal history of malignant neoplasm of large intestine,
rectum, rectosigmoid junction and anus
Personal history of malignant neoplasm of small intestine
CPT Codes
44388
44389
44390
44391
44392
44393
44394
44397
45355
45378
45379
45380
45381
45382
45383
45384
45385
45386
45387
Colonoscopy through stoma; diagnostic, with or without
collection of specimen(s) by brushing or washing
; with biopsy, single or multiple
; with removal of foreign body
; with control of bleeding (e.g., injection, bipolar cautery,
unipolar cautery, laser, heater probe, stapler. plasma
coagulator)
; with removal of tumor(s), polyp(s), or other lesion(s) by hot
biopsy forceps or bipolar cautery
; with ablation of tumor(s), polyp(s), other lesion(s) not
amenable to removal by hot biopsy forceps, bipolar cautery or
snare technique
; with removal of tumor(s), poly(s), or other lesion(s) by snare
technique
;with transendoscopic stent placement (includes predilation)
Colonoscopy, rigid or flexible, transabdominal via colotomy,
single or multiple
Colonoscopy, flexible, proximal to splenic flexure; diagnostic,
with or without collection of specimen(s) by brushing or
washing, with or without colon depression
; with removal of foreign body
; with biopsy, single or multiple
;with directed submucosal injection(s), any substance
; with control of bleeding (e.g., injection, bipolar cautery,
unipolar cautery, laser, heater probe, stapler. plasma
coagulator)
; with ablation of tumor(s), polyp(s), or other lesion(s) not
amendable to removal; by hot biopsy forceps, bipolar cautery
or snare technique
; with removal of tumor(s), polyp(s), or other lesion(s) by hot
biopsy forceps or bipolar cautery
; with removal of tumor(s), polyp(s), or other lesion(s) by
snare technique
;with dilation by balloon, 1 or more strictures
;with transendoscopic stent placement (includes predilation)
HCPCS Codes
G0105
G0121
Colorectal cancer screening; colonoscopy on individual at high
risk
Colorectal cancer screening; colonoscopy on individual not
meeting criteria for high risk
Scientific Rationale – Update February 2013
2012 recommendations for colonoscopic surveillance after screening and
polypectomy from the US Multi-Society Task Force on Colorectal Cancer, include the
following:
Colonoscopy Feb 14
11
1.
Baseline examination: no adenomas or polyps. Next exam recommended in 10
years.
There is now stronger evidence to support the 10-year interval after negative
findings on baseline colonoscopy for average-risk individuals, assuming that the
baseline colon examination is complete with a good bowel preparation.
2.
Baseline examination: no adenomas; distal small (<10 mm) hyperplastic polyps.
Next exam recommended in 10 years.
Prior and current evidence suggests that distal hyperplastic polyps (HPs) <10
mm are benign and non-neoplastic. If the most advanced lesions at baseline
colonoscopy are distal HPs <10 mm, the interval for colonoscopic follow-up
should be 10 years.
3.
Baseline examination: 1–2 tubular adenomas <10 mm. Next exam
recommended is recommended at 5-10 year intervals.
Data published since 2006 endorse the assessment that patients with 1–2
tubular adenomas with low-grade dysplasia <10 mm represent a low-risk group.
Three new studies suggest that this group may have only a small, nonsignificant
increase in risk of advanced neoplasia within 5 years compared with individuals
with no baseline neoplasia. The evidence supports a surveillance interval of
longer than 5 years for most patients
4.
Baseline examination: 3–10 adenomas. Recommendation for next exam at 3
year intervals
Two new studies reported outcomes in patients with multiple adenomas. The NCI
Pooling Project analysis found that with each additional adenoma, there is a
linear increase in risk for both advanced and nonadvanced neoplasia. The VA
study (which contributed data to the pooling project) also provided a second
referent group: patients with no baseline neoplasia. The risk of advanced
neoplasia at 5 years was 2.4% in the nonneoplasia referent group, 4.6% if
patients had 1–2 tubular adenomas <10 mm (RR, 1.92; 95% CI, 0.83–4.42),
and 11.9% if they had 3 or more tubular adenomas <10 mm (RR, 5.01; 95% CI,
2.10–11.96). The VA study shows that even if all of the adenomas are <10 mm,
there is increased risk of advanced neoplasia with multiplicity of adenomas. The
new information from the VA study and the NCI Pooling Project support the
previous recommendation that patients with 3 or more adenomas have a level of
risk for advanced neoplasia similar to other patients with advanced neoplasia
(adenoma >10 mm, adenoma with HGD)
5.
Baseline examination: >10 adenomas. Recommendation for next exam is <3
year interval.
The NCI Pooling Project notes a marked increased risk of advanced neoplasia
among patients with 5 or more adenomas at baseline.
6.
Baseline examination: one or more tubular adenomas ≥10 mm.
Recommendation for next exam is at 3 year intervals.
Colonoscopy Feb 14
12
New information provides additional data showing that patients with one or more
adenomas ≥10 mm have an increased risk of advanced neoplasia during
surveillance compared with those with no neoplasia or small (<10 mm)
adenomas. This recommendation assumes that the examination was of high
quality and complete removal of neoplastic tissue occurred at baseline. This
group represents a small proportion of all patients with adenomas. If there is
question about complete removal (ie, piecemeal resection), early follow-up
colonoscopy is warranted.
7.
Baseline examination: one or more adenomas with villous features of any size.
Recommendation for next exam at 3 year intervals
New information provides additional data showing that patients with one or more
adenomas with villous histology have an increased risk of advanced neoplasia
during surveillance compared with those with no neoplasia or small (<10 mm)
tubular adenomas.
8.
Baseline examination: one or more adenomas with HGD. Recommendation for
next examination at 3-year interval.
The presence of an adenoma with HGD is an important risk factor for
development of advanced neoplasia and CRC during surveillance.
9.
Baseline examination: serrated polyps. No follow up recommendations.
The clinical implications of serrated polyps are uncertain. The current evidence
suggests that size (>10 mm), histology (a sessile serrated polyp is a more
significant lesion than an HP; a sessile serrated polyp with cytological dysplasia
is more advanced than a sessile serrated polyp without dysplasia), and location
(proximal to the sigmoid colon) are risk factors that might be associated with
higher risk of CRC. A sessile serrated polyp ≥10 mm and a sessile serrated polyp
with cytological dysplasia should be managed like high risk adenoma (HRA).
Serrated polyps that are <10 mm and do not have cytological dysplasia may
have lower risk and can be managed like Low risk adenoma (LRA).
Note: HRA is defined as 3 or more adenomas, tubular adenoma ≥10 mm,
adenoma with villous histology, or HGD. LRA is defined as 1–2 tubular adenomas
<10 mm.
The National Comprehensive Care Network (NCCN) states, “Surveillance
colonoscopies are primarily aimed at identifying and removing metachronous polyps
because data show that patients with a history of colorectal cancer have an
increased risk of developing second cancers, particularly in the first 2 years after
resection. Furthermore, use of post-treatment surveillance colonoscopy has not
been shown to improve survival through the early detection of recurrence of the
original colorectal cancer. The recommended frequency of post- treatment
surveillance is higher for patients with Lynch Syndrome.”
Scientific Rationale - Update May 2013
According to the National Cancer Institute, colorectal cancer is the third most
commonly diagnosed cancer in the African American population. Over 18,000 new
cases of colorectal cancer are diagnosed in African Americans annually. Though the
overall CRC rates are declining in the United States, the rates for African Americans
Colonoscopy Feb 14
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are decreasing more slowly than the rates for white Americans. African Americans
are also more likely to be diagnosed when colorectal cancer is advanced and,
therefore, less treatable. Between 2002 and 2008, the likelihood of surviving 5 years
after a diagnosis of colorectal cancer was only 57 percent for African Americans,
compared with 65 percent for white Americans. The difference between African
Americans and whites in colorectal cancer death rates has actually widened over the
years.
The American College of Gastroenterology and the Institute for Clinical Systems
Improvement recommends that screening for colorectal cancer (CRC) in African
Americans may begin at age 45. The rationale is based on high incidence of CRC and
a greater prevalence of proximal or right-sided polyps and cancerous lesions in this
population.
Scientific Rationale – Update April 2009
Updated Guidelines for Detection of Adenomatous Polyps and Colorectal Cancer
Screening in Asymptomatic Average-Risk Adults and Guidelines from the American
Gastroenterological Association, the American Cancer Society, the U.S. Multi-Society
Task Force on Colorectal Cancer, the American College of Radiology Colon Cancer
Committee, the National Comprehensive Cancer Network and the Canadian
Association of Gastroenterology are very similar and state:

Patients with small rectal hyperplastic polyps should have colonoscopy or other
screening options at intervals recommended for average-risk individuals. (An
exception is patients with a hyperplastic polyposis syndrome. They are at
increased risk for adenomas and colorectal cancer and need to be identified for
more intensive follow-up);

Patients with 1 or 2 small tubular adenomas with low-grade dysplasia should
have colonoscopy 5 –10 years after the initial polypectomy. The precise timing
within this interval should be based on other clinical factors (such as prior
colonoscopy findings, family history, and the preferences of the patient and
judgment of the physician); [The American Gastroenterological Association notes
5 years for follow-up exam for low-risk patients].

Patients with 3 to 10 adenomas or 1 adenoma >1 cm or any adenoma with
villous features or high-grade dysplasia should have colonoscopy 3 years after
the initial polypectomy. Adenomas must have been completely removed. (If the
follow-up colonoscopy is normal or shows only 1 or 2 small, tubular adenomas
with low-grade dysplasia, then the interval for the subsequent examination
should be 5 years); [The American Society of Colon & Rectal Surgeons feel that
patients who have advanced or multiple adenomas should have their first followup colonoscopy at 5 years. They do not note the exact # of polyps. However,
they do state that numerous adenomas, a malignant adenoma with invasive
cancer or a large sessile adenoma should have a short interval follow-up
colonoscopy based on clinical judgement]. [2008- American Journal of
Gastroenterology recommend screening in this scenario, should be the same as
individuals who are at average-risk (colonoscopy every 10 years beginning at age
50 years)].

Patients with >10 adenomas on a single examination should have colonoscopy
<3 years after the initial polypectomy. (Consider the possibility of an underlying
familial syndrome);
Colonoscopy Feb 14
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
Patients with sessile adenomas that are removed piecemeal should have
colonoscopy 2 to 6 months to verify complete removal. (Once complete removal
has been established, subsequent surveillance needs to be individualized based
on the physician’s judgment. Completeness of removal should be based on both
endoscopic and pathologic assessments);

Patients with colon and rectal cancer should undergo high quality perioperative
clearing with colonoscopy recommended 3 to 6 months after cancer resection, if
no unresectable metastases are found during surgery; alternatively, colonoscopy
can be performed intraoperatively. (In the case of nonobstructing tumors, this
can be done by preoperative colonoscopy. In the case of obstructing colon
cancers, computed tomographic colonography [CTC] with intravenous contrast or
double-contrast barium enema [DCBE] can be used to detect neoplasms in the
proximal colon);

Patients undergoing curative resection for colon or rectal cancer should have
colonoscopy 1 year after the resection or 1 year following the performance of the
colonoscopy that was performed to clear the colon of synchronous disease. (This
colonoscopy at 1 year is in addition to the perioperative colonoscopy for
synchronous tumors. If the examination performed at 1 year is normal, then the
interval before the next subsequent examination should be 3 years. If that
colonoscopy is normal, then the interval before the next subsequent examination
should be 5 years. Following the examination at 1 year, the intervals before
subsequent examinations may be shortened if there is evidence of HNPCC or if
adenoma findings warrant earlier colonoscopy. Periodic examination of the
rectum for the purpose of identifying local recurrence, usually performed at 3 to
6 month intervals for the first 2 or 3 years, may be considered after low-anterior
resection of rectal cancer); [The American Society of Colon & Rectal Surgeons
state that colonoscopy should be done 6 months postoperative and if this is
normal, subsequent colonoscopy should be done after 3 years, and if this is
normal, every 5 years].

Either colorectal cancer or adenomatous polyps in a first-degree relative before
age 60 years or in 2 or more first-degree relatives at any age, colonoscopy
should be done at age 40 years or 10 years before the youngest case in the
immediate family. Colonoscopy should then be repeated every 5 years; [2008American Journal of Gastroenterology recommend screening as the same as
average risk (colonoscopy every 10 years beginning at age 50 years].

Either colorectal cancer or adenomatous polyps in a first-degree relative ≥age 60
years or in 2 second-degree relatives with colorectal cancer, colonoscopy should
be done at age 40 years. Screening options at intervals recommended for
average-risk individuals. (Screening should begin at an earlier age, but
individuals may choose to be screened with any recommended form of testing);

Genetic diagnosis of familial adenomatous polyposis (FAP) or suspected FAP
without genetic testing evidence, colonoscopy should be done at age 10 to 12
years. Annual flexible sigmoidoscopy (FSIG) to determine if the individual is
expressing the genetic abnormality and counseling to consider genetic testing. If
the genetic test is positive, colectomy should be considered;
Colonoscopy Feb 14
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
Genetic or clinical diagnosis of hereditary nonpolyposis colon cancer (HNPCC) or
individuals at increased risk of HNPCC. Colonoscopy aged 20 to 25 years or 10
years before the youngest case in the immediate family. Colonoscopy every 1 to
2 years and counseling to consider genetic testing. Genetic testing for HNPCC
should be offered to first-degree relatives of persons with a known inherited
mismatch repair (MMR) gene mutation. It should also be offered when the family
mutation is not already known, but 1 of the first 3 of the modified Bethesda
Criteria is present;

Inflammatory bowel disease, chronic ulcerative colitis, and Crohn’s colitis. Cancer
risk begins to be significant 8 years after the onset of pancolitis or 12 to 15 years
after the onset of left sided colitis. Colonoscopies with biopsy are recommended
every 1 to 2 years for dysplasia. These patients are best referred to a center with
experience in the surveillance and management of inflammatory bowel disease.
Colonic Polyps
Colonic polyps, or adenomas, are benign epithelial neoplasms that arise from the
epithelial cells lining the colon. Colonic polyps are traditionally divided into 3 groups,
hyperplastic polyps, adenomas, and polyposis syndromes.
Hyperplastic Polyps
Hyperplastic polyps are now recognized to possess some malignant potential in the
setting of hyperplastic polyposis syndrome. Patients who are affected have an
occurrence of hyperplastic polyps proximal to the sigmoid colon, with two or more
that are greater than 10 mm in diameter, a total of more than 30 polyps, or a firstdegree relative with the syndrome. The polyps in this syndrome may have
adenomatous components, display a serrated, saw-tooth surface epithelium, and
harbor methylation of specific target genes, including mismatch repair genes.
Adenomatous Polyps
Adenomas comprise approximately 10% of polyps. Approximately 90% of adenomas
are small, usually less than 1 cm in diameter, and have a small potential for
malignancy. The remaining 10% of adenomas are larger than 1 cm and approach a
10% chance of containing invasive cancer.
The risk of progression to carcinoma is related to both the size and the histology of
the adenoma. Adenomas that are greater than 1 cm, contain a substantial (>25%)
villous component, or have high-grade dysplasia are commonly referred to as
advanced neoplasms and carry an increased cancer risk. First, the pathway for
migration of invasive cells from the tumor into submucosal and more distant
structures is shorter. Second, the complete endoscopic removal is more challenging
and more difficult to ascertain.
Adenomas are traditionally divided by histology into the following three types:
tubular, tubulovillous, and villous. Tubular adenomas are the most common of the 3
types and can be found anywhere in the colon. Villous adenomas most commonly
occur in the rectal area; tend to be larger than the other two types; and tend to be
nonpedunculated, velvety, or cauliflowerlike in appearance. Villous adenomas are
associated with the highest morbidity and mortality rates of all polyps. They can
cause hypersecretory syndromes characterized by hypokalemia and profuse mucous
discharge and can harbor carcinoma in situ or invasive carcinoma more frequently
than other adenomas.
Colonoscopy Feb 14
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The shape or gross structure of the polyp is also clinically significant. Those polyps
with a stalk are called pedunculated. Those polyps without a stalk are called sessile.
Sessile polyps are more concerning than large pedunculated polyps for two reasons.
First, the pathway for migration of invasive cells from the tumor into submucosal and
more distant structures is shorter. Second, the complete endoscopic removal is more
challenging and more difficult to ascertain.
Some premalignant neoplasia is now recognized to be flat, rather than protuberant.
Such nonpolypoid neoplasia is more common in the setting of chronic colitis and may
be detected more readily by nontraditional endoscopic imaging methods, such as
narrow-band width imaging or mucosal staining.
Polyposis Syndromes
Polyposis syndromes are hereditary conditions that include familial adenomatous
polyposis (FAP), hereditary nonpolyposis (a misnomer) colorectal cancer
(HNPCC)/Lynch syndrome, Gardner syndrome, Turcot syndrome, Peutz-Jeghers
syndrome, Cowden disease, familial juvenile polyposis, and hyperplastic polyposis.
Progress has been made in understanding some of the genetic factors contributing to
the development of these syndromes. Some of the syndromes have extraintestinal
features that help differentiate one syndrome from the other. For example, FAP is
best understood in terms of the genetic basis and subsequent pathological and
genetic events leading to carcinoma.
Two other types of benign polyps are hamartomatous polyps, which contain a
mixture of normal tissues, and inflammatory polyps, which contain an inflammatory
epithelial reaction and are typically found in the context of colitis.
Summary
Although colonoscopy is considered to be the reference standard against which the
sensitivity of other colorectal cancer screening tests are compared, it is not perfect.
The relative sensitivity and specificity of the different colorectal screening tests with
adequate data to assess cancer detection such as colonoscopy, flexible
sigmoidoscopy, and fecal tests—can be depicted as follows:

Sensitivity: Hemoccult II < fecal immunochemical tests Hemoccult SENSA
flexible sigmoidoscopy < colonoscopy

Specificity: Hemoccult SENSA < fecal immunochemical tests Hemoccult II <
flexible sigmoidoscopy = colonoscopy
For the operator-dependent tests such as flexible sigmoidoscopy, CT colonography,
and colonoscopy, better operator training and more experience have a high
likelihood of improving sensitivity. Assurance of performance of high-quality
endoscopy should be part of all screening programs.
Screening for colorectal cancer reduces mortality through detection and treatment of
early-stage cancers and detection and removal of adenomatous polyps. The degree
to which each of these mechanisms contributes to a reduction in mortality is
unknown, although it is likely that the largest reduction in colorectal cancer mortality
during the 10 years after initial screening comes from the detection and removal of
early-stage cancers. Colonoscopy is a necessary step in any screening program that
reduces mortality from colorectal cancer.
Colonoscopy Feb 14
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There is adequate evidence that the benefits of detection and early intervention
decline after age 75. There is a substantial lead-time between the detection and
treatment of colorectal neoplasia and a mortality benefit, and competing causes of
mortality make it progressively less likely that this benefit will be realized with
advancing age.
In March 2008, the American Cancer Society, the U.S. Multi-Society Task Force on
Colorectal Cancer, and the American College of Radiology jointly recommended
screening for colorectal cancer beginning at 50 years of age by high-sensitivity fecal
occult blood test (FOBT) or fecal immunochemical testing annually, flexible
sigmoidoscopy every 5 years, double-contrast barium enema every 5 years, CT
colonography (virtual colonoscopy) every 5 years, colonoscopy every 10 years, or
fecal DNA at an unspecified interval.
(2008) American College of Gastroenterology states:
“The evidence that colonoscopy prevents incident colorectal cancer and
reduces the consequent mortality from colorectal cancer is indirect but
substantial. No prospective randomized controlled trials comparing
colonoscopy with no screening, have been completed. However, major
advantages of colonoscopy as a screening test include that it is widely
available, examines the entire colon, allows single-session diagnosis and
treatment, is comfortable when carried out with sedation, and is the only test
recommended at 10-year intervals for average-risk persons. The incremental
benefit of colonoscopy over sigmoidoscopy is the detection of patients with
proximal colon neoplasia (particularly advanced adenomas), as well as large
hyperplastic polyps that are not associated with distal neoplasia”.
In summary, there are no prospective randomized controlled trials of screening
colonoscopy for the reduction in incidence or mortality of colorectal cancer. However,
because colonoscopy and polypectomy is used to evaluate other positive screening
tests, there is evidence to indicate that these procedures result in incidence
reductions in randomized controlled trials of other screening tests. The evidence base
to support screening colonoscopy, though indirect, is substantial.
Scientific Rationale – Update November 2008
Winauer et al. (2003) Patients who have had one or more adenomatous polyps
removed at colonoscopy should be managed according to the findings on that
colonoscopy. Patients who have had numerous adenomas, a malignant adenoma
(with invasive cancer), a large sessile adenoma, or an incomplete colonoscopy
should have a short interval follow-up colonoscopy based on clinical judgment.
Screening for colonoscopy for patients with significant personal history is
noted below:

Patients who have advanced or multiple adenomas (>3) should have their first
follow-up colonoscopy in 3 years.

Patients who have 1 or 2 small (<1 cm) tubular adenomas should have their first
follow-up colonoscopy at 5 years. It is not unreasonable, given available
evidence, to choose even longer intervals. However, the evidence is still
evolving. Future evidence may clarify the intervals more precisely.
Colonoscopy Feb 14
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
The timing of the subsequent colonoscopy should depend on the pathology and
number of adenomas detected at follow-up colonoscopy. For example, if the first
follow-up colonoscopy is normal or only 1 or 2 small (<1 cm) tubular adenomas
are found, the next colonoscopy can be in 5 years.
 Patients with 3-10 adenomas or any adenoma or any adenoma >1cm
or any adenoma with villous features or high-grade dysplasia should
have colonoscopy every 3 years.

Patients with >10 adenomas should have colonoscopy more frequently than
every 3 years, determined by clinical judgment.

Patients with Sessile adenomas that are removed piecemeal should be offered a
colonoscopy at 2-6 months to verify complete removal.

Colon Cancer Screening for those with Family History of Colon Cancer is
noted below:

First degree relative with colon cancer or adenomatous polyps on biopsy age
>60 or two 1st degree relatives diagnosed with colorectal cancer at any age


Colonoscopy at age 40 or 10 years earlier than the earliest dx in their
family, whichever comes first

Repeat colonoscopy every 5 yrs
First degree relative with colon ca or adenomatous polyp dx age >60 or two 2nd
degree relatives with colon cancer

Screen like average risk patients but start at age 40
Scientific Rationale – Initial
Colorectal cancer is a major American health problem, ranking as the second leading
cause of cancer death, after lung cancer, in the United States. About 129,400 new
cases are diagnosed each year, and 56,600 Americans die annually from this
disorder. The etiology of colorectal cancer is heterogeneous, with environment or
genetics playing varying key roles in different patients. About 80% of patients with
colorectal cancer seem to have sporadic disease with no evidence of having inherited
the disorder. In the remaining 20%, there seems to be a potentially definable
genetic component. Colorectal polyps are classified histologically as neoplastic or
non-neoplastic. Most colorectal cancers arise from neoplastic adenomatous polyps
(adenomas). Adenomas are monoclonal derivatives of a mutated epithelial stem cell.
Scientific studies now conclusively show that resecting adenomatous polyps prevents
colorectal cancer.
Colonoscopy is a visual examination of the mucosa of the large intestine with a
flexible video or fiberoptic endoscope. The colonoscope is inserted through the anus,
a stoma or transabdominally and is advanced through the large intestine under direct
vision. Standard diagnostic functions include inspection, biopsy, photography and
video recording. Diagnostic observations are made concerning focal benign or
malignant lesions, diffuse mucosal changes, luminal obstruction, motility, and
extrinsic compression by contiguous structures. The most common therapeutic
endoscopic procedures include polypectomy, dilatation of strictures, removal of
foreign bodies and treatment of gastrointestinal bleeding with coagulation.
Colonoscopy Feb 14
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Colonoscopy is the most sensitive and specific test for detecting cancer and large
polyps but is associated with higher risks than other screening tests for colorectal
cancer. These include a small risk of bleeding and risk of perforation, primarily
associated with removal of polyps or biopsies performed during screening.
Potential screening options for colorectal cancer include home fecal occult blood test
(FOBT), flexible sigmoidoscopy, the combination of home FOBT and flexible
sigmoidoscopy, colonoscopy, and double-contrast barium enema. Each option has
advantages and disadvantages that may vary for individual patients and practice
settings. The American Cancer Society recommends screening people at average risk
for colorectal cancer beginning at 50 years of age by (1) FOBT annually; (2) flexible
sigmoidoscopy every five years; (3) annual FOBT plus flexible sigmoidoscopy every
five years; (4) double-contrast barium enema every five years; or (5) colonoscopy
every 10 years. A 10-year interval has been recommended for colonoscopy on the
basis of evidence regarding the natural history of adenomatous polyps. Shorter
intervals (five years) have been recommended for flexible sigmoidoscopy and
double-contrast barium enema because of their lower sensitivity, but there is no
direct evidence with which to determine the optimal interval for tests other than
FOBT. The US Preventive Services Task Force (USPSTF) recommends initiating
screening at 50 years of age for men and women at average risk for colorectal
cancer, based on the incidence of cancer above this age in the general population. In
persons at higher risk (for example, those with a first-degree relative who receives a
diagnosis of colorectal cancer before 60 years of age), initiating screening at an
earlier age is reasonable. Expert guidelines exist for screening very high-risk
patients, including those with a history suggestive of familial adenomatous polyposis
(FAP) or hereditary nonpolyposis colorectal cancer HNPCC), or those with a personal
history of ulcerative colitis. Similar recommendations are issued by the American
College of Surgeons, the American College of Obstetricians and Gynecologists, and
the American Academy of Family Physicians.
As a general rule, complete colonoscopy should be done at the time of initial
polypectomy to detect and resect all synchronous adenomas. Most patients with
polyps detected by barium enema or flexible sigmoidoscopy, especially if the polyps
are multiple or large, should undergo colonoscopy to excise the polyp and search for
additional neoplasms. As simple small (< 1 cm) tubular adenomas are extremely
common and the risk of subsequent cancer in these patients is approximately equal
to that of the general population (0.1%), the decision whether to perform
colonoscopy must be individualized depending on the patient's age, comorbidity, and
past or family history of colorectal neoplasia. Current recommendations for follow-up
surveillance colonoscopy assume that the initial clearing colonoscopy was complete
to the cecum with adequate preparation and removal of all visualized polyps. If,
because of multiple adenomas or other technical reasons, the colonoscopist is not
reasonably confident that all adenomas have been found and resected, clearance
should be verified at one year or sooner.
If only a single tubular adenoma < 1 cm in size is found, the first subsequent
examination can be in five years. If a subsequent colonoscopy is negative, further
examination can be performed at an interval of five years. After a complete clearing
colonoscopy has been accomplished after an initial polypectomy, repeat colonoscopy
to check for metachronous adenomas should be performed in 3 years for patients at
high risk for developing metachronous advanced adenomas. This includes those who
at baseline examination have multiple (> 2) adenomas, a large (> 1 cm) adenoma,
an adenoma with villous histology or high-grade dysplasia, or have a family history
Colonoscopy Feb 14
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of colorectal cancer. Efforts to control colon cancer now focus mainly on strategies to
reliably detect and resect advanced adenomas before they become malignant.
Patients with large (> 2 cm) sessile adenomas, especially if removed in piecemeal
fashion, should have additional clearing examinations at 3 - 6 month intervals until
complete polyp removal is verified. If residual polyp is present, it should be resected
and the completeness of resection documented in 3 months. After one negative
follow-up examination, care can revert to standard surveillance as performed for
patients with benign adenomas. If complete resection is not possible after two or
three examinations, the good-risk patient should usually be referred for surgical
therapy.
At the time of diagnosis of colon cancer, it is important to evaluate the remaining
colon for additional neoplastic lesions prior to surgery. If this is not possible due to
obstruction from the carcinoma or for other technical reasons, alternative options
include intraoperative colonoscopy or colonoscopy within three to six months of
resection. Once additional neoplasms have been excluded or removed, surveillance
colonoscopy to detect metachronous neoplasia should be carried out three years
after resection. If this examination is negative, subsequent colonoscopy may be
carried out at 3 to 5 year intervals. In patients with rectosigmoid cancer resected for
cure by low anterior resection, sigmoidoscopy may be considered every three to six
months for two years to evaluate possible suture line recurrence.
Because the risk for local recurrence or for lymph node metastasis from invasive
carcinoma in a colonoscopically resected polyp is less than the risk for death from
colonic surgery, no further treatment is indicated after colonoscopic resection of a
malignant polyp (an adenomatous polyp with cancer invading the submucosa) if the
endoscopic and pathological criteria listed below are fulfilled:





The polyp is considered to be completely excised by the endoscopist and is
submitted in toto for pathological examination.
In the pathology laboratory, the polyp is fixed and sectioned so that it is
possible to accurately determine the depth of invasion, grade of
differentiation, and completeness of excision of the carcinoma.
The cancer is not poorly differentiated.
There is no vascular or lymphatic involvement.
The margin of excision is not involved. Invasion of the stalk of a pedunculated
polyp, by itself, is not an unfavorable prognostic finding, as long as the cancer
does not extend to the margin of stalk resection.
When a patient's malignant polyp has poor prognostic features, the relative risks of
surgical resection should be weighed against the risk of death from metastatic
cancer. The patient at high risk for morbidity and mortality from surgery probably
should not have surgical resection. If a malignant polyp is located in that part of the
lower rectum that would require an abdominal-perineal resection, local excision
rather than a standard cancer resection usually is justified. Rectal ultrasound studies
may assist in determining correct treatment. During colonoscopic excision of a large
sessile polyp that may require subsequent surgical resection, it may be useful to
mark the polypectomy site with India ink.
There are groups that have a high incidence of colorectal cancer. These include those
with hereditary conditions, such FAP and HNPCC. Together they account for no more
than 6% of colorectal cancers. More common conditions associated with an increased
risk include: a personal history of colorectal cancer or adenomas, first degree relative
Colonoscopy Feb 14
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with colorectal cancer at any age, first degree relative with adenomas diagnosed
before 60 years of age, a personal history of ovarian, endometrial, or breast cancer,
and a personal history of long-standing chronic ulcerative colitis or Crohn’s colitis.
These high-risk groups account for only about a quarter of all colorectal cancers, so
limiting screening or early cancer detection to only these high-risk groups would miss
the majority of colorectal cancers.
Review History
February 2004
April 2006
November 2008
April 2009
February 2012
February 2013
May 2013
February 2014
Medical Advisory Council initial approval
Update – no revisions
Added the word ‘Treatment’ above the second column for Highrisk Patients with Significant Personal History and Significant
Family History.
Update. Revised Grid on Surveillance Colonoscopy. Codes
reviewed.
Update – no revisions
Update – no revisions. Added Coding updates.
Added constipation as an indication, added that screening for
African Americans may begin at 45
Update – Several revisions to policy statement regarding
surveillance colonoscopy for high risk individuals based on
recommendations from NCCN (2.2013 Colorectal cancer
screening and 2.2014 Colon cancer)
This policy is based on the following evidenced-based guidelines:
1.
2.
3.
4.
5.
6.
7.
8.
National Comprehensive Cancer Network (NCCN). Colorectal Cancer Screening.
Practice Guidelines in Oncology 2009.
Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology
Guidelines for Colorectal Cancer Screening 2008.
Clinical Guidelines. Screening for Colorectal Cancer: U.S. Preventive Services
Task Force Recommendation Statement. U.S. Preventive Services Task Force. 4
November 2008 | Volume 149 Issue 9.
Levin B, Lieberman DA, McFarland B, et al. Screening and Surveillance for the
Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008. A Joint
Guideline from the American Cancer Society, the US Multi-Society Task Force on
Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin
2008; 58:130-160. 2008 American Cancer Society.
American Society of Colon and Rectal Surgeons. Colorectal Cancer Screening and
Surveillance: Clinical Guidelines and Rationale. 2003. Available at:
http://www.fascrs.org/physicians/practice_parameters/colorectal_cancer_screen
ing_surveilance/
McFarland EG, Levin B, Lieberman DA, et al. Revised Colorectal Screening
Guidelines: Joint Effort of the American Cancer Society, U.S. Multisociety Task
Force on Colorectal Cancer, and American College of Radiology. 2008. Radiology.
DOI: 10.1148/radiol.2483080842.
Colorectal Cancer Screening and Surveillance: Clinical Guidelines and Rationale –
Update Based on New Evidence. General Recommendations. American Society of
Colon & Rectal Surgeons. 2003. Available at:
http://www.fascrs.org/physicians/practice_parameters/colorectal_cancer_screen
ing_surveilance/
Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy
surveillance after screening and polypectomy: a consensus update by the US
Colonoscopy Feb 14
22
Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012
Sep;143(3):844-57. Available at: http://www.gastrojournal.org/article/S00165085(12)00812-8/fulltext#sec2.2
9. National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in
Oncology. Colorectal Cancer Screening. Version 2.2013
10. National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in
Oncology. Colon Cancer. 2.2014
References – Update February 2014
1.
2.
3.
4.
Cone MM, Beck DE, Hicks TE, et al. Timing of colonoscopy after resection for
colorectal cancer: are we looking too soon? Dis Colon Rectum. 2013.
Nov;56(11):1233-6.
Cooper GS, Kou TD, Barnholtz Sloan JS, et al. Use of colonoscopy for polyp
surveillance in Medicare beneficiaries. Cancer. 2013 May 15;119(10):1800-7.
Hassan C, Quintero E, Dumonceau JM, et al. Post-polypectomy colonoscopy
surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
Endoscopy. 2013 Oct;45(10):842-51
Leddin D, Enns R, Hilsden R, et al. Colorectal cancer surveillance after index
colonoscopy: guidance from the Canadian Association of Gastroenterology. Can
J Gastroenterol. 2013 Apr;27(4):224-8.
References – Update May 2013
1.
2.
3.
Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM;
American College of Gastroenterology. American College of Gastroenterology
guidelines for colorectal cancer screening 2009. Erratum in Am J Gastroenterol.
2009 Jun;104(6):1613.
Agrawal J, Syngal S. Colon cancer screening strategies. Curr Opin Gastroenterol.
2005;21(1):59-63.
Agrawal S, Bhupinderjit A, Bhutani MS, et al. Colorectal cancer in African
Americans. Am J Gastroenterol. 2005;100(3):515-523.
References – Update February 2013
1.
2.
3.
4.
Chokshi RV, Hovis CE, Hollander T, et al. Prevalence of missed adenomas in
patients with inadequate bowel preparation on screening colonoscopy.
Gastrointest Endosc 2012; 75:1197.
Lee L, Saltzman JR. Overview of colonoscopy in adults. UpToDate. January 2,
2013.
Lee TJ, Blanks RG, Rees CJ, et al. Longer mean colonoscopy withdrawal time is
associated with increased adenoma detection: evidence from the Bowel Cancer
Screening Programme in England. Endoscopy 2013; 45:20.
Moritz V, Bretthauer M, Ruud HK, et al. Withdrawal time as a quality indicator for
colonoscopy - a nationwide analysis. Endoscopy 2012; 44:476.
References – Update February 2012
1.
2.
Cappell MS. Risks versus benefits of gastrointestinal endoscopy during
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Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering
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