Colorectal screening in Canada, 2023-24

Screening for individuals at increased risk

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Individuals at increased risk have certain risk factors that makes them more susceptible to developing colorectal cancer, developing more aggressive colorectal cancers, or developing colorectal cancer at an earlier age. Individuals at increased risk may be screened differently than individuals at average risk and are often screened outside of organized programs.

Many provinces and territories have specific factors they consider when identifying an individual at increased risk for colorectal cancer. The most common risk factor that places individuals at increased risk is having a 1st degree relative that was diagnosed with colorectal cancer.

Definitions of increased risk for colorectal cancer

P/T One 1st degree relative diagnosed with: Two or more 1st degree relatives diagnosed with: Two 2nd degree relatives diagnosed with: Personal history of:
YT Colorectal cancer*, Adenomatous polyps* Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps
NT Colorectal cancer* Colorectal cancer Colorectal cancer, Adenomatous polyps
NU Colorectal cancer* Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps
BC Colorectal cancer* Colorectal cancer
AB Colorectal cancer*, Adenomatous polyps* Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps
SK Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps
MB Colorectal cancer (one first-degree relative diagnosed at age ≥60) One or more first-degree relatives diagnosed with advanced adenomas at any age
ON^ Colorectal cancer Colorectal cancer
QC~, ** Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps
NB Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps
NS Colorectal cancer* Colorectal cancer Colorectal cancer, high-risk adenomatous polyps (as defined by size >10 mm, villous histology regardless of size, high-grade dysplasia regardless of size), sessile serrated lesion with dysplasia and/or >10 mm, traditional serrated adenomas, or three or more low-grade adenomas
PE Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps Colorectal cancer, Adenomatous polyps
NL Colorectal cancer* Colorectal cancer Colorectal cancer Colorectal cancer, Adenomatous polyps

*YT, NT, NU, BC, AB, NS, NL: Age ≤60.
^ON: The criteria for definition of increased risk for colorectal cancer are currently under review in Ontario.
~QC: In Quebec, one second or third-degree relative diagnosed with colorectal cancer or adenomatous polyps, one first-degree relative, and one second-degree relative from the same side of the family diagnosed with colorectal cancer at any age are considered. Also, slight or moderate increased risk is considered.
**QC: Monitoring and management algorithms have been revised based on risk and clinical follow-up according to pathology. These algorithms can be viewed on the MSSS website.

Increased risk recommendations

Provinces and territories may, outside of their population-based screening programs, recommend specific screening protocols and follow-up measures for individuals at increased risk. The Canadian Association of Gastroenterology (CAG) has issued guidelines for defining and screening individuals at increased risk.

Most provinces and territories recommend screening individuals at increased risk starting at age 40, or 10 years earlier than the participant’s youngest relative’s age at diagnosis, with colonoscopy every five or ten years. In some cases, the recommendation is that individuals at increased risk are screened similarly to those of average risk, but that they begin screening at age 40. Other provinces follow the recommendations outlined in the CAG guidelines for screening individuals at increased risk.

Recommendations for individuals at increased risk of colorectal cancer

P/T Screening recommendation for increased risk population Follow-up recommendations after normal colonoscopy
YT
  • Screening through colonoscopy
  • First-degree relative diagnosed with colorectal cancer or adenomatous polyps at age ≤60 years or two or more first-degree relatives diagnosed at any age with colorectal cancer or adenomatous polyps. Refer at age 40 years or 10 years prior to index case, whichever comes first. FIT is not recommended
  • First-degree relative diagnosed with colorectal cancer age ˃60 years screen with FIT every two years starting at age 50
  • Colonoscopy in five years or as directed by specialist
NT
  • Screening through colonoscopy at age 40 or 10 years earlier than the youngest relative’s diagnosis
  • Colonoscopy in 5–10 years
NU
  • Screening through colonoscopy, depending on result
  • Varies based on polyp type
BC
  • Strong family history of colorectal cancer
  • Recommendations for those with a personal history of pre-cancerous lesions is based on the Guidelines and Protocols Advisory Committee (GPAC) guidelines
  • Colonoscopy in five years
AB
  • Screening through colonoscopy at age 40, or 10 years prior to the index case, whichever is earliest
  • Colonoscopy in five years
SK
  • First-degree relative diagnosed with colorectal cancer screen through colonoscopy beginning at age 40 or 10 years earlier than the youngest relative’s diagnosis
  • First-degree relatives diagnosed at age ≥60 screen through FIT starting at age 40
  • Recommendations at the discretion of endoscopist and participant, monitored by PCP (based on CAG guidelines)
MB
  • Participate in routine screening starting at age 40 or 10 years earlier than the youngest relative’s age at diagnosis, whichever comes first
  • Testing is patient preference, either through FIT screening every two years or colonoscopy every 5–10 years
  • Guideline indicates patient preference to return to FIT in five years, or colonoscopy in 7–10 years
ON*
  • ColonCancerCheck recommends that people without symptoms and at increased risk of colorectal cancer be screened through colonoscopy.
  • Screening should start for those with increased risk at age 50, or 10 years earlier than the age their first-degree relative was diagnosed with colorectal cancer, whichever comes first.
  • People with a first-degree relative diagnosed with colorectal cancer before age 60 should get screened again after a normal colonoscopy in five years
  • People with a first-degree relative diagnosed with colorectal cancer at age 60 or older should get screened again after a normal colonoscopy in 10 years
QC^
  • Screening for those at slightly increased risk through FIT every two years starting at age 40
  • Screening for those at moderately increased risk through colonoscopy every five years starting at age 40, or 10 years earlier than the youngest relative’s diagnosis
  • FIT test every two years, after 10 years for those at slightly increased risk
  • Colonoscopy every five years for those at moderately increased risk
NB
  • One first-degree relative with colorectal cancer or adenomatous polyps diagnosed at age <60, or two or more first-degree relatives with colorectal cancer or adenomatous polyps diagnosed at any age screen through colonoscopy at age 40, or 10 years earlier than the youngest relative’s diagnosis
  • One first-degree relative with colorectal cancer or adenomatous polyps diagnosed at age >60, or two or more second-degree relatives with colorectal cancer or adenomatous polyps diagnosed at age >60 screen through FOBT test starting at age 40 and/or referral to a specialist
  • Colonoscopy every five years
NS
  • One first-degree relative with colorectal cancer diagnosed before age 60 screened through colonoscopy starting age 40, or 10 years younger than age of first-degree relative at diagnosis
  • Two or more first-degree relatives with colorectal cancer screened through colonoscopy starting age 40, or 10 years younger than age of first degree relative at diagnosis
  • Colonoscopy in 5 years
PE
  • An index colonoscopy is recommended for individuals with a family history of colorectal cancer/adenomas in a parent, sibling, or child. Starting age is 40, or 10 years earlier than youngest affected relative. The colonoscopy screening interval is every five years. The stop age is 75
  • For other increased risks such as genetic conditions with a predisposition to colorectal cancer, personal history of colorectal cancer or adenomas, inflammatory bowel disease, or symptoms of colorectal cancer follow CAG guidelines
  • PCPs manage individuals with increased risk and coordinate referrals to specialists
  • Recommendations at discretion of endoscopist, following CAG guidelines
NL
  • Screening through colonoscopy
  • Follow-up with colonoscopy

*ON: Screening recommendations for individuals at increased risk of colorectal cancer are currently under review in Ontario.
^QC: Monitoring and management algorithms have been revised based on risk and clinical follow-up according to pathology. These algorithms can be viewed at msss.gouv.qc.ca/professionnels/cancer/pqdccr/

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