Cancer Information

Colorectal Cancer Screening (PDQ®)

Summary of Evidence

Note: Separate PDQ summaries on Colorectal Cancer Prevention; Colon Cancer Treatment; and Rectal Cancer Treatment are also available.

Based on solid evidence, screening for colorectal cancer (CRC) reduces CRC mortality, but there is little evidence that it reduces all-cause mortality, possibly because of an observed increase in other causes of death.

Table 1. Effect of Screening Intervention on Reducing Mortality from Colorectal CanceraFecal Occult Blood Test SigmoidoscopyDigital Rectal Exam ColonoscopyRCT = randomized controlled trial.aThere are no data on the effect of other screening interventions (i.e., fecal occult blood test combined with sigmoidoscopy, barium enema, colonoscopy, computed tomographic colonography, and stool DNA mutation tests) on mortality from colorectal cancer. Study DesignRCTsCase-control studies [1], RCTs in progressCase-control studiesCase-control studies, RCTs in progressInternal ValidityGoodFairFairPoorConsistencyGood FairGoodPoorMagnitude of Effects15%–33% About 60%–70% for left colonNo effectAbout 60%–70% for left colon; uncertain for right colonExternal ValidityFairFairPoorFairTable 2. Effect of Screening Intervention on Surrogate Endpoints (e.g., Stage at Diagnosis and Adenoma Detection)Sigmoidoscopy [2] [3] FOBT/ Sigmoidoscopy [4][5]Barium Enema [6]Colonoscopy [7][8]CT Colonography [9] [10][11] Stool DNA Mutation Tests [12]Immunochemical FOBTCRC = colorectal cancer; CT = computed tomography; FOBT = fecal occult blood test; iFOBT = immunochemical fecal occult blood test; N/A = not available.Study DesignCase-control studies Randomized controlled studiesEcologic and descriptive studiesEcologic and descriptive studiesEcologic and descriptive studiesStudies in progressCross-sectional study in which iFOBT is administered to persons receiving colonoscopyInternal ValidityPoorFairFairFairFairUnknownGoodConsistencyFairPoorPoorPoorPoorUnknownGoodMagnitude of Effects on Surrogate EndpointsAbout 45% decrease in detection rate of cancers compared with colonoscopyNo difference in diagnostic yield between sigmoidoscopy + FOBT vs. sigmoidoscopy aloneBarium enema detects about 30%–50% of cancers detected by colonoscopyAbout 3% of patients with no distal adenomas have advanced proximal neoplasia. There is a threefold increase in this rate in patients with distal adenomas.CT colonography may have similar sensitivity to colonoscopy in certain centers UnknowniFOBT detects >60% and ≤90% of CRCsExternal ValidityPoorN/A N/AN/A PoorUnknownN/A1Thiis-Evensen E, Hoff GS, Sauar J, et al.: Population-based surveillance by colonoscopy: effect on the incidence of colorectal cancer. Telemark Polyp Study I. Scand J Gastroenterol 34 (4): 414-20, 1999.2Cotterchio M, Manno M, Klar N, et al.: Colorectal screening is associated with reduced colorectal cancer risk: a case-control study within the population-based Ontario Familial Colorectal Cancer Registry. Cancer Causes Control 16 (7): 865-75, 2005.3Schoenfeld P, Cash B, Flood A, et al.: Colonoscopic screening of average-risk women for colorectal neoplasia. N Engl J Med 352 (20): 2061-8, 2005.4Segnan N, Senore C, Andreoni B, et al.: Randomized trial of different screening strategies for colorectal cancer: patient response and detection rates. J Natl Cancer Inst 97 (5): 347-57, 2005.5Gondal G, Grotmol T, Hofstad B, et al.: The Norwegian Colorectal Cancer Prevention (NORCCAP) screening study: baseline findings and implementations for clinical work-up in age groups 50-64 years. Scand J Gastroenterol 38 (6): 635-42, 2003.6Winawer SJ, Stewart ET, Zauber AG, et al.: A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National Polyp Study Work Group. N Engl J Med 342 (24): 1766-72, 2000.7Lieberman DA, Weiss DG, Bond JH, et al.: Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med 343 (3): 162-8, 2000.8Imperiale TF, Wagner DR, Lin CY, et al.: Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. N Engl J Med 343 (3): 169-74, 2000.9Pickhardt PJ, Choi JR, Hwang I, et al.: Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 349 (23): 2191-200, 2003.10Cotton PB, Durkalski VL, Pineau BC, et al.: Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA 291 (14): 1713-9, 2004.11Mulhall BP, Veerappan GR, Jackson JL: Meta-analysis: computed tomographic colonography. Ann Intern Med 142 (8): 635-50, 2005.12Imperiale TF, Ransohoff DF, Itzkowitz SH, et al.: Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average-risk population. N Engl J Med 351 (26): 2704-14, 2004.

[Back to Top]


Colorectal cancer (CRC) is the third most common malignant neoplasm worldwide [1] and the second leading cause of cancer deaths in the United States.[2] It is estimated that there will be 142,820 new cases diagnosed in the United States in 2013 and 50,830 deaths due to this disease. From 2005 to 2009, CRC incidence declined by 4.1% per year among adults aged 50 years and older. However, in adults younger than 50 years, CRC incidence rates have been increasing by 1.1% per year. From 2005 to 2009, mortality from CRC declined by 2.4% per year in men and 3.1% per year in women.[2] The incidence is higher in men than in women. It ranges from 46.1 per 100,000 per year in Hispanic men to 66.9 per 100,000 per year in African American men. In women it ranges from 31.9 per 100,000 per year in Hispanics to 50.3 per 100,000 per year in African Americans.[3] The age-adjusted mortality rates for men and women are 20.2 per 100,000 per year in men and 14.1 per 100,000 per year in women.[3] About 5% of Americans are expected to develop the disease within their lifetime and about half of those will die from it.[3] Age-specific incidence and mortality rates show that the vast majority of cases are diagnosed after age 50 years; about 4% of CRCs occur younger than age 50 years.[3][4]

Among the groups that have a high incidence of CRC are those with hereditary conditions, such as familial adenomatous polyposis and hereditary nonpolyposis CRC (inherited in an autosomal dominant manner). Combined, the two groups account for no more than 6% of CRCs. More common conditions associated with an increased risk include a personal history of CRC or adenomas; first-degree relative with CRC; a personal history of ovarian, endometrial, or breast cancer; and a personal history of long-standing chronic ulcerative colitis or Crohn colitis.[5][6][7] These high-risk groups account for about a quarter of all CRCs. Limiting screening or early cancer detection to only these high-risk groups would miss the majority of CRCs.[8]

Genetic,[9] experimental, and epidemiologic[10] studies suggest that CRC results from complex interactions between inherited susceptibility and environmental or lifestyle factors. Efforts to identify causes led to the hypothesis that adenomatous polyps (adenomas) are precursors for the vast majority of CRCs.[11] In effect, measures that reduce the incidence and prevalence of adenomas may result in a subsequent decrease in the risk of CRCs [12]; however, some CRC mortality may be caused by fast-growing lesions and even lesions that do not pass through an adenomatous phase. Overall, the details of growth rates of adenomas and cancer are unknown; most likely there is a broad spectrum of growth patterns, including formation and spontaneous regression of adenomas.[13]

1Shike M, Winawer SJ, Greenwald PH, et al.: Primary prevention of colorectal cancer. The WHO Collaborating Centre for the Prevention of Colorectal Cancer. Bull World Health Organ 68 (3): 377-85, 1990.2American Cancer Society.: Cancer Facts and Figures 2013. Atlanta, Ga: American Cancer Society, 2013. Available online. Last accessed May 2, 2013.3Howlader N, Noone AM, Krapcho M, et al., eds.: SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations). Bethesda, Md: National Cancer Institute, 2012. Also available online. Last accessed February 21, 2013.4Imperiale TF, Wagner DR, Lin CY, et al.: Results of screening colonoscopy among persons 40 to 49 years of age. N Engl J Med 346 (23): 1781-5, 2002.5Fuchs CS, Giovannucci EL, Colditz GA, et al.: A prospective study of family history and the risk of colorectal cancer. N Engl J Med 331 (25): 1669-74, 1994.6Smith RA, von Eschenbach AC, Wender R, et al.: American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: update 2001--testing for early lung cancer detection. CA Cancer J Clin 51 (1): 38-75; quiz 77-80, 2001 Jan-Feb.7Levin B, Rozen P, Young GP: How should we follow up colorectal premalignant conditions? In: Rozen P, Young G, Levin B, et al.: Colorectal Cancer in Clinical Practice: Prevention, Early Detection, and Management. London, UK: Martin Dunitz, 2002, pp 67-76.8Winawer SJ, Fletcher RH, Miller L, et al.: Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 112 (2): 594-642, 1997.9Fearon ER, Vogelstein B: A genetic model for colorectal tumorigenesis. Cell 61 (5): 759-67, 1990.10Young GP, Rozen P, Levin B: How does colorectal cancer develop? In: Rozen P, Young G, Levin B, et al.: Colorectal Cancer in Clinical Practice: Prevention, Early Detection, and Management. London, UK: Martin Dunitz, 2002, pp 23-37.11Muto T, Bussey HJ, Morson BC: The evolution of cancer of the colon and rectum. Cancer 36 (6): 2251-70, 1975.12Winawer SJ, Zauber AG, Ho MN, et al.: Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 329 (27): 1977-81, 1993.13Loeve F, Boer R, Zauber AG, et al.: National Polyp Study data: evidence for regression of adenomas. Int J Cancer 111 (4): 633-9, 2004.

[Back to Top]

Evidence of Benefit

Fecal Occult Blood Test (FOBT)

In FOBT testing, a person collects stool samples that are analyzed for the presence of small amounts of blood. Collection details vary somewhat for different tests, but typically involve collection of as many as three different specimens on 3 different days, with small amounts from one specimen smeared by a wooden stick on a card with two windows or otherwise placed in a specimen container.

The guaiac test identifies peroxidase-like activity that is characteristic of human and nonhuman hemoglobin. Thus, it will record blood from ingested meat, upper airway bleeding such as epistaxis, upper gastrointestinal (GI) bleeding, as well as colonic lesions.

Five controlled clinical trials have been completed or are in progress to evaluate the efficacy of screening utilizing the FOBT. The Swedish trial is a targeted study for individuals aged 60 to 64 years.[1] The English trial selects candidates from lists of family practitioners.[2] The Danish trial offers screening to a population aged 45 to 75 years randomly assigned to a control or study group.[3][4]

The Minnesota trial demonstrated that annual guaiac-based FOBT (gFOBT) testing using primarily rehydrated samples decreased mortality from colorectal cancer (CRC) by 33% [5] and that biennial testing developed a 21% relative mortality reduction.[6] Some part of the reduction may have been attributed to chance detection of cancer by colonoscopies; rehydration of guaiac test slides greatly increased positivity and consequently increased the number of colonoscopies performed.[7] Subsequent analyses by the Minnesota investigators using mathematical modeling suggested that for 75% to 84% of the patients mortality reduction was achieved because of sensitive detection of CRCs by the test; chance detection played a modest role (16%–25% of the reduction).[8] Nearly 85% of patients with a positive test underwent diagnostic procedures that included colonoscopy or double-contrast barium enema plus flexible sigmoidoscopy (FS). After 18 years of follow-up, the incidence of CRC was reduced by 20% in the annually screened arm and 17% in the biennially screened arm.[9]

The English trial allocated approximately 76,000 individuals to each arm. Those in the screened arm were offered nonrehydrated gFOBT testing every 2 years for three to six rounds from 1985 to 1995. At a median follow-up time of 7.8 years, 60% completed at least one test, and 38% completed all tests. Cumulative incidence of CRC was similar in both arms, and the trial reported a relative risk (RR) reduction of 15% in CRC mortality (odds ratio [OR] = 0.85; 95% confidence interval [CI], 0.74–0.98).[10] The serious complication rate of colonoscopy was 0.5%. There were five deaths within 30 days of surgery for screen-detected CRC or adenoma in a total of 75,253 individuals screened.[11] After a median follow-up of 11.8 years, no difference in CRC incidence between the intervention and control groups was observed. The disease-specific mortality rate ratio associated with screening was 0.87 (0.78–0.97; P = .01). The rate ratio for death from all causes was 1.00 (0.98–1.02; P = .79).[12] When the median follow-up was extended to 19.5 years, there was a 9% reduction in CRC mortality (RR = 0.91; 95% CI, 0.84–0.98) but no reduction in CRC incidence (RR = 0.97; 95% CI, 0.91–1.03), or death from all causes (RR = 1.00; 95% CI, 0.99–1.02).[13]

The Danish trial in Funen, Denmark, entered approximately 31,000 individuals into two arms, in which individuals in the screened arm were offered nonrehydrated gFOBT testing every 2 years for nine rounds over a 17-year period. Sixty-seven percent completed the first screen, and more than 90% of individuals invited to each subsequent screen underwent FOBT testing. This trial demonstrated an 18% reduction in CRC mortality at 10 years of follow-up,[14] 15% at 13 years of follow-up (RR = 0.85; 95% CI, 0.73–1.00),[15] and 11% at 17 years of follow-up (RR = 0.89; 95% CI, 0.78–1.01).[16] CRC incidence and overall mortality were virtually identical in both arms.

The Swedish trial in Goteborg enrolled all 68,308 citizens in the city born between 1918 and 1931 that were aged 60 to 64 years, and randomly assigned them to screening and control groups of nearly equal size. Participants in the control group were not contacted and were unaware they were part of the trial. Screening was offered at different frequencies to three different cohorts according to year of birth. Screening was done using the gFOBT Hemoccult-II test after dietary restriction. Nearly 92% of tests were rehydrated. Individuals with a positive test result were invited to an examination consisting of a case history, FS, and double-contrast barium enema. The range of follow-up times was from 6 years 7 months to 19 years 5 months, depending on the date of enrollment. The primary endpoint was CRC-specific mortality. The overall screening compliance rate was 70%, and 47.2% of participants completed all screenings. Of the 2,180 participants with a positive test, 1,890 (86.7%) underwent a complete diagnostic evaluation with 104 cancers and 305 adenomas of at least 10 mm detected. In total, there were 721 CRCs (152 Dukes D, 184 Dukes C) in the screening group and 754 CRCs (161 Dukes D, 221 Dukes C) in the control group, with an incidence ratio of 0.96 (95% CI, 0.86–1.06). Deaths from CRC were 252 in the screening group and 300 in the control group, with a mortality ratio of 0.84 (95% CI, 0.71–0.99). This CRC mortality difference emerged after 9 years of follow-up. Deaths from all causes were very similar in the two groups, with a mortality ratio of 1.02 (95% CI, 0.99–1.06).[1]

All trials have shown a more favorable stage distribution in the screened population compared with controls (Table 3). Data from the Danish trial indicate that while the cumulative incidence of CRC was similar in the screened and control groups, a higher percentage of CRCs and adenomas were Dukes A and B lesions in the screened group.[14] A meta-analysis of all previously reported randomized trials using biennial FOBT showed no overall mortality reduction by gFOBT screening (RR = 1.002; 95% CI, 0.989–1.085). The RR of CRC death in the gFOBT arm was 0.87 (95% CI, 0.8–0.95), and the RR of non-CRC death in the gFOBT group was 1.02 (95% CI, 1.00–1.04; P = .015).[17]

Mathematical models have been constructed to extrapolate the results of screening trials to screening programs for the general population in community health care delivery settings. These models project a reduction in CRC mortality or an increase in life expectancy using currently available screening methodology.[18][19][20][21] The anticipated success of such methodology is critically dependent on the appropriate use of the FOBT and an effective clinical management plan.[22][23]

A systematic review done through the Cochrane Collaboration examined all CRC screening randomized trials that involved gFOBT testing on more than one occasion. The combined results showed that trial participants allocated to screening had a 16% lower CRC mortality (RR = 0.84; 95% CI, 0.78–0.90). There was, however, no difference in all-cause mortality between the screened and control groups (RR = 1.00; 95% CI, 0.99–1.02). Furthermore, the trials reported a low positive predictive value (PPV) for the FOBT test, suggesting that most positive tests were false positives. From the trials with nonrehydrated slides (Funen and Nottingham), the PPV was 5.0% to 18.7%, while the PPV in the trials using rehydrated slides (Goteborg and Minnesota) was 0.9% to 6.1%. The report contains no discussion on contamination in the control arms of the trials and no information on treatment by stage.[24][25]

On initial (prevalence) examinations, from 1% to 5% of unselected persons tested with gFOBT have positive test results. Of those persons with positive test results, approximately 2% to 10% have cancer and approximately 20% to 30% have adenomas,[26][27] depending on how the test is done. Data from randomized controlled trials (RCT) are summarized in Table 3.

Table 3. Randomized Controlled Screening Trials: Fecal Occult Blood Testing SitePopulation Size Positivity Rate (%) % Cancers LocalizedaTesting IntervalRelative Mortality ReductionN/A = not available.a% Localized = T1–3 N0 M0.ScreenedControlMinnesota [5][6] 48,000 Unrehydrated: 2.4% 59 53 Annual 33% Rehydrated: 9.8% Biennial 21%United Kingdom [10] 150,000 Unrehydrated: 2.1% 5244 Biennial 15%Denmark [14] 62,000 Unrehydrated: 1.0% 56 48 Biennial 18%Sweden [28]68,308 Unrehydrated: 1.9%525016%Rehydrated: 5.8%

Newer FOBTs: Nonrandomized Controlled Trial Evidence

The immunochemical FOBT (iFOBT) was developed to detect intact human hemoglobin. The advantage of iFOBT over guaiac FOBT (gFOBT) is that it does not detect hemoglobin from nonhuman dietary sources. It also does not detect partly digested human hemoglobin that comes from the upper respiratory or GI tract. Preliminary studies of several commercially developed iFOBT tests define their sensitivity and specificity compared with concurrently performed colonoscopy. These studies also examine these outcomes for different cut points, and the benefit of multiple versus single stool samples.[29] Generally, iFOBT testing is more sensitive for cancers than for benign neoplasias. As expected, higher cut points decrease sensitivity and increase specificity.

In one study, 2,188 patients scheduled for colonoscopy because of an elevated risk due to personal or family history of colorectal neoplasm, positive gFOBT result, change in bowel habits, anemia, abdominal pain with weight loss, or anal symptoms were invited to participate in a comparative assessment of iFOBT against colonoscopy findings. After exclusions for health and cognitive reasons, 1,859 patients were offered iFOBT, 1,116 patients adhered to the protocol, and 1,000 patients completed the procedure. Sensitivity and specificity were calculated at various cut-points. At a cut-point of 100 ng/mL, sensitivity and specificity were, respectively, 88.2% and 89.7% for cancer and 61.5% and 91.4% for any clinically significant neoplasia (cancer and advanced polyps). At 150 ng/mL the respective sensitivities and specificities were 82.4% and 91.9% for cancer and 53.8% and 95% for any clinically significant neoplasia. Calculations were based on the most severe pathologic finding from colonoscopy and the highest fecal-hemoglobin concentration measured by iFOBT applied to three stool samples collected prior to the colonoscopy. Stool samples were collected by patients following iFOBT kit instructions and analyzed by the OC-MICRO analyzer (from the Eiken Chemical Company in Tokyo, Japan).[30]

In another study, 21,805 asymptomatic patients received iFOBT based on one stool sample collected by patients following the kit instructions on the day of or the day before the colonoscopy. Stool samples were analyzed using the Magstream 1,000/Hem SP automated system (from Fujirebio Incorporated, Tokyo, Japan), which is based on the HemeSelect system (from Beckman Coulter, Palo Alto, California). Sensitivity and specificity based on subsequent colonoscopy were, respectively, 65.8% and 94.6% for cancer and 27.1% and 95.1% for advanced neoplasm.[31]

Fecal immunochemical tests may vary with regard to numbers of stools tested and cut-off values for a positive result.[29][32][33]

A systematic review to evaluate the comparative diagnostic performance of gFOBT and iFOBT in the context of a decision to introduce screening for CRC in the United Kingdom, included 33 studies evaluating gFOBT and 35 studies evaluating iFOBT, including nine that evaluated both gFOBT and iFOBT. There was no clear evidence for superiority of either gFOBT or iFOBT. Sensitivities for the detection of all neoplasms ranged from 6.2% (specificity 98%) to 83.3% (specificity 98.4%) for gFOBTs and 5.4% (specificity 98.5%) to 62.6% (specificity 94.3%) for iFOBT. Increasing sensitivity entailed adjusting cut-points to decrease specificity. Sensitivities were higher for the detection of CRC and lower for adenomas.[34]

Some studies have utilized the quantitative ability of iFOBT to consider detection and specificity at various test cut-points for defining a positive test. One study [35] found that reducing the cut-point from the standard 100 ng/mL to 50 ng/mL increased the detection of advanced adenomas but had little impact on the detection of cancer. The number of colonoscopies required to detect a single advanced adenoma or cancer increased from 1.9 to 2.3; a 20% increase. Specificity declined from 97.8% to 96%.

Potential false-positive test results due to an increased risk of upper GI bleeding are of concern with FOBT testing and pretest protocols, therefore; low-dose aspirin regimens should be discontinued for a week or more prior to FOBT. The performance of iFOBT was tested in an ongoing diagnostic study (2005–2009) at 20 internal medicine GI practices in southern Germany. Nineteen hundred seventy-nine patients (233 regular low-dose aspirin users and 1,746 never users) were identified in the records for inclusion in the analysis. All patients provided one stool sample taken within a week before colonoscopy preparation, which was collected according to instructions in a container that was kept refrigerated or frozen until rendered to the clinic on the day of colonoscopy, and the patients agreed to complete a standard questionnaire regarding the use of analgesics and low-dose aspirin (for prevention of cardiovascular disease). Stool samples were thawed within a median of 4 days after arrival at the central laboratory (shipped frozen from the recipient clinics). Fecal occult blood levels were measured by two automated iFOBT tests according to the manufacturer’s instructions (RIDASCREEN Haemoglobin and RIDASCREEN Haemo-/Haptoglobin Complex, r-biopharm, Bensheim, Germany) following clinical procedures and blinded to colonoscopy results. Advanced neoplasms were found in 24 aspirin users (10.3%) and in 181 nonusers (10.4%). At the cut-point recommended by the manufacturer, sensitivities for the two tests were 70.8% (95% CI, 48.9%–87.4%) for users compared with 35.9% (95% CI, 28.9%–43.4%) for nonusers and 58.3% (95% CI, 36.6%–77.9%) for users compared with 32% (95% CI, 25.3%–39.4%) for nonusers (P = .001 and P = .01, respectively). Specificities were 85.7% (95% CI, 80.2–90.1%) for users compared with 89.2% (95% CI, 87.6%–90.7%) for nonusers and 85.7% (95% CI, 80.2%–90.1%) for users compared with 91.1% (95% CI, 89.5%–92.4%) for nonusers (P = .13 and P = .01, respectively). For these iFOBTs, sensitivity for advanced neoplasms was notably higher with the use of low-dose aspirin while specificity was only slightly reduced, suggesting that there might be an advantage to aspirin use to increase sensitivity without much decrease in specificity.[36]


The flexible fiberoptic sigmoidoscope was introduced in 1969. The 60 cm flexible sigmoidoscope became available in 1976.[37] The flexible sigmoidoscope permits a more complete examination of the distal colon with more acceptable patient tolerance than the older rigid sigmoidoscope. The rigid instrument can discover 25% of polyps, and the 60 cm scope can find as many as 65%. The finding of an adenoma by FS may warrant colonoscopy to evaluate the more proximal portion of the colon.[38][39] The prevalence of advanced proximal neoplasia is increased in patients with a villous or tubulovillous adenoma distally and is also increased in those aged 65 years or older with a positive family history of CRC and with multiple distal adenomas.[40] Most of these adenomas are polypoid, flat and depressed lesions, which may be somewhat more prevalent than previously recognized.[41]

Virtually all screening studies using these types of sigmoidoscopes have demonstrated an increase in the proportion of early cases and a corresponding increase in survival compared with cases diagnosed in a nonscreening environment. Most of these studies, however, lack appropriate comparison groups, and their interpretation is unclear because of screening biases.

The first incidence and mortality results from a randomized trial of sigmoidoscopy were reported in the Norwegian Colorectal Cancer Prevention (NORCCAP) trial. This trial randomly assigned 41,913 men and women aged 55 to 64 years to a usual-care control group and 13,823 individuals to a screening group, 6,915 of whom received one-time FS and 6,908 of whom received both FS and iFOBT. Screening was conducted from January 1999 to December 2000. Follow-up was through national registries in Norway and ended December 31, 2006 for incidence and December 31, 2005 for mortality. The primary endpoint was incidence of CRC after 5, 10, and 15 years of follow-up based on an intention-to-screen analysis. The two randomly assigned groups had the same median age of 59 years and equal gender distribution. The attendance rate for screening was 65%. Mean insertion depth of the endoscope was 48.9 cm for men and 44.0 cm for women, with no severe complications. A neoplastic lesion was found in 19% of people screened, and 5% had a high-risk adenoma or invasive cancer. There were 33 prevalent CRCs, 17 in the subgroup invited for sigmoidoscopy only and 16 in the subgroup invited to both tests. Compliance for colonoscopy work-up was 97%. There was no difference in the cumulative hazard of CRC between the screened and control groups; 134.5 versus 131.9 cases per 100,000 person years, after a median follow-up of 7 years. The hazard ratio (HR) for CRC mortality was 0.73 (95% CI, 0.47–1.13) and for rectosigmoidal cancer mortality was 0.63 (95% CI, 0.34–1.18) after a median follow-up of 6 years. The HR for all-cause mortality was 1.02 (95% CI, 0.98–1.07). Additional follow-up is planned.[42]

In the Telemark Study in Norway, 400 people aged 50 to 59 years were offered FS in 1983 and, if polyps were found, a colonoscopy was available to them at that time, and again 2 years later, and also 6 years later (the intervention was more aggressive than the one-time sigmoidoscopy currently being tested in the United Kingdom). A nonrandomized control group was selected that did not have a baseline examination. In 1996, all persons were invited to have a colonoscopy. The result was that ten persons in the control group and two in the screening group developed CRC (RR = 0.2; 95% CI, 0.03–0.95). The screening group, however, had a higher overall mortality compared with the control group.[43]

A RCT of sigmoidoscopy screening in the United Kingdom suggests that the impact of endoscopic screening, at least on the left side of the colon, is substantial and prolonged. In this RCT, 170,000 persons were randomly assigned to one-time sigmoidoscopy versus usual care. At sigmoidoscopy, polyps were removed and patients with cancer were referred for treatment. Based on sigmoidoscopy findings, persons were considered to be low risk if they had normal exams or only one or two small (<1 cm) tubular adenomas; such persons were not referred for either colonoscopy workup or colonoscopic surveillance. In a follow-up of 10 years, the left-sided CRC incidence in the low-risk group (about 95% of attendees were low risk) was 0.02% to 0.04% per year—a very low risk of CRC compared with average risk. The cause of reduced risk—whether due to detection and removal of large or small polyps, or selection of individuals at lower risk—is yet unclear,[44] but may be assessed in further analysis. The natural history of large polyps is not well known, but some evidence suggests that such lesions become clinical CRC at a rate of approximately 1% per year.[45] Evidence from multiple studies has raised questions about the ability of endoscopy to reduce CRC mortality in the right colon.[46][47][48] Thus, it is unclear what the overall impact of endoscopy (e.g., colonoscopy screening) is, and whether there may be a large difference in impact on the left side of the colon compared with the right side.[46]

The SCORE RCT from Italy randomly assigned 34,272 participants aged 55 to 64 years to either one-time FS or control. About 58% of FS group participants actually had an FS. After 10.5 years of follow-up, CRC incidence was reduced in the FS group by 18% (RR, 0.82; 95% CI, 0.69–0.96), with the reduction beginning about 5 years after randomization. CRC mortality in the FS group was also lower than in the control group, but not to a statistically significant degree (RR, 0.78; 95% CI, 0.56–1.08). Overall, these results are consistent with the United Kingdom results.[49]

Sigmoidoscopy screening was also evaluated in the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) screening randomized trial.[50] Results were very similar to those of the United Kingdom trial. In PLCO, 77,445 men and women aged 55 to 74 years were randomly assigned to receive 60 cm flexible sigmoidoscopy screening at baseline and again at 3 or 5 years from 1993 to 2001 depending on their date of entry into the trial. The 77,455 men and women randomly allocated to the control arm received usual medical care. An examination was considered positive if a polyp or mass was detected. Participants were then referred to their primary care physicians for diagnostic follow-up. A total of 86.6% of participants underwent at least one sigmoidoscopy screening and 28.5% were positive. Of these, 80.5% had a diagnostic evaluation, of which 95.6% underwent colonoscopy. Thus 21.9% of participants in the intervention arm had a colonoscopy. Colorectal cancer screening in the control arm (contamination) was assessed by a questionnaire in a small sample of participants. The rate was estimated as 46.5%. In addition, the rate of colonoscopy after the screening phase was estimated as 47.7% in the intervention arm and 48.0% in the control arm.

The primary endpoint was colorectal cancer mortality, with colorectal cancer incidence a key secondary endpoint. All cancers and deaths were ascertained primarily by means of an annual questionnaire. Median follow-up time was 11.9 years and vital status within a year of the cutoff date was known for 99.9% of participants. The incidence rate of colorectal cancer was 11.9 per 10,000 person years in the intervention arm (1,012 cases) versus 15.2 in the usual care arm (1,287 cases) yielding a statistically significant RR of 0.79 (95% CI, 0.72–0.85). The absolute colorectal cancer risk reduction was 0.35%. In the distal colon the RR was 0.71 (95% CI, 0.64–0.80) while in the proximal colon the RR was 0.86 (95% CI, 0.76–0.97). The colorectal cancer mortality rate was 2.9 deaths per 10,000 person-years in the intervention arm (252 deaths) versus 3.9 deaths in the usual care arm (341 deaths) for a statistically significant RR of 0.74 (95% CI, 0.63–0.87). The absolute reduction in risk of colorectal cancer death was 0.11%. The mortality RR for the distal colon was 0.50 (95% CI, 0.38–0.64) while that for the proximal colon was 0.97 (95% CI, 0.77–1.22). Treatment of diagnosed colorectal cancers was very similar by arm within each stage. The rate of bowel perforations was 2.8 per 100,000 sigmoidoscopies. False positive screening results were observed in 20% of men and 13% of women. The RR for deaths from all causes excluding prostate, lung, colorectal, and ovarian cancers was 0.98 (95% CI, 0.96–1.01).[50]

Two case-control studies have been reported that evaluate the efficacy of screening sigmoidoscopy in preventing CRC mortality;[51][52] one study used rigid sigmoidoscopy, and the other used rigid and FS. Both studies were conducted in prepaid health plans and suggested a significantly decreased risk (70%–90%) of fatal cancer of the distal colon or rectum among individuals with a history of one or more sigmoidoscopic examinations compared with nonscreened patients.

There are no strong direct data to determine frequency of screening tests in programs of screening.

Combination of FOBT and Flexible Sigmoidoscopy

A combination of FOBT and sigmoidoscopy might increase the detection of lesions in the left colon (compared with sigmoidoscopy alone) while also increasing the detection of lesions in the right colon. Sigmoidoscopy detects lesions in the left colon directly but detects lesions in the right colon only indirectly when a positive sigmoidoscopy (that may variously be defined as a finding of advanced adenoma, any adenoma, or any polyp) is used to trigger a colonoscopic examination of the whole colon.

In 2,885 veterans (97% male; mean age 63 years), the prevalence of advanced adenoma at colonoscopy was 10.6%. It was estimated that combined screening with one-time FOBT and sigmoidoscopy would detect 75.8% (95% CI, 71.0%–80.6%) of advanced neoplasms. Examination of the rectum and sigmoid colon during colonoscopy was defined as a surrogate for sigmoidoscopy. This represented a small but statistically insignificant increase in the rate of detection of advanced neoplasia when compared with FS alone (70.3%; 95% CI, 65.2%–75.4%). The latter result could be achieved assuming that all patients with an adenoma in the distal colon undergo complete colonoscopy. Advanced neoplasia was defined as a lesion measuring at least 10 mm in diameter, containing 25% or more villous histology, high-grade dysplasia, or invasive cancer.[53] One-time use of FOBT differs from the annual or biennial application reported in those studies summarized in Table 1.

A study of 21,794 asymptomatic persons (72% were men) who had both colonoscopy and fecal immunochemical testing (FIT) for occult blood compared the detection of right-sided cancers as triggered by different test results. FIT alone resulted in a sensitivity of 58.3% and a specificity of 94.5% for proximal cancer diagnosis. FIT plus the finding of advanced neoplasia in the rectosigmoid colon yielded a sensitivity of 62.5% and a specificity of 93%. Thus, in this trial, the addition of sigmoidoscopy to FIT did not substantially improve the detection of right-sided colon cancers, compared with FIT alone.[54]

The NORCCAP once-only screening study randomly assigned 20,780 men and women, aged 50 to 64 years, to FS only or a combination of FS and FOBT with FlexSure OBT.[55] A positive FS was defined as a finding of any neoplasia or any polyp at least 10 mm. A positive FS or FOBT qualified for colonoscopy. Attendance in this study was 65%. Forty-one cases of CRC were detected (0.3% of screened individuals). Adenomas were found in 2,208 participants (17%), and 545 (4.2%) had high-risk adenomas. There was no difference in diagnosis yield between the FS only and the FS and FOBT groups regarding CRC or high-risk adenoma. There were no serious complications after FS, but there were six perforations after therapeutic colonoscopy (1:336).

Barium Enema

As part of the National Polyp Study, colonoscopic examination and barium enema were compared in paired surveillance examinations in those who had undergone a prior colonoscopic polypectomy.[56] The proportion of examinations in which adenomatous polyps were detected by barium enema was related to the size of the adenoma (P = .009); the rate was 32% for colonoscopic examinations in which the largest adenomas detected were no larger than 5 mm, 53% for those in which the largest adenomas detected were 6 mm to 10 mm, and 48% for those in which the largest adenomas detected were larger than 10 mm. In patients who have undergone colonoscopic polypectomy, colonoscopic examination is a more sensitive method of surveillance than double-contrast barium enema.


Because there are no RCTs of colonoscopy, evidence of benefit is indirect. Most indirect evidence is about detection rate of lesions that may be clinically important (like early CRC or advanced adenomas). Some case-control results are available. One RCT of colonoscopy has been initiated.[57]

Evidence about lesion detection rate

In a colonoscopic study of 3,121 predominantly male U.S. veterans (mean age: 63 years), advanced neoplasia (defined as an adenoma that was ≥10.0 mm in diameter, a villous adenoma, an adenoma with high-grade dysplasia, or invasive cancer) was identified in 10.5% of the individuals.[58] Among patients with no adenomas distal to the splenic flexure, 2.7% had advanced proximal neoplasia. Patients with large adenomas (≥10.0 mm) or small adenomas (<10.0 mm) in the distal colon were more likely to have advanced proximal neoplasia than were patients with no distal adenomas (OR = 3.4; 90% CI, 1.8–6.5 and OR = 2.6; 90% CI, 1.7–4.1, respectively). One-half of those with advanced proximal neoplasia, however, had no distal adenomas. In a study of 1,994 adults (aged 50 years or older) who underwent colonoscopic screening as part of a program sponsored by an employer, 5.6% had advanced neoplasms.[59] Forty-six percent of those with advanced proximal neoplasms had no distal polyps (hyperplastic or adenomatous). If colonoscopic screening is performed only in patients with distal polyps, about half the cases of advanced proximal neoplasia will not be detected.

A study of colonoscopy in women compared the yield of sigmoidoscopy versus colonoscopy. Among 1,463 women, cancer was found in one woman and advanced colonic neoplasia in 72 women or 4.9% (about one-half the prevalence compared with men). The authors focused, however, on RR (i.e., RR of missing an advanced neoplasm) as the outcome, instead of absolute risk of such neoplasms, which is substantially lower in women. In addition, the natural history of advanced neoplasia is not known, so its importance as an outcome in studies of detection is not clear.[60]

Analysis of data from a colonoscopy-based screening program in Warsaw, Poland demonstrated higher rates of advanced neoplasia in men than in women. The predominant age range of participants was 50 to 66 years. Of the 43,042 participants aged 50 to 66 years, advanced neoplasia was detected in 5.9% (5.7% among women with a family history of CRC, 4.3% among women without a family history of CRC, 12.2% among men with a family history of CRC, and 8.0% among men without a family history of CRC). Clinically significant complications requiring medical intervention were rare (0.1%) consisting of five perforations, 13 episodes of bleeding, 22 cardiovascular events, and 11 other events over the entire population of 50,148 screened persons. There were no deaths; however, the author reported that collection of 30-day complications data was not systematic (therefore, the data may not be reliable).[61]

Detection rates in colonoscopy screening vary with the rate at which the endoscopist examines the colon while withdrawing the scope. Detection rates among gastroenterologists (mean number of lesions per patient screened, 0.10–1.05; range of the percentage of patients with adenomas, 9.4%–23.7%) and the times to withdraw (3.1–16.8 minutes for procedures not including polyp removal). Examiners whose mean withdrawal time was 6 minutes or more had higher detection rates than those with mean withdrawal times of less than 6 minutes (28.3% vs. 11.8%; P < .001 for any neoplasia) and (6.4% vs. 2.6%; P < .005 for advanced neoplasia).[62] Overall detection rate of adenomas and cancer may be affected by how thoroughly endoscopists search for flat adenomas and flat cancer. While the phenomenon of flat neoplasms has been appreciated for years in Japan, it has more recently been described in the United States. In a study in which endoscopists used high-resolution white-light endoscopes, flat or nonpolypoid lesions were found to account for only 11% of all superficial colon lesions, but they were about 9.8 times as likely to contain cancer (in situ neoplasia or invasive cancer) compared with polypoid lesions.[41] However, because the definition of flat or nonpolypoid was height less than one-half of the diameter, it is likely that many lesions classified as nonpolypoid in this study would be routinely found and described by U.S. endoscopists as sessile. At the same time, the existence of very flat or depressed lesions (depressed lesions are very uncommon but are highly likely to contain cancer) means that endoscopists will want to pay increasing attention to this problem.[63] Flat lesions may play a role in the phenomenon of missed cancers.[64]

Flat or difficult-to-detect lesions include "serrated polyps," which may be more common in the right colon than they are in the left. The term serrated polyp is currently used to include hyperplastic polyps, sessile serrated adenomas, traditional serrated adenomas, and mixed serrated polyps.[65][66] The clinical significance of these lesions is uncertain, because the natural history is so difficult to learn for any polypoid lesion. However, the histologic and molecular characteristics of some serrated lesions suggest possibly important malignant potential (mutations in the BRAF gene may be an early step toward carcinogenesis in serrated polyps).[66] This potential, along with the challenges of detecting flat lesions, may partially account for recent reports of a colonoscopy's lesser protective effect in the right colon compared to the left.

In 2011, authors of one study reported variability of detection rates for proximal serrated polyps. They studied 15 colonoscopists on faculty at one university and showed, during the years 2000 to 2009, a wide variation in detection rate for proximal serrated polyps, ranging (per colonoscopy) from 0.01 to 0.26, suggesting that many proximal serrated lesions may be missed on routine exam.[65] The overall proportion of polyps that are "serrated" is unknown, in part because these lesions have been unappreciated and/or difficult to identify.

Evidence about colorectal cancer mortality reduction

Although there is no RCT to assess reduction of CRC incidence or mortality by colonoscopy, some case-control evidence is available. Based on case-control data about sigmoidoscopy, noted above, it has been speculated in the past that protection for the right colon might be similar to that found for the left colon. However, a recent case-control study of colonoscopy raises questions about whether the impact of colonoscopy on right-sided lesions might be different than the impact on left-sided lesions.[47] Using a province-wide administrative data base in Ontario, investigators compared cases of persons who had received a diagnosis of CRC from 1996 to 2001 and had died by 2003. Controls were selected from persons who did not die of CRC. Billing claims were used to assess exposure to previous colonoscopy. The OR for the association between complete colonoscopy and left-sided lesions was 0.33, suggesting a substantial mortality reduction. For right-sided lesions, however, the OR of 0.99 indicated virtually no mortality reduction.

This difference, which was striking and unexpected, might be explained in several possible ways and has been discussed extensively.[67] It is possible that exams were incomplete and did not reach the cecum even though they were coded as complete. It is possible that poor prep or incomplete mucosal inspection caused important lesions to be missed. It is also possible that examination was complete but some right-sided lesions simply grow rapidly and are not detected and treated by periodic colonoscopy. In other words, it is impossible to determine the reason for the dramatically different results on the right side compared to the left side, which are either the result of physician-related and patient-related factors or are the result of the biology of cancer.

Even if it is not possible to determine which reasons may be responsible for the right side versus the left side difference, the findings beg the question, “What is the degree of mortality reduction from colonoscopy?” While a figure of 90% is sometimes cited as the degree of mortality reduction,[68] the question will not be properly answered until the European study is completed.[57] In the meantime, the results of the study mentioned above [47] question what is known about the degree of CRC mortality reduction provided by colonoscopy. Until there are more reliable results from RCTs, it may be prudent to expect an approximately 60% to 70% CRC mortality reduction, based on consideration of these studies and other data.[67]

Evidence about colorectal cancer reduction

A case-control study assessed CRC reduction (not CRC mortality reduction) in the right side versus the left side. In a population-based study from Germany, data were obtained from administrative records and medical records; 1,688 case patients (with CRC) were compared with 1,932 participants (without CRC), aged 50 years or older.[46] Data were collected about demographics, risk factors, and previous screening examinations. According to colonoscopy records, the cecum was reached 91% of the time. Colonoscopy in the previous 10 years was associated with an OR for any CRC of 0.23, for right-sided CRC of 0.44, and for left-sided CRC of 0.16. While this study does not assess CRC mortality, the results suggest that the magnitude of the right side versus the left side difference may be smaller than previously found.[47] It would be extremely useful to assess right side versus left side differences in a RCT.

Virtual Colonoscopy (Computed Tomographic [CT] Colonography)

Virtual colonoscopy (also known as CT colonography or CT pneumocolon) refers to the examination of computer-generated images of the colon constructed from data obtained from an abdominal CT examination. These images simulate the effect of a conventional colonoscopy. Patients must take laxatives to clean the colon before the procedure, and the colon is insufflated with air (sometimes carbon dioxide) by insertion of a rectal tube just prior to radiographic examination.[69]

A large, paired-design study was conducted by the American College of Radiology Imaging Network group, with 2,531 average-risk people (prevalence of polyps or cancer greater than or equal to 10 mm = 4%; mean age about 58 years) screened with both CT colonography and optical colonoscopy (OC). The gold standard was the OC, including repeat OC exams for people with lesions found by computed tomographic colonography (CTC) but not by OC. Of 109 people with at least one adenoma or cancer greater than or equal to 10 mm, 98 (90%) were detected by CTC (referring everyone with a CTC lesion of 5 mm or greater). Specificity was 86% and PPV was 23%. There are several concerns from this study, including the following:

  • Most, but not all, lesions found by CTC and not by OC were followed up with repeat OC.
  • The design itself did not allow for following patients, thus potentially missing lesions that grow rapidly and would only be seen after follow-up.
  • Because the centers conducting the screening were primarily academic centers and the radiologists and endoscopists were carefully trained, the generalizability of the findings is not clear.
  • Sixteen percent of people had an extracolonic finding that required further evaluation.

Unknowns from the study include the following for either OC or CTC: the number of detected polyps that would have progressed to invasive cancer, and the number of people harmed by the screening process.[70]

Another study reported similar sensitivity and specificity in persons with an increased risk of CRC.[71] In this study, the sensitivity of OC could not be determined because it was done in an unblinded manner. This study suggests that virtual colonoscopy might be an acceptable screening or surveillance test for persons with a high risk of CRC, but this cross-sectional study does not address outcome or frequency of testing in high-risk persons.

Some studies have assessed how well virtual colonoscopy can detect colorectal polyps without a laxative prep. The question is of great importance for implementation because the laxative prep required by both conventional colonoscopy and virtual colonoscopy is considered a great disadvantage by patients. By tagging feces with iodinated contrast material ingested during several days prior to the procedure, investigators in one study were able to detect lesions larger than 8 mm with 95% sensitivity and 92% specificity.[72] The particular tagging material used in this study caused about 10% of patients to become nauseated; however, other materials are being assessed.

Another study [73] utilized low fiber diet, orally ingested contrast, and 'electronic cleansing', a process that subtracts tagged feces. CTC identified 91% of persons with adenomas 10 mm or larger, but detected fewer (70%) lesions greater than or equal to 8 mm. Patients who received both CTC and optical colonoscopy preferred CTC to optical colonoscopy (290 vs. 175). This study shows that CTC without a laxative prep detects small 1 cm lesions with high sensitivity and is acceptable to patients. Long-term utilization of CTC will depend on several issues including the frequency of follow-up exams that would be needed to detect smaller lesions that were undetected and may grow over time.

Extracolonic abnormalities are common in CT colonography. Fifteen percent of patients in an Australian series of 100 patients, referred for colonography because of symptoms or family history, were found to have extracolonic findings, and 11% of the patients needed further medical workups for renal, splenic, uterine, liver, and gallbladder abnormalities.[74] In another study, 59% of 111 symptomatic patients referred for clinical colonoscopy in a Swedish hospital between June 1998 and September 1999 were found to have moderate or major extracolonic conditions on CT colonography. CT colonography was performed immediately prior to colonoscopy and these findings required further evaluation. It is unstated to what extent the follow-up of these incidental findings benefited patients.[75]

Sixty-nine percent of 681 asymptomatic patients in Minnesota had extracolonic findings, of which 10% were considered to be highly important by the investigators, requiring further medical workup. Suspected abnormalities involved kidney (34), chest (22), liver (8), ovary (6), renal or splenic arteries (4), retroperitoneum (3), and pancreas (1);[76] however, the extent to which these findings will contribute to benefits or harms is uncertain. Two other studies, one large (n = 2,195) and one small (n = 136) examined the moderate or high importance of extracolonic findings from CTC. The larger study [77] found that 8.6% of patients had an extracolonic finding of at least moderate importance, while 24% of patients in the smaller study [78] required some evaluation for an extracolonic finding. The larger study found nine cancers from these evaluations, at a partial cost (they did not include all costs) of $98.56 per patient initially screened. The smaller study found no important lesions from evaluation, at a cost of $248 per person screened. Both of these estimates of cost are higher than previous studies have found. The extent to which any patients benefited from the detection of extracolonic findings is not clear. Because both of these studies were conducted in academic medical centers, the generalizability to other settings is also not clear. Neither of these studies examined the effect of extracolonic findings on patient anxiety and psychological function.

Technical improvements involving both the interpretation methodology, such as three dimensional (3-D) imaging, and bowel preparation are under study in many centers. While specificity for detection of polyps is homogeneously high in many studies, sensitivity can vary widely. These variations are attributable to a number of factors including characteristics of the CT scanner and detector, width of collimation, mode of imaging (two dimensional [2-D] vs. 3-D and/or "fly-through"), and variability in expertise of radiologists.[79]

Digital Rectal Examination

A case-control study reported that routine digital rectal examination was not associated with any statistically significant reduction in mortality from distal rectal cancer.[80]

Detection of DNA Mutations in the Stool

The molecular genetic changes that are associated with the development of colorectal adenomas and carcinoma have been well characterized.[81] Advanced techniques have been developed to detect several of these gene mutations that have been shed into the stool.[82][83][84][85] Stool DNA testing was recently assessed in a prospective study of asymptomatic persons who received colonoscopy, three-card FOBT (Hemoccult II), and stool DNA testing based on a panel of markers assessing 21 mutations. Conducted in a blinded way with prestated hypotheses and analyses, the study found that among 4,404 patients, the DNA panel had a sensitivity for CRC of 51.6% (for all stages of CRC) versus 12.9% for Hemoccult II, while the false-positive rates were 5.6% and 4.8%, respectively. On this basis, the approach looks promising but would be improved, if possible, by increased sensitivity (perhaps by increasing the number of DNA markers) and by reduced cost.[86][87]

1Lindholm E, Brevinge H, Haglind E: Survival benefit in a randomized clinical trial of faecal occult blood screening for colorectal cancer. Br J Surg 95 (8): 1029-36, 2008.2Hardcastle JD, Thomas WM, Chamberlain J, et al.: Randomised, controlled trial of faecal occult blood screening for colorectal cancer. Results for first 107,349 subjects. Lancet 1 (8648): 1160-4, 1989.3Kronborg O, Fenger C, Søndergaard O, et al.: Initial mass screening for colorectal cancer with fecal occult blood test. A prospective randomized study at Funen in Denmark. Scand J Gastroenterol 22 (6): 677-86, 1987.4Kronborg O, Fenger C, Olsen J, et al.: Repeated screening for colorectal cancer with fecal occult blood test. A prospective randomized study at Funen, Denmark. Scand J Gastroenterol 24 (5): 599-606, 1989.5Mandel JS, Bond JH, Church TR, et al.: Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 328 (19): 1365-71, 1993.6Mandel JS, Church TR, Ederer F, et al.: Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood. J Natl Cancer Inst 91 (5): 434-7, 1999.7Lang CA, Ransohoff DF: Fecal occult blood screening for colorectal cancer. Is mortality reduced by chance selection for screening colonoscopy? JAMA 271 (13): 1011-3, 1994.8Ederer F, Church TR, Mandel JS: Fecal occult blood screening in the Minnesota study: role of chance detection of lesions. J Natl Cancer Inst 89 (19): 1423-8, 1997.9Mandel JS, Church TR, Bond JH, et al.: The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med 343 (22): 1603-7, 2000.10Hardcastle JD, Chamberlain JO, Robinson MH, et al.: Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 348 (9040): 1472-7, 1996.11Robinson MH, Hardcastle JD, Moss SM, et al.: The risks of screening: data from the Nottingham randomised controlled trial of faecal occult blood screening for colorectal cancer. Gut 45 (4): 588-92, 1999.12Scholefield JH, Moss S, Sufi F, et al.: Effect of faecal occult blood screening on mortality from colorectal cancer: results from a randomised controlled trial. Gut 50 (6): 840-4, 2002.13Scholefield JH, Moss SM, Mangham CM, et al.: Nottingham trial of faecal occult blood testing for colorectal cancer: a 20-year follow-up. Gut 61 (7): 1036-40, 2012.14Kronborg O, Fenger C, Olsen J, et al.: Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 348 (9040): 1467-71, 1996.15Jørgensen OD, Kronborg O, Fenger C: A randomised study of screening for colorectal cancer using faecal occult blood testing: results after 13 years and seven biennial screening rounds. Gut 50 (1): 29-32, 2002.16Kronborg O, Jørgensen OD, Fenger C, et al.: Randomized study of biennial screening with a faecal occult blood test: results after nine screening rounds. Scand J Gastroenterol 39 (9): 846-51, 2004.17Moayyedi P, Achkar E: Does fecal occult blood testing really reduce mortality? A reanalysis of systematic review data. Am J Gastroenterol 101 (2): 380-4, 2006.18Gyrd-Hansen D, Søgaard J, Kronborg O: Colorectal cancer screening: efficiency and effectiveness. Health Econ 7 (1): 9-20, 1998.19Loeve F, Boer R, van Oortmarssen GJ, et al.: The MISCAN-COLON simulation model for the evaluation of colorectal cancer screening. Comput Biomed Res 32 (1): 13-33, 1999.20Wagner JL, Tunis S, Brown M, et al.: Cost-effectiveness of colorectal cancer screening in average-risk adults. In: Young GP, Rozen P, Levin B, eds.: Prevention and Early Detection of Colorectal Cancer. London, England: WB Saunders, 1996, pp 321-356.21Whynes DK, Neilson AR, Walker AR, et al.: Faecal occult blood screening for colorectal cancer: is it cost-effective? Health Econ 7 (1): 21-9, 1998.22Suggested technique for fecal occult blood testing and interpretation in colorectal cancer screening. American College of Physicians. Ann Intern Med 126 (10): 808-10, 1997.23Ransohoff DF, Lang CA: Screening for colorectal cancer with the fecal occult blood test: a background paper. American College of Physicians. Ann Intern Med 126 (10): 811-22, 1997.24Hewitson P, Glasziou P, Irwig L, et al.: Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev (1): CD001216, 2007.25Hewitson P, Glasziou P, Watson E, et al.: Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update. Am J Gastroenterol 103 (6): 1541-9, 2008.26Eddy DM: Screening for colorectal cancer. Ann Intern Med 113 (5): 373-84, 1990.27Allison JE, Feldman R, Tekawa IS: Hemoccult screening in detecting colorectal neoplasm: sensitivity, specificity, and predictive value. Long-term follow-up in a large group practice setting. Ann Intern Med 112 (5): 328-33, 1990.28Kewenter J, Björk S, Haglind E, et al.: Screening and rescreening for colorectal cancer. A controlled trial of fecal occult blood testing in 27,700 subjects. Cancer 62 (3): 645-51, 1988.29Grazzini G, Visioli CB, Zorzi M, et al.: Immunochemical faecal occult blood test: number of samples and positivity cutoff. What is the best strategy for colorectal cancer screening? Br J Cancer 100 (2): 259-65, 2009.30Levi Z, Rozen P, Hazazi R, et al.: A quantitative immunochemical fecal occult blood test for colorectal neoplasia. Ann Intern Med 146 (4): 244-55, 2007.31Morikawa T, Kato J, Yamaji Y, et al.: A comparison of the immunochemical fecal occult blood test and total colonoscopy in the asymptomatic population. Gastroenterology 129 (2): 422-8, 2005.32Whitlock EP, Lin JS, Liles E, et al.: Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 149 (9): 638-58, 2008.33Allison JE, Lawson M: Screening tests for colorectal cancer: a menu of options remains relevant. Curr Oncol Rep 8 (6): 492-8, 2006.34Burch JA, Soares-Weiser K, St John DJ, et al.: Diagnostic accuracy of faecal occult blood tests used in screening for colorectal cancer: a systematic review. J Med Screen 14 (3): 132-7, 2007.35van Rossum LG, van Rijn AF, Laheij RJ, et al.: Cutoff value determines the performance of a semi-quantitative immunochemical faecal occult blood test in a colorectal cancer screening programme. Br J Cancer 101 (8): 1274-81, 2009.36Brenner H, Tao S, Haug U: Low-dose aspirin use and performance of immunochemical fecal occult blood tests. JAMA 304 (22): 2513-20, 2010.37Fath RB, Winawer SJ: Endoscopic screening by flexible fiberoptic sigmoidoscopy. Front Gastrointest Res 10: 102-111, 1986.38Read TE, Read JD, Butterly LF: Importance of adenomas 5 mm or less in diameter that are detected by sigmoidoscopy. N Engl J Med 336 (1): 8-12, 1997.39Wallace MB, Kemp JA, Trnka YM, et al.: Is colonoscopy indicated for small adenomas found by screening flexible sigmoidoscopy? Ann Intern Med 129 (4): 273-8, 1998.40Levin TR, Palitz A, Grossman S, et al.: Predicting advanced proximal colonic neoplasia with screening sigmoidoscopy. JAMA 281 (17): 1611-7, 1999.41Soetikno RM, Kaltenbach T, Rouse RV, et al.: Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults. JAMA 299 (9): 1027-35, 2008.42Hoff G, Grotmol T, Skovlund E, et al.: Risk of colorectal cancer seven years after flexible sigmoidoscopy screening: randomised controlled trial. BMJ 338: b1846, 2009.43Thiis-Evensen E, Hoff GS, Sauar J, et al.: Population-based surveillance by colonoscopy: effect on the incidence of colorectal cancer. Telemark Polyp Study I. Scand J Gastroenterol 34 (4): 414-20, 1999.44Atkin WS, Edwards R, Kralj-Hans I, et al.: Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 375 (9726): 1624-33, 2010.45Stryker SJ, Wolff BG, Culp CE, et al.: Natural history of untreated colonic polyps. Gastroenterology 93 (5): 1009-13, 1987.46Brenner H, Chang-Claude J, Seiler CM, et al.: Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med 154 (1): 22-30, 2011.47Baxter NN, Goldwasser MA, Paszat LF, et al.: Association of colonoscopy and death from colorectal cancer. Ann Intern Med 150 (1): 1-8, 2009.48Brenner H, Hoffmeister M, Arndt V, et al.: Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst 102 (2): 89-95, 2010.49Segnan N, Armaroli P, Bonelli L, et al.: Once-only sigmoidoscopy in colorectal cancer screening: follow-up findings of the Italian Randomized Controlled Trial--SCORE. J Natl Cancer Inst 103 (17): 1310-22, 2011.50Schoen RE, Pinsky PF, Weissfeld JL, et al.: Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy. N Engl J Med 366 (25): 2345-57, 2012.51Selby JV, Friedman GD, Quesenberry CP Jr, et al.: A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med 326 (10): 653-7, 1992.52Newcomb PA, Norfleet RG, Storer BE, et al.: Screening sigmoidoscopy and colorectal cancer mortality. J Natl Cancer Inst 84 (20): 1572-5, 1992.53Lieberman DA, Weiss DG; Veterans Affairs Cooperative Study Group 380.: One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. N Engl J Med 345 (8): 555-60, 2001.54Kato J, Morikawa T, Kuriyama M, et al.: Combination of sigmoidoscopy and a fecal immunochemical test to detect proximal colon neoplasia. Clin Gastroenterol Hepatol 7 (12): 1341-6, 2009.55Gondal G, Grotmol T, Hofstad B, et al.: The Norwegian Colorectal Cancer Prevention (NORCCAP) screening study: baseline findings and implementations for clinical work-up in age groups 50-64 years. Scand J Gastroenterol 38 (6): 635-42, 2003.56Winawer SJ, Stewart ET, Zauber AG, et al.: A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National Polyp Study Work Group. N Engl J Med 342 (24): 1766-72, 2000.57Bretthauer M, Ekbom A, Malila N, et al.: [Politics and science in colorectal cancer screening] Tidsskr Nor Laegeforen 126 (13): 1766-7, 2006.58Lieberman DA, Weiss DG, Bond JH, et al.: Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med 343 (3): 162-8, 2000.59Imperiale TF, Wagner DR, Lin CY, et al.: Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. N Engl J Med 343 (3): 169-74, 2000.60Schoenfeld P, Cash B, Flood A, et al.: Colonoscopic screening of average-risk women for colorectal neoplasia. N Engl J Med 352 (20): 2061-8, 2005.61Regula J, Rupinski M, Kraszewska E, et al.: Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N Engl J Med 355 (18): 1863-72, 2006.62Barclay RL, Vicari JJ, Doughty AS, et al.: Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 355 (24): 2533-41, 2006.63Lieberman D: Nonpolypoid colorectal neoplasia in the United States: the parachute is open. JAMA 299 (9): 1068-9, 2008.64Robertson DJ, Greenberg ER, Beach M, et al.: Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology 129 (1): 34-41, 2005.65Kahi CJ, Hewett DG, Norton DL, et al.: Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clin Gastroenterol Hepatol 9 (1): 42-6, 2011.66Snover DC, Jass JR, Fenoglio-Preiser C, et al.: Serrated polyps of the large intestine: a morphologic and molecular review of an evolving concept. Am J Clin Pathol 124 (3): 380-91, 2005.67Ransohoff DF: How much does colonoscopy reduce colon cancer mortality? Ann Intern Med 150 (1): 50-2, 2009.68Smith MJ: Colon cancer screening hitting its stride but obstacles impair reaching final goal. Gastroenterology and Endoscopy News 59 (3): 9, 2008. [Refer to "Screening: it’s not just a good idea, it’s the law … almost" within the article].69Ferrucci JT: Colon cancer screening with virtual colonoscopy: promise, polyps, politics. AJR Am J Roentgenol 177 (5): 975-88, 2001.70Johnson CD, Chen MH, Toledano AY, et al.: Accuracy of CT colonography for detection of large adenomas and cancers. N Engl J Med 359 (12): 1207-17, 2008.71Regge D, Laudi C, Galatola G, et al.: Diagnostic accuracy of computed tomographic colonography for the detection of advanced neoplasia in individuals at increased risk of colorectal cancer. JAMA 301 (23): 2453-61, 2009.72Iannaccone R, Laghi A, Catalano C, et al.: Computed tomographic colonography without cathartic preparation for the detection of colorectal polyps. Gastroenterology 127 (5): 1300-11, 2004.73Zalis ME, Blake MA, Cai W, et al.: Diagnostic accuracy of laxative-free computed tomographic colonography for detection of adenomatous polyps in asymptomatic adults: a prospective evaluation. Ann Intern Med 156 (10): 692-702, 2012.74Edwards JT, Wood CJ, Mendelson RM, et al.: Extracolonic findings at virtual colonoscopy: implications for screening programs. Am J Gastroenterol 96 (10): 3009-12, 2001.75Hellström M, Svensson MH, Lasson A: Extracolonic and incidental findings on CT colonography (virtual colonoscopy). AJR Am J Roentgenol 182 (3): 631-8, 2004.76Gluecker TM, Johnson CD, Wilson LA, et al.: Extracolonic findings at CT colonography: evaluation of prevalence and cost in a screening population. Gastroenterology 124 (4): 911-6, 2003.77Pickhardt PJ, Hanson ME, Vanness DJ, et al.: Unsuspected extracolonic findings at screening CT colonography: clinical and economic impact. Radiology 249 (1): 151-9, 2008.78Kimberly JR, Phillips KC, Santago P, et al.: Extracolonic findings at virtual colonoscopy: an important consideration in asymptomatic colorectal cancer screening. J Gen Intern Med 24 (1): 69-73, 2009.79Mulhall BP, Veerappan GR, Jackson JL: Meta-analysis: computed tomographic colonography. Ann Intern Med 142 (8): 635-50, 2005.80Herrinton LJ, Selby JV, Friedman GD, et al.: Case-control study of digital-rectal screening in relation to mortality from cancer of the distal rectum. Am J Epidemiol 142 (9): 961-4, 1995.81Kinzler KW, Vogelstein B: Lessons from hereditary colorectal cancer. Cell 87 (2): 159-70, 1996.82Dong SM, Traverso G, Johnson C, et al.: Detecting colorectal cancer in stool with the use of multiple genetic targets. J Natl Cancer Inst 93 (11): 858-65, 2001.83Traverso G, Shuber A, Levin B, et al.: Detection of APC mutations in fecal DNA from patients with colorectal tumors. N Engl J Med 346 (5): 311-20, 2002.84Traverso G, Shuber A, Olsson L, et al.: Detection of proximal colorectal cancers through analysis of faecal DNA. Lancet 359 (9304): 403-4, 2002.85Ahlquist DA, Skoletsky JE, Boynton KA, et al.: Colorectal cancer screening by detection of altered human DNA in stool: feasibility of a multitarget assay panel. Gastroenterology 119 (5): 1219-27, 2000.86Imperiale TF, Ransohoff DF, Itzkowitz SH, et al.: Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average-risk population. N Engl J Med 351 (26): 2704-14, 2004.87Woolf SH: A smarter strategy? Reflections on fecal DNA screening for colorectal cancer. N Engl J Med 351 (26): 2755-8, 2004.

[Back to Top]

Evidence of Harms

Harms are associated with the various modalities used to screen for colorectal cancer (CRC).

Fecal Occult Blood Testing (FOBT)

A systematic review done through the Cochrane Collaboration examined all CRC screening randomized trials that involved FOBT on more than one occasion. The trials reported a low positive predictive value for the FOBT, suggesting that more than 80% of all positive tests were false-positives.[1] A positive test can lead to further diagnostic procedures that include colonoscopy or double-contrast barium enema plus flexible sigmoidoscopy.


Sigmoidoscopy can be an uncomfortable or painful procedure. Women may have more pain during the procedure, which may discourage them from returning for future screening sigmoidoscopies. Sigmoidoscopy can also cause perforation and bleeding, although this is rare.


Clinically significant complications requiring medical intervention are rare but can include the following: perforations, bleeding, cardiovascular events, and other adverse events. The rate of complications may increase among older persons.[2]

Computed Tomographic (CT) Colonography

Extracolonic abnormalities are common in CT colonography. Fifteen percent of patients in an Australian series of 100 patients, referred for colonography because of symptoms or family history, were found to have extracolonic findings, and 11% of the patients needed further medical workups for renal, splenic, uterine, liver, and gallbladder abnormalities.[3] Other areas of extracolonic findings include the chest, ovary, and pancreas. In another study, 59% of 111 symptomatic patients referred for clinical colonoscopy in a Swedish hospital between June 1998 and September 1999 were found to have moderate or major extracolonic conditions on CT colonography. CT colonography was performed immediately prior to colonoscopy, and these findings required further evaluation. It is unstated to what extent the follow-up of these incidental findings benefited patients.[4]

Sixty-nine percent of 681 asymptomatic patients in Minnesota had extracolonic findings, of which 10% were considered to be highly important by the investigators, requiring further medical workup. Suspected abnormalities involved kidney (34), chest (22), liver (8), ovary (6), renal or splenic arteries (4), retroperitoneum (3), and pancreas (1).[5]

1Hewitson P, Glasziou P, Irwig L, et al.: Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev (1): CD001216, 2007.2Warren JL, Klabunde CN, Mariotto AB, et al.: Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med 150 (12): 849-57, W152, 2009.3Edwards JT, Wood CJ, Mendelson RM, et al.: Extracolonic findings at virtual colonoscopy: implications for screening programs. Am J Gastroenterol 96 (10): 3009-12, 2001.4Hellström M, Svensson MH, Lasson A: Extracolonic and incidental findings on CT colonography (virtual colonoscopy). AJR Am J Roentgenol 182 (3): 631-8, 2004.5Gluecker TM, Johnson CD, Wilson LA, et al.: Extracolonic findings at CT colonography: evaluation of prevalence and cost in a screening population. Gastroenterology 124 (4): 911-6, 2003.

[Back to Top]

Changes to This Summary (02/26/2013)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.


Updated statistics with estimated new cases and deaths for 2013 (cited American Cancer Society as reference 2 and Howlader et al. as reference 3).

This summary is written and maintained by the PDQ Screening and Prevention Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.

[Back to Top]

Questions or Comments About This Summary

If you have questions or comments about this summary, please send them to through the Web site’s Contact Form. We can respond only to email messages written in English.

[Back to Top]

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about colorectal cancer screening. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Screening and Prevention Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

  • be discussed at a meeting,
  • be cited with text, or
  • replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

Any comments or questions about the summary content should be submitted to through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Screening and Prevention Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”

The preferred citation for this PDQ summary is:

National Cancer Institute: PDQ® Colorectal Cancer Screening. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: Accessed <MM/DD/YYYY>.

Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.


The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on on the Coping with Cancer: Financial, Insurance, and Legal Information page.

Contact Us

More information about contacting us or receiving help with the Web site can be found on our Contact Us for Help page. Questions can also be submitted to through the Web site’s Contact Form.

[Back to Top]

Get More Information From NCI

Call 1-800-4-CANCER

For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer your questions.

Chat online

The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.

Write to us

For more information from the NCI, please write to this address:

  • NCI Public Inquiries Office
  • 9609 Medical Center Dr.
  • Room 2E532 MSC 9760
  • Bethesda, MD 20892-9760

Search the NCI Web site

The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use the search box in the upper right corner of each Web page. The results for a wide range of search terms will include a list of "Best Bets," editorially chosen Web pages that are most closely related to the search term entered.

There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.

Find Publications

The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).

[Back to Top]

This information was last updated on 2013-02-26