Screening guidelines — United States

In short

For adults at average risk in the United States, the U.S. Preventive Services Task Force currently recommends starting colorectal cancer screening at age 45 and continuing to 75, with screening between 76 and 85 considered case by case. Several professional bodies — including the American College of Gastroenterology, the American Cancer Society, and a multi-society task force — agree on the broad outlines but differ in their preferences for which test to use first. Coloscopy is one of several acceptable screening options.

What this page covers

The current screening recommendations from the major United States bodies, where they agree, where they differ, and how to think about the choice between coloscopy and a stool-based test. This page is for adults at average risk. Family history, prior polyps, inflammatory bowel disease, and known genetic syndromes change the picture; those situations are covered on related pages.

Who is considered average risk and who is not
The starting age, the stopping age, and the reasoning behind both
Side-by-side comparison of the major United States recommendations
How the menu of screening tests fits together
What to ask your clinician when deciding

Who counts as average risk

Average risk, in this context, means an adult with no personal history of colorectal cancer or advanced polyps, no history of inflammatory bowel disease (Crohn's disease or ulcerative colitis), no known inherited syndrome that raises colorectal risk (such as Lynch syndrome or familial adenomatous polyposis), and no first-degree relative — parent, sibling, or child — with colorectal cancer or an advanced polyp diagnosed at a young age.

If any of those apply to you, your screening should be planned individually, often starting earlier and using coloscopy specifically rather than a stool-based test. The pages on family history and genetics, and on screening versus surveillance, go through the details. Everything below describes the average-risk pathway.

The starting age

The U.S. Preventive Services Task Force currently recommends that average-risk adults begin colorectal cancer screening at age 45. The American College of Gastroenterology, the American Cancer Society, and the U.S. Multi-Society Task Force on Colorectal Cancer (a joint group representing the ACG, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy) align with this starting age.

The shift from age 50 to age 45 reflects rising rates of colorectal cancer in adults under 50 over the past several decades. The earlier start is intended to identify and remove polyps before they progress, and to find cancers at curable stages.

If you have already turned 45 and have not been screened, you are not late — most adults in the United States are not screened on time. The next step is a conversation with your primary care clinician about which test to use first.

The stopping age

The USPSTF recommends routine screening through age 75. Between ages 76 and 85, the recommendation is for selective screening — meaning the decision should weigh life expectancy, prior screening history, and personal preference, rather than be made by age alone. After age 85, routine screening is generally not recommended.

The reasoning is that the benefit of finding and removing a polyp depends on living long enough for that polyp to have caused harm. For an adult who has been well screened and who has limited remaining life expectancy because of other illness, another coloscopy may carry risk without offering meaningful benefit. For a healthy adult in their late seventies or early eighties whose previous test was many years ago, continued screening may still make sense. The page on older adults goes into how this conversation usually goes.

Side-by-side: the major United States recommendations

The bodies listed below are the four most often referenced in the United States. They use slightly different formats and emphases, but converge on a similar starting age and a similar menu of acceptable tests.

Body	Start age	Stop age	Notable preference
USPSTF	45	Routine to 75; selective 76–85	Lists coloscopy, FIT, stool DNA, sigmoidoscopy, and CT colonography as acceptable. Does not rank them.
American College of Gastroenterology	45	Decisions individualised in older adults	Names coloscopy and the faecal immunochemical test (FIT) as the two preferred options for average-risk screening.
American Cancer Society	45	Routine through 75; individualised after	Treats all options on the menu as acceptable; emphasises the test that gets done.
U.S. Multi-Society Task Force	45	Individualised after 75	Tiers the options: coloscopy and FIT first, then stool DNA, CT colonography, and flexible sigmoidoscopy.

Two practical points follow. First, every body considers coloscopy an acceptable first-line test, but none requires it — a stool-based test followed by coloscopy if the result is abnormal is also a complete screening strategy. Second, a stool-based test is only complete if the abnormal result is followed up with coloscopy. A positive FIT or stool DNA test that is not investigated leaves the screening unfinished.

The menu of tests

All of the tests below are recommended somewhere on the United States menu. They differ in what they look for, how often they are done, and what happens if they are positive.

Coloscopy every ten years for average-risk adults with a complete and normal exam. Looks at the entire colon and removes polyps in the same procedure.
Faecal immunochemical test (FIT) annually. Detects human blood in the stool. A positive result requires coloscopy to investigate.
Stool DNA test (sometimes branded as a multi-target stool test) every one to three years depending on the product. Combines FIT with markers of altered DNA. A positive result requires coloscopy.
Flexible sigmoidoscopy every five to ten years, sometimes combined with FIT. Examines the lower portion of the colon only.
CT colonography (sometimes called virtual coloscopy) every five years. A radiology study using a CT scanner. Polyps above a size threshold lead to coloscopy; smaller findings may be followed.

Newer options — including blood-based tests for circulating tumour DNA — have entered the United States market and are recognised by some bodies as acceptable for adults who decline other screening. Blood tests are not yet considered first-line in the major guidelines because their performance for polyps, in particular, is lower than for stool-based or visual tests.

How to think about the choice

The recommendation that screening get done matters more than which test is used. A FIT done on time every year is a complete screening strategy. A coloscopy done well, every ten years, is a complete screening strategy. A stool DNA test followed by a coloscopy when needed is a complete screening strategy. The strategy that fails is the one that is not done.

That said, a few practical differences are worth knowing. Coloscopy is the only test that both detects and removes polyps in the same visit. The other tests require coloscopy as a follow-up if abnormal. Stool-based tests are done at home and require nothing in the way of preparation; coloscopy requires bowel preparation, time off, and someone to drive you home if you are sedated. Coloscopy carries small but real procedural risks; the other tests do not.

Cost and coverage in the United States vary by insurance and by whether the test is screening or diagnostic. The pages on understanding billing and on screening versus diagnostic versus surveillance go through the categorisation, which has practical consequences for what you pay.

What to ask your clinician

Given my age and family history, am I at average risk, or higher?
Which screening tests does this practice recommend as a first step, and why?
If I choose FIT or a stool DNA test, what happens if it comes back positive?
If I choose coloscopy, what is the expected interval afterwards if everything is normal?
How does my insurance categorise the test — as screening or diagnostic — and what would change that?
What is the ADR (adenoma detection rate) of the endoscopist or unit you are referring me to?
Is there anything in my history — medications, prior surgery, prior reactions to sedation — that you would factor in?
If I am older than 75, what is your view on whether continued screening is worthwhile in my case?

Common worries, briefly addressed

I am 45 and otherwise well — is screening really for me?

Yes. The major United States recommendations all start at 45 for average-risk adults. The reason is the increasing share of colorectal cancers diagnosed in adults under 50 over the past several decades. Choosing not to screen is a reasonable decision after an informed conversation with your clinician, but the recommendation as it stands is to start.

I had a normal coloscopy years ago — do I need to do anything now?

If your last coloscopy was normal and was performed at average risk, the standard interval is ten years. Some clinicians will ask you to do a FIT in the interval; others will not. If you cannot find your last report, your endoscopy unit can usually retrieve it; the report determines the interval, not your memory of the visit.

Is the home stool test as good as a coloscopy?

The honest answer is that the two tests are different rather than ranked. Coloscopy is more sensitive for polyps in a single sitting. A stool test done every year is sensitive enough for cancer that, over many years, the cumulative detection approaches that of coloscopy. The strategies have different failure modes — a coloscopy can miss a polyp on the day, a stool test can miss a polyp because it is not bleeding — and different convenience profiles.

I am 78. Should I have another coloscopy?

This is a conversation worth having with your primary care clinician rather than a yes-or-no answer in a guideline. Factors include your previous screening, your other health conditions, your life expectancy, and your own preferences. The page on older adults explores the conversation in more detail.

Does this page apply if I am Black, or have a particular family history?

The current USPSTF recommendation does not separate the start age by race. Some earlier guidelines from individual bodies once recommended starting earlier for Black adults specifically; the current consensus is age 45 for average-risk adults across groups, with earlier or different screening for those with family history or genetic risk. If a parent, sibling, or child of yours has had colorectal cancer or an advanced polyp, see the family history page.

Sources

U.S. Preventive Services Task Force — colorectal cancer screening recommendation statement
American College of Gastroenterology — clinical guideline on colorectal cancer screening
American Cancer Society — colorectal cancer screening guideline for average-risk adults
U.S. Multi-Society Task Force on Colorectal Cancer — recommendations for screening
American Gastroenterological Association — clinical practice updates on screening
American Society for Gastrointestinal Endoscopy — quality indicators for coloscopy
Centers for Disease Control and Prevention — colorectal cancer statistics and screening data