Colorectal, in full.

Offer anal cancer screening only where there is capacity to perform high-resolution anoscopy (HRA) and to treat what it finds. Screening is RECOMMENDED for: MSM and transgender women with HIV, beginning at age 35; all other people with HIV, and MSM and transgender women without HIV, beginning at age 45; solid organ transplant recipients, beginning 10 years post-transplant; and persons with a history of vulvar HSIL or vulvar cancer, beginning within 1 year of that diagnosis. Screening may be CONSIDERED via shared decision-making, and only where HRA capacity is adequate, for persons aged 45 or older with a history of cervical or vaginal HSIL/cancer, perianal warts, persistent (>1 year) cervical HPV16, or autoimmune conditions. Screen with anal cytology alone, high-risk HPV testing alone (with HPV16 genotyping), or hrHPV-cytology co-testing, all three perform acceptably; HRA is the DIAGNOSTIC procedure for an abnormal screen, not itself a screening test. Perform digital anal rectal examination as part of the physical exam at every screening visit. Refer immediately to HRA for any abnormal cytology, ASC-US or worse, when screening is by cytology alone, since there is no hrHPV result available to triage it; for ASC-US or worse cytology accompanied by a positive hrHPV result on co-testing; for ASC-H or HSIL cytology regardless of HPV result; and for any HPV16-positive result regardless of cytology. Repeat screening in 12 months after NILM cytology alone or a negative HPV test alone, or after ASC-US cytology with negative hrHPV; repeat in 12-24 months after co-testing that is both NILM and hrHPV-negative. Where HRA capacity is reduced, restrict immediate referral to ASC-H/HSIL cytology and to HPV16-positive results, and manage the remainder with repeat screening. Treat HSIL found at HRA-directed biopsy rather than observing it: in ANCHOR, treatment reduced progression to invasive cancer by approximately 57% in people with HIV aged 35 and older.

Polyposis syndromes are now governed by ACG 2026 (Mankaney G, Idos GE, Stoffel EM, Weiss JM, Shah S, Qayed E, Harnegie MP, Burke CA; Am J Gastroenterol 2026;121(9):2086-2120, GRADE). For polyposis, it replaces the 2015 ACG hereditary GI cancer guideline (Syngal et al.), Recommendations 10-11. Germline multigene panel testing is recommended for anyone with 20 or more cumulative lifetime colorectal adenomas (strong recommendation) and suggested for 10-19 adenomas (conditional, because the yield is lower). The 2015 polyposis testing trigger was more than 10 adenomas. Asymptomatic APC carriers, biallelic MUTYH carriers, and untested people at risk for AFAP or MAP should have a baseline colonoscopy by age 18-20. Colonoscopy then repeats every 1-3 years depending on the histology, size and number of polyps. It moves to every 3-6 months when there are many or large polyps, or high-grade dysplasia. This replaces the 2015 schedules of annual sigmoidoscopy/colonoscopy from puberty for classic FAP, colonoscopy every 1-2 years from the late teens for AFAP, and from age 25-30 for MAP. Whether at-risk children in classic-FAP families still start younger is not stated in the excerpt available at review; confirm against the full text. For FAP, AFAP and MAP, upper endoscopic surveillance that includes viewing the duodenal papilla is suggested over no surveillance (Recommendation 8, conditional). Duodenal management is still staged by Spigelman, which has acknowledged limits in sensitivity for duodenal and papillary cancer. The 2026 starting age and intervals for upper endoscopy are not stated in the excerpt available at review. The choice of operation (total colectomy with IRA, IPAA, or end ileostomy) is individualized by genotype, polyp distribution, cancer status, comorbidity and preference, with early referral to an experienced colorectal surgeon. IRA is generally favored with up to about 20 rectal adenomas and IPAA above that, though this is not a fixed cutoff. The rectum or pouch should be checked endoscopically every year after IRA or IPAA. Chemoprevention is recommended against as a substitute for colectomy when surgery is indicated. Whether 2026 keeps annual thyroid ultrasound is not stated in the excerpt available at review. Lynch syndrome and serrated polyposis syndrome are outside the 2026 document, so the Lynch and SPS parts of the standard on file were not re-verified here: Lynch colonoscopy every 1-2 years from age 20-25, gyn and upper-GI surveillance, and SPS colonoscopy every 1-3 years with removal of polyps over 5 mm.