Brian Jacobson, MD, MPH, is an associate professor of medicine at Harvard Medical School and director of program development for gastroenterology at Massachusetts General Hospital.

Brian Jacobson, MD, MPH

Key Concepts in the USMSTF Bowel Preparation Guidance

 is the second leading cause of cancer-related death in the United States, a stark reality that underscores the need for effective screening and prevention.

Each March, Colorectal Cancer Awareness Month serves as a reminder of the importance of early detection to reduce colorectal cancer’s significant impact. Colonoscopy remains the gold-standard screening tool, but its effectiveness relies heavily on adequate bowel preparation. Inadequate preparation can lead to missed lesions, prolonged procedures, and the need for repeat exams, diminishing its preventive power.

New guidance from the US Multi-Society Task Force on Colorectal Cancer (USMSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, provides clinical recommendations to address challenges related to bowel preparation for colonoscopy, focusing specifically on outpatients at low risk for inadequate bowel preparation.

In the final segment of this 6-part HCPLive RX Review, Brian Jacobson, MD, MPH, and Joseph Anderson, MD, discuss what they consider to be a key strength of the updated bowel preparation guidance—the inclusion of expert-driven key concepts where evidence is limited.

While the document is grounded in consensus statements supported by varying levels of evidence, Jacobson and Anderson note the key concepts offer practical guidance for real-world scenarios where robust data may be lacking.

Specifically, Jacobson highlights a key concept for inadequate colonoscopies recommending using the situation as an opportunity for shared decision-making with the patient. Physicians can discuss alternative colorectal cancer screening options, including noninvasive tests, rather than defaulting to a rescheduled colonoscopy.

Anderson agrees, emphasizing that the goal of the recommendations is to provide practical, user-friendly guidance for clinicians navigating real-world challenges. He notes that flexible sigmoidoscopy was historically a primary screening tool, with evidence demonstrating a reduction in left-sided colorectal cancer incidence among individuals screened with either rigid or flexible sigmoidoscopy. In cases of incomplete colonoscopy, he says revisiting this approach could be a viable option, ensuring patients remain engaged in screening rather than losing them to follow-up.

He also reinforces the overarching theme of the discussion: physicians already face significant demands, and inadequate bowel preparation should not create undue burdens. By incorporating alternative strategies—whether through noninvasive tests or leveraging partial colonoscopy findings—clinicians can maintain effective colorectal cancer screening while optimizing patient-centered care.

: Brian Jacobson, MD, MPH, an associate professor of medicine at Harvard Medical School and director of program development for gastroenterology at Massachusetts General Hospital

: Joseph Anderson, MD, a professor of medicine at Geisel School of Medicine at Dartmouth and a gastroenterologist at White River Junction VAMC

Editors’ note: Jacobson has relevant disclosures with Curis and Guardant Health. Anderson has no relevant disclosures.

Jacobson BC, Anderson JC, Burke CA, et al. Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer. 

The American Journal of Gastroenterology.

Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. 

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In the final segment of this 6-part RX Review, experts discuss key concepts from the USMSTF guidance where evidence is limited.

Areas for Future Bowel Preparation Research

In the fifth segment of this 6-part HCPLive RX Review, Brian Jacobson, MD, MPH, and Joseph Anderson, MD, discuss key areas for future research and potential improvements in bowel preparation, emphasizing both clinical and technological advancements that could enhance colonoscopy outcomes.

Anderson identifies several gaps in evidence that warrant further study. One critical area is dietary recommendations leading up to colonoscopy, specifically the role of low-residue diets and fiber intake. Another area of interest he points to is optimizing one-liter bowel preparation regimens to enhance efficacy as well as research into preventative strategies for bubbles in the colon to improve visualization and efficiency.

Jacobson adds that future research could leverage artificial intelligence to personalize bowel prep regimens based on patient history, medications, and comorbidities, streamlining the scheduling process and improving adherence. Anderson agrees that predictive analytics in electronic health records could enhance patient-specific preparation plans but notes that direct patient engagement remains crucial. He says that traditional internist-led longitudinal care has diminished over the years, making it essential to reintroduce personalized interactions—whether through AI-driven insights or direct patient interviews.

In the fifth segment of this 6-part RX Review, experts discuss areas where more research is needed on bowel preparation for colonoscopy.

Barriers, Challenges to Compliance with New Bowel Prep Guidance

In the fourth segment of this 6-part HCPLive RX Review, Brian Jacobson, MD, MPH, and Joseph Anderson, MD, discuss potential patient and provider challenges that may impact compliance with the guidance.

Anderson acknowledges that while the updated guidelines are more patient-centered, logistical challenges remain, including compliance with split-dose bowel preparation. For patients, he points out the practical burden of waking early or traveling long distances can lead to incomplete preparation. Specifically, Anderson notes that a patient with an afternoon procedure may find it feasible to finish the prep by 10 AM, but early morning appointments often require patients to wake up at inconvenient hours, sacrificing sleep.

Provider practices also contribute to the challenge of assessing and improving bowel preparation quality. Anderson says some endoscopists do not consistently report the quality of bowel preparation using standardized scales, and while Jacobson notes the USMSTF does not endorse a specific scale, the guidance encourages documentation of bowel cleanliness as adequate or inadequate to properly assess adequacy rates.

Despite these challenges, Jacobson highlights the patient-centered approach of the updated guidelines, which include more flexible dietary options and practical tools like sample diets to simplify patient education. However, he acknowledges that some clinicians may still favor more intensive, "kitchen sink" preparations for patients perceived to be at higher risk of poor bowel prep. The USMSTF addresses these situations by recommending more extended preparation regimens — including prolonged clear liquid diets, higher-volume preps, and adjunctive agents like bisacodyl — for patients with predictors of inadequate bowel preparation or a history of suboptimal prep.

In the fourth segment of this 6-part RX Review, experts discuss potential barriers to implementation of the USMSTF guidance and compliance challenges.

Updates in the 2025 USMSTF Bowel Prep Guidance

In the third segment of this 6-part HCPLive RX Review, Brian Jacobson, MD, MPH, and Joseph Anderson, MD, highlight key changes from the previous 2014 iteration of the guidance.

Anderson begins by describing the recommendation of a 2-liter, low-volume bowel preparation for average-risk individuals undergoing colonoscopy, which has shown non-inferiority to traditional 4-liter preparations in trials. He notes that this recommendation does not extend to patients with predictors of inadequate bowel preparation but that the shift to a lower volume in average-risk patients is intended to enhance compliance, as patient adherence to bowel preparation can significantly impact exam quality.

He also mentions the updated guidelines include more flexible dietary recommendations before colonoscopy. Stricter low-residue diets, while potentially improving prep quality, can create additional barriers for patients—especially those balancing work or other obligations. Anderson says the more lenient approach in the guidance aims to reduce these barriers and improve overall compliance with bowel preparation.

Jacobson goes on to highlight the guidance supporting same-day bowel preparation for afternoon procedures, citing data suggesting that patients can take a 2-liter preparation in the morning and still achieve a high rate of adequate bowel cleanliness for a same-day procedure.

In the third segment of this 6-part RX Review, experts discuss key updates from the previous 2014 iteration of the USMSTF guidance.

Brian Jacobson, MD, MPH

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