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MLH1: Risk Management

People with an MLH1 mutation have options for managing their cancer risk. Learn about the screening and prevention guidelines. Stay up to date by signing up for our community newsletter.

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MLH1: The Basics MLH1 (Lynch Syndrome): Cancer Risks MLH1: Risk Management MLH1 (Lynch Syndrome): Cancer Treatment MLH1 (Lynch Syndrome): Other Considerations

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Risk Management for People with an Inherited Mutation

Experts at the National Comprehensive Cancer Network (NCCN) created guidelines for people with an mutation to manage their cancer risk.

This section covers risk-management guidelines for the following cancers:

Colorectal cancer

Endometrial cancer

Ovarian and fallopian tube cancer

We recommend that you speak with a genetics expert who can look at your personal and family history of cancer and can help you decide on a plan for managing your risk.

People with an mutation may also qualify for clinical trials looking for more effective screening or prevention for cancer.

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Study : Resistant starch may help prevent some cancers in people with Lynch syndrome

Risk management guidelines

NCCN recommends that all people with an inherited mutation receive education on the signs and symptoms of Lynch syndrome-related cancers. NCCN guidelines for specific cancers are listed below. You can learn more about risk management options in our section on Screening and Risk Reduction by Cancer Type.

Colorectal cancer

Beginning Age	Recommendation
20-25 (or 2-5 years before the earliest age of colon cancer in the family, if diagnosed before age 25)	High quality colonoscopy every 1-2 years. Speak with your doctor about whether your screenings should be yearly or every two years. Men, people over age 40, and people with a personal history of colon cancer or colon polyps may benefit most from yearly screenings.
No set age	Daily aspirin can decrease the risk for colorectal cancer. The best dose and timing for aspirin is not known. Speak with your doctor about the benefits and risks, best timing and dose.
Source: NCCN Guidelines: Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric; v. 3, 2024.

Endometrial cancer

Beginning Age	Recommendation	Additional Information
No set age	Endometrial cancer can often be caught early based on symptom awareness followed by a biopsy. Learn to be aware of the symptoms of endometrial cancer and immediately report any symptoms to your doctor. Keep a diary of menstrual cycles in order to detect any changes in bleeding.	Symptoms of endometrial cancer include: unusual vaginal bleeding pelvic or abdominal pain bloating or distended belly difficulty eating increased urination or pressure to urinate
30-35	Discuss the benefits, risks and costs of an endometrial biospsy every 1-2 years with your doctor.	Endometrial cancer screening does not have proven benefit in individuals with Lynch syndrome. However, endometrial biopsy is an accurate test for finding cancer.
After menopause	Discuss the benefits, risks and costs of regular endometrial cancer screening through transvaginal ultrasound.	Endometrial cancer screening does not have proven benefit in individuals with Lynch syndrome. Despite this, some people prefer to undergo regular screening through transvaginal ultrasound.
After age 40 (or personalized based on childbearing plans)	Discuss the benefits, risks and costs of a risk-reducing hysterectomy (surgical removal of the uterus) and salpingectomy (surgical removal of the fallopian tubes).	For people who need colorectal surgery, consider coordinating hysterectomy at the same time. Total hysterectomy lowers the risk, but it has not been shown to reduce death from endometrial cancer.
No specified age	Speak with your doctor about the benefits, risks and timing of oral contraceptives or progestin intrauterine devices (IUD).	Oral contraceptive pills (birth control) and progestin intrauterine devices (IUD) may lower the risk for endometrial cancer associated with Lynch syndrome.
Source: NCCN Guidelines: Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric; v. 3, 2024.

Ovarian and cancer

Beginning Age	Recommendation	Additional Information
No set age	Be aware of ovarian cancer symptoms. Report any of the following symptoms that persist for several weeks and are a change from normal to your doctor. Routine ovarian cancer screening using transvaginal ultrasound and a CA-125 blood test has not shown benefit and is not recommended.	Symptoms of ovarian cancer include: pelvic or abdominal pain bloating or distended belly difficulty eating feeling full sooner than normal increased urination or pressure to urinate
After completion of child-bearing	Speak with your doctor about the benefits, risks and timing of risk-reducing removal of ovaries and fallopian tubes (RRSO).	For people who need colorectal surgery, consider coordinating oophorectomy at the same time. Discuss options for managing the effects of early menopause with your doctor. After RRSO, a very small risk remains for a related cancer known as primary peritoneal cancer (PPC). There is no effective screening for PPC.
No set age	Speak with your doctor about the benefits, risks and timing of oral contraceptives or progestin intrauterine devices (IUD).	Oral contraceptive pills (birth control) and progestin intrauterine devices (IUD) may lower the risk for ovarian cancer associated with Lynch syndrome.
Source: NCCN Guidelines: Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric; v. 3, 2024.

Pancreatic cancer

There are two tests that are used to look for pancreatic cancer in high-risk people.

MRCP (Contrast-enhanced magnetic resonance cholangiopancreatography) is a special type of imaging that looks closely at the pancreas, liver, gallbladder, bile duct and pancreatic duct to find abnormalities such as cancer.
EUS (Endoscopic ) involves passing a tiny scope with an attached probe down the esophagus to the stomach. This allows doctors to look closely at the pancreas.

Beginning Age

Recommendation

50 (or younger based on family history)

For MLH1 mutation carriers with a first- or second- degree relative with pancreatic cancer

Discuss the benefits, risks, costs and limitations of screening with your doctor.
Screening should include annual MRCP or EUS or both.
Screening should be performed in a facility with experience in screening high-risk patients for pancreatic cancer.

Source: NCCN Guidelines: Genetic/Familial High-Risk Assessment: Breast, Ovarian; Pancreatic and Prostate; v. 3, 2025.

Bladder, kidney and ureteral cancer

Beginning Age

Recommendation

30-35

For MLH1 mutation carriers with a relative with bladder, kidney or ureteral cancer

Discuss the benefits, risks, costs and limitations of screening with your doctor.

Source: NCCN Guidelines: Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric; v. 3, 2024.

cancer

Beginning Age

Recommendation

Have a conversation with your doctor about the potential benefits, risks, costs and limitations of screening for prostate cancer.

If you choose to have screening, the guidelines recommend an annual digital rectal exam and Prostate Specific Antigen (PSA) test.

Source: NCCN Guidelines: Prostate Cancer Early Detection; v. 1, 2025.

Stomach cancer

Beginning Age

Recommendation

30-40 (or younger based on family history)

Begin stomach cancer screening using a procedure known as EGD (esophagogastroduodenocopy) and repeat every 2-4 years.

More frequent screening may be recommended based on prior screening findings.
If gastric screening is performed, considered random biopsy to test for H. pylori. If gastric biopsy is not performed, consider non-invasive testing for H. pylori.
- People who test positive should receive treatment for H. pylori.

Source: NCCN Guidelines: Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric; v. 3, 2024.

Brain cancer

Beginning Age	Recommendation
No set age	Learn the signs of brain cancer and report any symptoms to your doctor.
Source: NCCN Guidelines: Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric; v. 3, 2024.

Skin cancer

Beginning Age	Recommendation
No set age	Talk with your doctor about the benefits of having a skin exam every 1-2 years with an expert trained in finding skin changes related to Lynch syndrome
Source: NCCN Guidelines: Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric; v. 3, 2024.

Other cancers

The guidelines do not address screening or prevention of other cancers for people with mutations. However, clinical trials may be available.

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Participate in Prevention Research

Below are some of our featured research studies looking at new ways to screen for, prevent or intercept cancer in people with mutations. To search for additional studies, visit our Search and Enroll Tool.