A national panel of medical experts recommended on Tuesday that most Americans start being screened for colorectal cancer five years earlier than called for in current guidelines — at age 45 instead of 50 — to combat increasing rates of the illness in younger people. With 53,200 people expected to die this year, the disease is the third leading cause of cancer-related deaths in men and women in the U.S. But with early screening, it is among the most preventable forms of cancer.
The U.S. Preventive Services Task Force, an independent group of physicians that provides guidelines on preventive care, noted that it was especially concerned about increasing cases among Black Americans, who are at higher risk of developing colorectal cancer early and dying from it.
“Black men and women are disproportionately affected, both in terms of the development of colorectal cancer and unfortunately they have lower survival rates with colorectal cancer,” said John Wong, a physician at Tufts Medical Center in Boston and a member of the task force. “That disparity, relative to other racial and ethnic groups, is an important part of our recommendations to lower the screening age at which to start.”
The draft recommendation broadens the group of adults in the U.S. who should receive colorectal screening. Once it is finalized, after a public comment period of four weeks, it will replace the task force’s 2016 guidelines that state adults without risk factors for colorectal cancer should begin screening at age 50 and continue periodically until 75. The task force based the draft recommendations on a review of new peer-reviewed research, including an analysis of the benefits and potential harms of screening.
“We’re seeing just as much colon cancer newly developing in the 45-to-49-year-olds as we used to see in 50-to-54-year-olds,” Wong said. “The evidence suggests that screening is both effective and saves lives.”
About 18,000 people under age 50 will be diagnosed with colorectal cancer in the U.S. this year — 12% of total cases — and more than 3,600 are projected to die, the American Cancer Society estimates. The research the task force examined showed that adults who were 45 in 2016 had a similar incidence of colorectal cancer as people who were 50 in 1992, during a time before colorectal cancer screening was widely used. The reasons for the rise are uncertain.
Under the Affordable Care Act, the task force’s recommendations are used to determine preventive services that insurers must cover at no cost to patients. If the draft recommendation stays as is following the final deliberations, then colorectal screening for people between the ages of 45 and 49 would be covered, said Wong. He noted the task force’s judgements were based on an examination of the clinical science and were not made with consideration to insurance coverage or cost to patients.
Gastroenterologists not involved with the task force welcomed the new recommendations, but noted they will present some challenges.
“What this equates to is about an additional 21 million Americans that will need to be screened,” said Fola May, a gastroenterologist at the University of California, Los Angeles. From a public health standpoint, she said she worries about how to get all of these additional Americans screened. “Colon cancer screening was just one of the measures we as a nation were always poor at and we were especially bad with ethnic and racial minorities, Blacks, Latinos, Asians, and Native Americans.”
While 69% of white adults in the 50-to-75 age group were up to date on colorectal cancer screenings in 2018, according to the American Cancer Society, the rate fell to 66% for Black adults and between 56% and 59% for Hispanic, American Indian/Alaska Native, and Asian adults.
The two screening measures the task force recommends include “direct visualization tests,” like colonoscopies, and stool-based tests that analyze a person’s stool for blood or signs of cancer. The task force noted that after getting screened at 45, a person would have to receive a colonoscopy every 10 years or a stool-based test every one to three years, depending on the test.
“I hope that people will embrace that we should use even the non-invasive methods, like the stool tests,” said May, “and not for everyone to get a colonoscopy because I think that would be virtually impossible.”
Because colonoscopies carry a low risk of complications like bleeding and damage to the colon, the task force physicians had to weigh those possible harms against the potential lifesaving benefits of the screening. They estimated that complications would occur in 1 in every 63 to 102 adults screened from ages 45 to 75 years. The recommendation for screening people ages 45 to 49 was given a “B” grade, meaning the task force had “moderate certainty” of a net benefit, while the recommendation for screening for people 50 to 75 remained an “A” grade, meaning the team had “high certainty” the net benefit was substantial.
The draft guidelines do not change previous guidance concerning adults aged 76 to 85. People in this age group should continue to consult their physicians on the risks about whether or not they should get screened, they said, and those older than 85 years should discontinue screening. The new recommendations apply to asymptomatic adults and not to people who already have colorectal cancer signs, a family history of colorectal cancer, or abnormal growths known as polyps in their colon.
The preventive services task force is not the only medical body that provides guidelines for colon cancer screening. Many recommend screening of most adults from 50 to 75. The U.S. Multi-Society Task Force on Colorectal Screening, which includes medical experts from various gastroenterological societies, recommended in 2017 that Black adults begin screening at 45 years old and that anyone with a family history start screening at 40 years of age or 10 years before the age when their family member was first diagnosed.
The new USPSTF screening guidelines do not make any specific recommendations based on race or ethnicity, but do call for additional research into understanding what contributes to the increased colorectal cancer incidence and death rates in Black adults. The average annual death rate from colorectal cancer in the U.S. is 12.2 deaths per 100,000 women, but 16.1 deaths per 100,000 Black women, and 17.3 deaths per 100,000 men, but 24.4 deaths per 100,000 Black men, according to the task force.
The guidelines also encourage clinicians to pay particular attention to having conversations about colorectal cancer screening with their Black patients.
“I think it’s important to realize that lowering the screening age doesn’t necessarily increase access to screening,” said Adjoa Anyane-Yeboa, a gastroenterologist at Massachusetts General Hospital who was not a part of the task force. “But I do think that this is an important step forward and hopefully will help get more people covered and ideally will get more people screened.”
Charles Rogers, an assistant professor of public health at the University of Utah School of Medicine, said there is compelling evidence the screening age in the task force’s draft recommendations should be even lower for Black Americans because they are increasingly developing the disease at even younger ages. He pointed to examples like the actor Chadwick Boseman, who was diagnosed with stage 3 colon cancer at 39 and, in August, died at 43.
“I just keep continuing to see the issue getting worse and worse,” Rogers said. “Yeah, this is great that we’re going to 45. But what are we going to do for those that are much younger?”
The stepped up screening would not be nearly so burdensome if the GE community would be more open and honest about the true medical value of Cologuard and FIT testing. These stool-based methods do not involve nearly the physical burden, risk, or financial costs associated with colonoscopies, which could be reserved for those special categories of patients for whom they are actually medically indicated. Hopefully, this new guideline will be viewed by GE’s as an opportunity to prevent cancer rather than as a financial bonanza from doing more colonoscopies.
I see colorerctal cancer screening as designed to detect existing disease, not as preventative. That would be recommending a plant-based diet.
Don’t forget the other direct visualization test that is approved for colorectal screening: CT Colonography (aka Virtual Colonoscopy)!
There is a much larger capacity for CT scans than endoscopies in the US so much of the increased screening burden can be shouldered by Radiology.
We’re here to help,
Kevin J. Chang, MD, FACR, FSAR
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