USPSTF issues updated recommendations for colorectal cancer screening
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The U.S. Preventive Services Task Force issued updated recommendations for colorectal cancer screening in JAMA.
“Colorectal cancer is a devastating disease and the third leading cause of cancer deaths in the United States, yet about a quarter of adults ages 50 to 75 have never been screened for colorectal cancer. The Task Force reviews its recommendations about every five years to make sure they reflect the latest research,” Martha Kubik, PhD, RN, professor and director of the School of Nursing in the College of Health and Human Services at George Mason University, U.S. Preventive Services Task Force (USPSTF) member, told Healio. “Screening for colorectal cancer is effective and saves lives. New science about colorectal cancer in people younger than 50 has enabled us to expand our recommendation to include people ages 45 to 49. Everyone who is 45 to 75 years old should be screened for colorectal cancer to reduce their risk of dying from this disease.”
In a systematic review, the USPSTF evaluated the benefits and harms of CRC screening in asymptomatic adults aged 40 years and older to update its 2016 recommendations. They further assessed the magnitude of net benefit for each recommendation.
Key recommendations include:
All adults aged 50 years to 75 years should be screened for CRC
According to the task force, age is one of the most important risk factors for CRC with incidence rates increasing with age. The USPSTF recommended CRC screening for all adults aged 50 years to 75 years regardless of risk factor presence; this recommendation has substantial net benefit.
Screening for adults aged 45 years to 49 years
Although the risk for CRC development is lower in adults below age 50 years, age-period cohort analyses indicated recent trends of CRC incidence at younger ages with nearly 94% of new cases occurring in adults as young as 45 years old.
The USPSTF recommended screening for CRC in asymptomatic adults aged 45 years to 49 years; this recommendation has been amended from the 2016 recommendation with moderate net benefit.
“Far too many people in the U.S. are not receiving this lifesaving preventive service,” Michael Barry, MD, USPSTF vice chair, said in a press release. “We hope that this new recommendation to screen people ages 45 to 49, coupled with our long-standing recommendation to screen people 50 to 75, will prevent more people from dying from colorectal cancer.”
Selective screening for adults aged 76 years to 85 years
In adults aged 76 years to 85 years, evidence suggests the harms of CRC screening may outweigh the benefits in many cases. The USPSTF recommends selective screening among this age group dependent on health status, prior screening history and patient preferences. This recommendation has small net benefit.
The USPSTF further recommended the use of direct visualization tests and stool-based tests for CRC screening.
“With these expanded screening guidelines, it is our hope that more people will be screened for colorectal cancer, resulting in significantly more lives saved,” Kubik concluded. There are several tests available that can effectively screen adults ages 45 to 75 for colorectal cancer, clinicians and patients should consider the pros and cons of the various options to help decide which test is best for their individual needs.”
Perspective
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Carol Burke, MD
Colorectal cancer screening saves lives. We have witnessed the powerful impact screening has had on decreasing both the occurrence of and death from the disease. Over the past 3.5 decades about a 1% per annum decrease in CRC has been observed in individuals 50 years or older who have undergone CRC screening. Clinicians have noticed over the last 15 years an increasing number of individuals younger than 50 years with CRC. Cancer registry data from 2006 to 2015 revealed a per annum increase of about 1% in colon cancer and a nearly 2% per annum increase in rectal cancer. While only about 10% of the 150,000 CRC cases estimated to occur in the United States is in individuals younger than 50 years, substantial impact occurs for the patient, their family and society when CRC affects young individuals. The United States Preventive Services Task Force updated their recommendations to provide a grade B endorsement for CRC screening in average risk individuals starting at age 45. Data to support their recommendation are based upon models that used 100% adherence to screening. While no particular screening method is suggested for those aged 45 to 49 years, average risk options include annual stool testing with fecal immunochemical testing (FIT) or high-sensitivity guaiac fecal occult blood test, or stool DNA-FIT every 1 year (3 years was not cost effective in the models) or direct visualization tests with CT colonography or flexible sigmoidoscopy every 5 years, or flexible sigmoidoscopy every 10 years with FIT annually, or colonoscopy every 10 years. We cannot let up the gas pedal, we need to increase adherence to screening amongst all age groups, it is the only way to decrease death from the disease; 45 is the new 50.
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This is an updated recommendation statement from the U.S. Preventive Services Task Force related to screening for colorectal cancer. Their overall findings are that there is “high certainty” that screening for CRC in adults aged 50 to 75 years has a substantial benefit, screening for CRC in adults aged 45 to 49 years has a moderate benefit and lastly that screening for CRC in older patients aged 76 to 85 years who have been screened has a small benefit.
The authors reviewed different screening options for patients, although the gold standard remains direct visualization with a colonoscopy.
As a clinician specializing in CRC, we are seeing younger patients with colon cancer; these numbers are staggering, and we are already seeing our concerns that these numbers are going to be much worse because of the COVID-19 pandemic and decreased or delayed screening for all types of cancers. In addition, the USPSTF recognize higher CRC incidence and mortality in Black adults and strongly encourage clinicians to ensure their Black patients receive recommended CRC screening.
Overall, this is an excellent consensus confirming and strengthening our approach of screening younger asymptomatic patients starting at age 45, working with health advocacy groups and education to increase screening referrals for patients aged 50 to 75 years and to only selectively screen patients who are older than 76 years. As a society, CRC is curable and preventable, we need to improve education, advocacy and access to screening in the U.S. and this statement supports this strategy.
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Robin Mendelsohn, MD
Colorectal cancer screening saves lives so I think this is a great idea. Since the 1990s, we have seen a decrease in incidence and mortality from colorectal cancer (CRC) in the United States. The majority of this decrease has been attributed to CRC screening. In the same time period, we have seen an increase in CRC among those aged younger than 50 years. By decreasing the screening age from 50 to 45, we are hopeful to have a meaningful impact on incidence and mortality among younger people.
Though this change in recommendations does help more people get screened, it does not address the increase in CRC incidence among those aged younger than 45 years. The reasons behind the increase in CRC in this younger population remain unclear, and we are working on identifying risk factors so we can target a higher-risk group to screen. Until then, it is so important for both patients and providers to be aware of this increased incidence so any symptoms can be evaluated promptly.
A change in guidelines also affords us the opportunity to discuss screening in general. Our hope is that it will act as a reminder to those who are eligible for screening and have not yet undergone screening to do so.
Though I do think colonoscopy is the best test — because it is able to not only detect cancer early but also prevent cancer by detecting and removing precancerous polyps — I am a firm believer that the best test is the one that gets done. Having a discussion about the pros and cons of different screening tests is important so people understand options and implications. The more people we screen, the more lives we can save.
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