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Task Force Recommends Routine Colorectal Cancer Screening for Adults Aged 50 to 75 Years
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Routine colorectal cancer screening should continue to be performed among adults aged 50 to 75 years, according to an updated recommendation from the U.S. Preventive Services Task Force.
The decision to screen adults aged 76 to 85 years should be based on a person’s overall health and prior screening history, the task force concluded.
Kirsten Bibbins-Domingo
The task force also found convincing evidence that several screening methods can accurately detect early-stage disease and adenomatous polyps.
Many in the clinical community hailed that conclusion and called on private insurers and Medicare to cover the costs of viable alternatives to colonoscopy.
“The best test is one that patients will actually use,” William T. Thorwarth, MD, FACR, CEO of the American College of Radiology, said in a press release. “A third of those who should be screened for colorectal cancer still choose not to be tested. Patients need more fully covered screening options if we are going to reduce colorectal cancer deaths.”
Colorectal cancer is the second leading cause of cancer death in the United States. An estimated 134,000 Americans will be diagnosed with colorectal cancer this year, and approximately 49,000 will die of the disease.
Colorectal cancer most often is diagnosed among those aged 65 to 74 years, and the median age of colorectal cancer death is 68 years.
Despite growing evidence of the effectiveness of colorectal cancer screening, it “is a substantially underused preventive health strategy in the United States,” task force chair Kirsten Bibbins-Domingo, PhD, MD, MAS, and colleagues wrote in their recommendation statement.
The task force conducted a systematic evidence review to update its 2008 recommendation on colorectal cancer screening. The review assessed:
- the effectiveness of screening — including colonoscopy, flexible sigmoidoscopy, CT colonography, guaiac-based fecal occult blood test, fecal immunochemical tests, a multitargeted stool DNA test and methylated SEPT9 DNA test — for reducing colorectal cancer incidence and mortality;
- the harms of the various screening tests; and
- the ability of the tests to detect adenomatous polyps, advanced adenomas or colorectal cancer.
The task force concluded colorectal cancer screening substantially reduces colorectal cancer deaths among adults aged 50 to 75 years, and that the decision to screen those aged 76 to 85 years should be an individual one.
“The age at which the balance of benefits and harms of colorectal cancer screening becomes less favorable varies based on a patient’s life expectancy, health status, comorbid conditions and prior screening status,” Bibbins-Domingo and colleagues wrote. “The USPSTF does not recommend routine screening for colorectal cancer in adults 86 years and older.”
Task force members determined older age was the most important risk factor for colorectal cancer. Other risk factors included family history of colorectal cancer, male sex and black race.
Overall, the harms associated with colorectal cancer screening are small, with the majority resulting from colonoscopy. Serious adverse events can increase with age.
“Multiple screening strategies are available to choose from, with different levels of evidence to support their effectiveness, as well as unique advantages and limitations,” Bibbins-Domingo and colleagues wrote. “There are no empirical data to demonstrate that any of the reviewed strategies provide a greater net benefit.”
Although the task force did not specify a preference for screening method, a person is more likely to undergo a test if it aligns with his or her preferences, David F. Ransohoff, MD, professor at University of North Carolina Lineberger Comprehensive Cancer Center, and Harold C. Sox, MD, active emeritus professor of medicine at The Dartmouth Institute for Health Policy and Clinical Practice, wrote in an accompanying editorial. The task force recommends shared decision-making between physicians and patients, and its willingness to embrace this concept is “a pivotal step forward,” Ransohoff and Sox wrote.
However, the lack of a recommendation of a specific screening test or strategy creates ambiguity about whether private insurance should cover each option listed in the recommendation statement, they wrote.
“The unique feature of the 2016 recommendations is that a goal — to increasing screening rates — is driving the implementation strategy, which is to use shared decision-making about an unusually broad range of screening options,” Ransohoff and Sox wrote. “Stakeholders — patients, physicians, health plans and insurers — will want to know if the task force plans to take this approach for future screening topics. When the task force does recommend shared decision-making, it would be helpful to develop a patient-friendly table that displays all of the evidence about all of the acceptable strategies.” – by Kristie L. Kahl
Disclosures: Please see the full study for a list of task force members’ relevant financial disclosures. Ransohoff reports prior paid consultant roles with Exact Sciences, and contributions to colorectal cancer screening validation studies funded by Exact Sciences and Epigenomics. Sox chaired the U.S. Preventive Services Task Force from 1991 to 1996 and served as a member from 1998 to 2001. He also reports a previous unpaid medical advisory board role with Epigenomics.
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