USPSTF expands colorectal cancer screening recommendation to include adults aged 45 years
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All adults should begin to get screened for colorectal cancer at age 45 years, according to a draft recommendation by the U.S. Preventive Services Task Force.
This is the first time the USPSTF has recommended screening initiation at age 45 years. The “B” recommendation indicates high certainty that the net benefit is moderate or moderate certainty that the net benefit is moderate or substantial.
The task force continues to strongly recommend screening for adults between the ages of 50 and 75 years. The “A” recommendation indicates high certainty that the net benefit of screening for this age group is substantial.
Decisions on screening for adults aged 76 to 85 years should be made on an individual basis. The “C” recommendation indicates moderate certainty that the net benefit of screening for this age group is small.
This draft recommendation is now open for public comment.
“New science about colorectal cancer in younger people has enabled us to expand our recommendation to screen all adults starting at age 45 [years], especially Black adults who are more likely to die [of] this disease,” Michael Barry, MD, task force member and director of the Informed Medical Decisions Program at Massachusetts General Hospital, said in a USPSTF press release. “Screening earlier will help prevent more people from dying [of] colorectal cancer.”
This new draft recommendation applies to adults without symptoms who do not have a personal history of colorectal polyps or a personal or family health history of genetic disorders that may increase risk for colorectal cancer.
Colorectal cancer is the third leading cause of cancer death in the United States, according to the USPSTF, with about 53,200 people projected to die of the disease in 2020.
About 10.5% of new colorectal cancer cases occur in people aged younger than 50 years; however, most diagnoses occur between the ages of 65 and 74 years.
Recent epidemiological data suggest incidence among adults aged 45 years is almost equivalent to incidence among those age 50 years.
In 2016, about 25% of eligible adults in the U.S. had never undergone colorectal cancer screening.
“Unfortunately, not enough people in the U.S. receive this effective preventive service that has been proven to save lives,” Alex Krist, MD, MPH, task force chair and professor of family medicine and population health at Virginia Commonwealth University, said in the press release. “We hope that this recommendation to screen people ages 45 to 75 [years] for colorectal cancer will encourage more screening and reduce people's risk of dying [of] this disease.”
Specifically, Black adults are more likely than other populations to be diagnosed with colorectal cancer and to die of the disease. The USPSTF particularly encourages clinicians to recommended colorectal cancer screening to their Black patients beginning at age 45 years.
Colorectal cancer incidence rates from 2013 to 2017 were 43.6 cases per 100,000 for Black adults, 37.8 per 100,000 for white adults, 31.8 per 100,000 for Asian/Pacific Islander adults, 39 per 100,000 for American Indian/Alaska Native adults and 33.7 per 100,000 for Hispanic/Latino adults, according to the draft recommendation.
Death rates were 18.5 per 100,000 for Black adults, 13.6 per 100,000 for white adults, 9.6 per 100,000 for Asian/Pacific Islander adults, 15.8 per 100,000 for American Indian/Alaska Native adults and 11.1 per 100,000 for Hispanic/Latino adults.
It remains unclear whether the disparity is driven primarily by biology, access to and utilization of screening and treatment, or disparities in screening and treatment quality, according to the task force.
Additionally, the task force recommends direct visualization tests and stool-based tests to screen for disease. The recommendation does not include serum tests, urine tests or capsule endoscopy.
“There are many tests available that can effectively screen for colorectal cancer,” Martha Kubik, PhD, RN, task force member and professor and director of the school of nursing in the College of Health and Human Services at George Mason University, said in the release. “We urge primary care clinicians to discuss the pros and cons of the various recommended options with their patients to help decide which test is best for each person.”
Perspective
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Daniel M. Labow, MD
This recommendation supports those of medical societies over the last year that have evolved based on database studies that showed younger people are at risk for colorectal diseases.
We have seen a decline in some advanced cancers because we screen and find these polyps or lesions before they become malignant. The fastest-rising group is younger patients, mostly between ages 45 to 50 years. The absolute number of people getting colorectal cancer at this younger age is still small, but the rate of increase compared with what we are used to is rising. This is probably because we are lowering the rate of diagnosis in the older group through effective screening.
This guidance is for people without symptoms. People with bleeding, pain, change in bowel habits or unexplained weight loss should be screened regardless of age.
To have an effective screening program, you have to have a high enough incidence to pick up enough patients in the population and a procedure safe enough to not cause more harm than good.
Some physicians already have started recommending screening at age 45 years. A colonoscopy is a safe test and very effective for detecting a polyp before it becomes cancer.
One of the issues is that insurance companies don’t pay for early screening tests before there are established recommendations and guidelines. As more medical societies come out with recommendations, the insurance companies will follow.
It’s always good to reassess our guidelines and practices, so I am supportive of lowering the age of screening. A colonoscopy is a safe test and is 100% effective. That is something of value that we shouldn’t deny our patients.
Perspective
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Many in the GI community agree that the draft recommendations for the US Preventive Services Task Force (USPSTF) are appropriate. In particular, there is support of the B recommendation to begin screening at age 45 years. There is general acknowledgement of accumulated supportive data, although not as strong as the evidence for screening individuals older than 50 years.
Approximately 90% of screening in the United States is by colonoscopy. By lowering the age of screening initiation, we will add another cohort to the screening pool which will affect our resources. Importantly, the USPSTF continues to provide a list of several recommended tests with the specified screening interval. Screening need not be synonymous with colonoscopy.
Some of the tests listed by USPSTF, however, are not practical. The Task Force focuses on evaluating the quality of the data for benefits and harm. Cost and insurance coverage are explicitly not considered. Screening by CT colonography, for example, is usually not covered by insurance and is not widely available. Sigmoidoscopy has excellent data, but it is not readily available. These barriers are important to consider when implementing guidelines into practice.
Furthermore, there is a long-standing concern that the required follow-up colonoscopy for a positive colorectal cancer screening test, such as FIT, FIT-DNA, CT colonography is currently termed a “diagnostic” colonoscopy. This has direct implications for coverage by insurance, specifically whether there is a co-pay or not. In gastroenterology, we have come to a consensus that the colonoscopy after a positive screening test is not a diagnostic test and rather a “follow-up screening test” and necessary component of a screening program.
Screening is not a single test. Negative screening tests are repeated at regular intervals (specific to the test) and positive tests require follow-up. While it seems pedantic to argue over the terminology used in the draft recommendations, the use of the word “diagnostic,” has had a direct impact on whether a procedure is covered as a screening test or not.
These cost implications may discourage people who want a non-invasive screening test from pursuing one. The lack of complete coverage for a follow-up colonoscopy could discourage a person from undertaking any screening. Data support that having a choice improves screening rates. These coverage decisions tied to terminology can remove patient choice.
Finally, an overshadowed message from the USPSTF is the C recommendation for screening older adults (age 76-85). There is often a disconnect between gastroenterologists and primary care in who should recommend that screening be discontinued. Primary care providers know the patient but may feel uncomfortable discussing the risks and benefits of continuing screening. Gastroenterologists understand the risks and benefits, but may not know the patient. With open access endoscopy units, a gastroenterologist may first meet the patient on the day of the colonoscopy. We need to have better processes to determine when to stop screening, including who will make the recommendation and how patient preferences will be incorporated into the discussion.
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USPSTF. Draft recommendation statement. Colorectal cancer: Screening. Available at: www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/colorectal-cancer-screening3. Accessed Oct. 27, 2020.
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