ACP: Begin screening asymptomatic adults for colorectal cancer at age 50 years
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Key takeaways:
- The ACP updated its guidance on colorectal cancer screening.
- The guidance conflicts with recommendations from the USPSTF, which lowered the recommended age to begin screening from age 50 to 45 years.
The ACP recently issued guidance that recommends colorectal cancer screening in asymptomatic, average-risk adults starting at age 50 years, going against some other organizations that recommend screening at an earlier age.
Recent data indicate that colorectal cancer (CRC) incidence is rising among younger adults.
“Although there has been a small increase in CRC incidence among persons aged 45 to 49 years, it is lower than in those aged 50 to 64 years and 65 to 74 years (35.1 vs. 71.9 vs. 128.9 per 100 000, respectively),” Amir Qaseem, MD, PhD, MHA, chief science officer and senior vice president of clinical policy and the Center for Evidence Reviews at ACP, and colleagues wrote in Annals of Internal Medicine.
Clinical guidelines addressing CRC screening vary on the recommended screening tests and time intervals, ages to stop and start screening and strength of recommendations, the authors wrote. So, they updated ACP’s 2019 stance.
To develop the updated guidance statement, they searched PubMed and the Guidelines International Network library for critically appraised clinical guidelines published after the ACP’s 2019 guidance. The researchers selected two guidelines for adaptation and adoption and used their modeling studies and evidence reviews to synthesize the evidence on benefits vs. risks, diagnostic test accuracy and effectiveness of CRC screening interventions.
CRC screening recommendations
“The thing for [primary care physicians] to keep in mind is when to start screening, when to stop and what tests to use,” Qaseem told Healio.
Qaseem and colleagues decided that in asymptomatic, average-risk adults:
- physicians should begin screening for CRC when patients are aged 50 years;
- physicians should stop screening patients aged older than 75 years;
- physicians should stop screening patients with a life expectancy of 10 years or less;
- physicians should consider not screening adults aged 45 to 49 years and discuss the uncertainty around harms and benefits of screening in this population;
- physicians should consult with their patient when selecting a screening test and consider harms and benefits, availability, frequency, cost and patient preferences;
- physicians should not screen for CRC with stool DNA, urine, capsule endoscopy, computed tomography colonography or serum screening tests; and
- as a screening test, physicians should use either colonoscopy every 10 years, flexible sigmoidoscopy every 10 years plus a fecal immunochemical test every 2 years or a fecal immunochemical or high-sensitivity guaiac fecal occult blood test every 2 years.
“The way I look at it, even now, all organizations agree we should be screening from 50 to 75. There is a net benefit; it helps in this age group. It reduces the incidence of cancer and mortality,” Qaseem said. “Let’s get everyone screened for CRC in this age group.”
For patients aged 45 to 49 years, though, “what we say is to consider not screening,” he said.
“There is no direct evidence. Incidence in this group is lower. The net benefit is much less favorable in this age group. We believe that the benefits do not outweigh the harms,” Qaseem said. “Sit down with your patients. Talk to them about uncertainty around benefits and discuss harms. Include them in the decision-making.”
Qaseem emphasized that the guidelines are only for patients of average risk, not high risk, and that physicians “should assess baseline risks of CRC, such as family history,” when making screening decisions for their patients.
Conflicting guidelines
The ACP’s updated guidance conflicts with those from other organizations such as the U.S. Preventive Services Task Force (USPSTF), which lowered the recommended age to start CRC screening from 50 to 45 years in 2021. Since then, research showed that screening rates more than doubled among adults aged 45 to 49 years.
In a related editorial, Michael Bretthauer, MD, PhD, a professor at the University of Oslo, and Yu-Xiao Yang, MD, an associate professor at the University of Pennsylvania Perelman School of Medicine, wrote that, “although the new ACP statement is at odds with USPSTF and American Cancer Society guidance in important ways and will spark debate in the United States, it is more in line with international guidelines.”
“The updated guidance statement from ACP advocates for reserving screening recommendations for tests and patient populations associated with favorable high-quality benefit–harm assessments,” they wrote. “It shifts away from the more-testing-to-more-people approach in other U.S. guidelines.”
References:
- Bretthauer M, et al. Ann Intern Med. 2023;doi:10.7326/M23-1695.
- Qaseem A, et al. Ann Intern Med. 2023;doi:10.7326/M23-0779.
Perspective
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The criteria for recommending screening are:
- the burden of disease is important;
- there is an effective screening test;
- early detection makes a difference; and
- benefits outweigh harms.
CRC screening beginning at age 45 meets each of these.
Greater than 10% of all life-years lost to a premature death from CRC are attributable to a diagnosis between 45 to 49 years, and half of the cases diagnosed before age 50 were ages 45 to 49 when we updated our guideline. No screening test is equally efficient at all ages. Incidence is still rising, and what used to be the risk of CRC in a 50-year-old is now the risk in a 45-year-old.
Since our guideline came out, there has been a lot of research done with registry data to ascertain if screening in the 45- to 49-year age group is effective. There have been no randomized studies because it is highly unlikely that anyone would fund them and highly unlikely that anyone would participate.
- Kolb JM, et al. 2021. This was a systematic review of 17 studies published between 2002 to 2020 that reported colonoscopy findings in 51,811 average-risk individuals younger than 50 years. The researchers reported that “the prevalence of overall and advanced colorectal neoplasia on screening colonoscopy for average-risk individuals younger than 50 years is 14% and 2%, respectively. In adults aged 45 to 49 years, 18% have any neoplasia and 4% have advanced neoplasia. These rates are similar to rates observed in adults aged 50 to 59 years.”
- Abualkhair WH, et al. 2020. “Early-onset colorectal cancer incidence rates among patients aged 45 to 49 years have been considered much lower compared with the rates among patients aged 50 to 54 years, prompting debate about earlier screening benefits at 45 years” — but rates in the 50- to 54-year age group are artificially inflated by lead time because screening is recommended to begin at age 50. So, cases that are prevented or would not be detected with symptoms for some years are picked up by screening. Finding a steep incidence increases of invasive stage CRC from age 49 to 50 years would be consistent with high rates of preexisting, undetected cancers in younger patients ultimately receiving a diagnosis of colorectal cancer after undergoing screening at 50 years. A total of 170,434 cases of colorectal cancer were analyzed among 165,160 patients. Steep incidence increases between 49 and 50 years of age (76% increase in localized disease, 30% increase in regional disease and 16% increase in distant disease) “are consistent with previously undetected colorectal cancers diagnosed via screening uptake at 50 years,” the researchers wrote. These cancers are not reflected in observed rates of colorectal cancer in the SEER registries in 5-year age-specific groups younger than 50 years, which is where most comparative estimates of age-specific disease burden have been drawn.
- Sehgal M, et al. 2021. The authors looked at CRC incidence rates of adults 45 to 49 years — 195,000 with exposure to colonoscopy (20.8 per 100,000 person-years) and 2.6 million without (30.6 per 100,000 person years) — and 50 to 54 years — 660,248 with exposure to colonoscopy (19 per 100,000 person years) and 2.4 million without (51.9 per 100,000 person years) — to measure CRC incidence rates. Adults ages 45 to 49 years exposed to colonoscopy were 50% less likely to develop CRC compared with adults ages 45 to 49 years not exposed to colonoscopy, similar to adults ages 50 to 54 years (68% less likely to develop CRC).
Numerous other studies illustrate benefits in the 45- to 49-age group that are similar to the 50- to 54-age group, and they note that they have not experienced any significant strain on services.
References:
- Abualkhair WH, et al. JAMA Netw Open. 2020;doi:10.1001/jamanetworkopen.2019.20407.
- Kolb JM, et al. Gastroenterology. 2021;doi:10.1053/j.gastro.2021.06.006.
- Sehgal M, et al. Gastroenterology. 2021;doi:10.1053/j.gastro.2021.02.015.
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