New guidelines lower colorectal screening age from 50 to 45

Karen KIm, MD, and her patient before colonoscopy procedure

The American Cancer Society has updated its guidelines for colorectal screening, lowering the age at which adults at average risk should start screening from 50 to 45. These recommendations are based in part on data showing that while screening has helped reduce the rates of colorectal cancer in older adults, incidence rates are increasing in young and middle-age populations.

The specific recommendations, released in May 2018, include:

  • Starting at age 45, individuals with an average risk of colorectal cancer should undergo regular screening with one of six different tests depending on patient preference and test availability. These tests include a FIT (fecal immunochemical test) or FOBT (fecal occult blood test) every year, stool DNA test every three years, a CT colonography or flexible sigmoidoscopy every five years, or colonoscopy every 10 years. The recommendations do not prioritize any one test over another.
  • Following a positive result from a non-colonoscopy screening test, a timely follow-up colonoscopy should be performed.
  • Average-risk adults in good health should continue colorectal cancer screening through age 75.
  • For patients between 76 and 85, screening decisions should be made jointly with clinicians based on patient preferences, life expectancy, health status, and prior screening history.
  • Individuals over age 85 should be discouraged from continuing screening.

Gastroenterologist Karen Kim, MD, professor of medicine and associate director for community engagement and cancer disparities at the University of Chicago Medicine Comprehensive Cancer Center, thinks these updated guidelines are a move in the right direction.

"This is definitely an important step for addressing the high rates of colorectal cancer among those younger than 50,” Kim said. “But given the infrequent updates to recommendations by the U.S. Preventive Services Task Force, an independent panel that issues advice for clinical preventive services, this will likely be a battle among insurers.”

Not only do we need to ensure our screening recommendations evolve along with our scientific knowledge, but we also need to ensure those individuals who need screening are getting it. 

And if screening is not covered by insurance, compliance will be a challenge, especially for population groups, such as African Americans, who face the highest rates of death caused by colorectal cancer.

It is also important to note that these changes in screening recommendations apply to individuals at average risk of developing colorectal cancer. For those who have risk factors associated with colorectal cancer, such as a family history, they should work with their physician to determine the best age to start screening.

More than 140,000 Americans are expected to be diagnosed with colorectal cancer in 2018, and it is the second leading cause of cancer death in the U.S., with over 50,000 deaths annually. Nationwide initiatives to improve colorectal cancer screening rates, such as “80 by 2018” led by the National Colorectal Cancer Roundtable, have improved screening rates and are contributing to decreased incidence rates in older adults. Yet, in Illinois, only 65 percent of eligible individuals have ever had a colorectal cancer screening test.

“Not only do we need to ensure our screening recommendations evolve along with our scientific knowledge, but we also need to ensure those individuals who need screening are getting it,” Kim said.

Programs such as Cook County CARES (Colon Cancer Alliance to Reignite and Enhance Screening), launched by Kim’s team in 2015, are developing innovative approaches to improve screening rates in the local community. For example, a new web portal is linking patients in need from community health centers with donated colonoscopy appointments at local hospital systems. These efforts, among others, have led to significant increases in screening rates at multiple community centers already.

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Neil Hyman, MD, in surgical setting

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