Guidelines

Now USPSTF also suggests start CRC screening at age 45

Publish date: October 27, 2020
Author(s):
Roxanne Nelson, RN, BSN

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Moving the goal posts for colorectal cancer screening

Clinicians and researchers have actively debated the pros and cons of lowering the screening age to 45 years since 2018, when the American Cancer Society released its colorectal cancer (CRC) screening guidelines. The most compelling argument in support of lowering the screening age is that recent data from Surveillance Epidemiology and End Results (SEER) show that the CRC incidence rates in 45- to 50-year-olds are similar to rates seen in 50- to 54-year-olds about 20 years ago, when the first guidelines to initiate screening at age 50 were widely established. Termed early-onset CRC (EOCRC), the underlying reasons for this increase are not completely understood, and while the absolute numbers of EOCRC cases are smaller than in older age groups, modeling studies show that screening this age group is both efficient and effective.

Dr. Aasma Shaukat


Over the last 20 years we have made major strides in reducing the incidence and mortality from CRC in ages 50 years and older, and now we must rise to the challenge of delivering CRC screening to this younger group in order to see similar dividends over time and curb the rising incidence curve of EOCRC. And we must do so without direct evidence to guide us as to the magnitude of the benefit of screening this younger group, the best modality to use, or tools to risk stratify who is likely to benefit from screening in this group. We must also be careful not to worsen racial and geographic disparities in CRC screening, which already exist for African Americans, Native Americans, and other minorities and rural residents. Finally, even though the goal posts are changing, our target remains to get to 80% screening rates for all age groups, and not neglect the currently underscreened 50- to 75-year-olds, who are at a much higher risk of CRC than their younger counterparts.

Aasma Shaukat, MD, MPH, is an investigator, Center for Care Delivery and Outcomes Research, section chief and staff physician, GI section, Minneapolis VA Health Care System; staff physician, Fairview University of Minnesota Medical Center, Minneapolis; and professor, University of Minnesota department of medicine, division of gastroenterology, Minneapolis. She has no conflicts of interest.


 

Screening for colorectal cancer (CRC) should begin at age 45 years instead of 50 years, as recommended in the current guideline, the US Preventive Services Task Force (USPSTF) said in a draft recommendation that is open for public comment.

“This is the only change that was made,” said task force member Michael Barry, MD, director of the Informed Medical Decisions Program in the Health Decision Sciences Center at Massachusetts General Hospital, Boston.

The recommendation is that all adults aged 45-75 years be screened for CRC.

This is an “A” recommendation for adults aged 50-75 and a “B” recommendation for adults aged 45-49. Dr. Barry explained that the reason for this difference is that the benefit is smaller for the 45- to 49-years age group. “But there’s not much difference between A and B from a practical standpoint,” he explained.

For adults aged 76-85, the benefits and harms of screening need to be weighed against the individual’s overall health and personal circumstances. This is a “C” recommendation.

Barry emphasized that the USPSTF document is not final. The draft recommendation and supporting evidence is posted on the task force website and will be available for public comments until Nov. 23.

Mounting pressure

The move comes after mounting evidence of an increase in CRC among younger adults and mounting pressure to lower the starting age.

Two years ago, the American Cancer Society (ACS) revised its own screening guidelines and lowered the starting age to 45 years. Soon afterward, a coalition of 22 public health and patient advocacy groups joined the ACS in submitting a letter to the USPSTF asking that the task force reconsider its 2016 guidance (which recommends starting at age 50 years).

The starting age for screening is an important issue, commented Judy Yee, MD, chair of radiology at the Albert Einstein College of Medicine and the Montefiore Health System in New York and chair of the Colon Cancer Committee of the American College of Radiology.

“Right now it is very confusing to physicians and to the public,” Dr. Yee said in an interview at that time. “The USPSTF and the ACS differ as far as the age to begin screening, and insurers may not cover the cost of colorectal cancer screening before age 50.”

Dr. Barry said that the Task Force took notice of recent data showing an increase in the incidence of CRC among younger adults. “The risk now for age 45 to 49 is pretty similar to the risk for people in their early 50s. So in some ways, today’s late 40-year-olds are like yesterday’s 50-year-olds,” he commented.

The task force used simulation models that confirmed what the epidemiologic data suggested and “that we could prevent some additional colorectal cancer deaths by starting screening at age 45,” he said.

The rest of the new draft recommendation is similar to the 2016 guidelines, in which the task force says there is convincing evidence that CRC screening substantially reduces disease-related mortality. However, it does not recommend any one screening approach over another. It recommends both direct visualization, such as colonoscopy, as well as noninvasive stool-based tests. It does not recommend serum tests, urine tests, or capsule endoscopy because there is not yet enough evidence about the benefits and harms of these tests.

“The right test is the one a patient will do,” Dr. Barry commented.

Defining populations

CRC in young adults made the news in August 2020 when Chadwick Boseman, known for his role as King T’Challa in Marvel’s “Black Panther,” died of colon cancer. Diagnosed in 2016, he was only 43 years old.

“The recent passing of Chadwick Boseman is tragic, and our thoughts are with his loved ones during this difficult time,” said Dr. Barry. “As a Black man, the data show that Chadwick was at higher risk for developing colorectal cancer.”

Unfortunately, there is currently not enough evidence that screening Black men younger than 45 could help prevent tragic deaths such as Chadwick’s, he commented. “The task force is calling for more research on colorectal cancer screening in Black adults,” he added.

Limit screening to those at higher risk

In contrast to the USPSTF and ACS guidelines, which recommend screening for CRC for everyone over a certain age, a set of recommendations developed by an international panel of experts suggests screening only for individuals who are at higher risk for CRC.

As previously reported, these guidelines suggest restricting screening to adults whose cumulative cancer risk is 3% or more in the next 15 years, the point at which the balance between benefits and harms favors screening.

The authors, led by Lise Helsingen, MD, Clinical Effectiveness Research Group, University of Oslo, said “the optimal choice for each person requires shared decision-making.”

Such a risk-based approach is “increasingly regarded as the most appropriate way to discuss cancer screening.” That approach is already used in prostate and lung cancer screening, they noted.

A version of this article originally appeared on Medscape.com.

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