USPSTF Lowers Age to Begin Colorectal Cancer Screening

In a shift from its 2016 recommendations around colorectal cancer, the U.S. Preventive Services Task Force (USPSTF) announced Tuesday that it now supports initiating screening efforts as early as age 45.

Colorectal cancer is the third leading cause of death in the United States, claiming 52,980 lives annually. While most cases are diagnosed between ages 65 and 74, the incidence of the disease is rising in patients under age 50. In fact, between 2000 and 2016, cases in the 40-to-49 age group spiked 15 percent.

To address this upward trend and, potentially, save lives, the Task Force published this new guidance on May 18 in JAMA.

“The USPSTF recommends that adults ages 45 to 75 be screened for colorectal cancer, lowering the age for screening that was previously 50 to 75,” the Task Force members said. “The USPSTF also recommends that clinicians selectively offer screening to adults 76 to 85 years of age.”

According to estimates, lowering the screening age could lead to an additional 10.7 million colonoscopies each year.

The lowered screening initiation age is a “B” recommendation, and it applies to asymptomatic adults who are at average risk for colorectal cancer and who have no prior diagnosis, polyps, inflammatory bowel disease, or family history. It is important to note that colorectal cancer incidence is higher among Black, American Indian, and Alaskan Native patients, as well as those who are obese, have diabetes, are long-term smokers, or those with unhealthy alcohol use.

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In addition to the fecal tests and flexible sigmoidoscopy, the Task Force reiterated their support for a colonoscopy every 10 years or a CT colonography every five years as screening options. According to members, patients who opt for colonoscopy or CT colonography screening experience greater estimated life-years gained when compared with flexible sigmoidoscopy. In addition, CT colonography can reveal other extracolonic findings that could lead to other benefits or harms and would require additional workup.

To make this recommendation change, the Task Force examined multiple studies that analyzed the accuracy, benefits, and harms of the various screening options, and they tested three microsimulation models. Based on their findings, neither CT colonography or colonoscopy can accurately identify all cancers, but colonoscopy – which is the most sensitive and common exam – is associated with lower colorectal cancer mortality from both distal and proximal cancers.

Both screening studies have high sensitivity for detecting polyps. Colonoscopy offers a sensitivity range of 0.75 to 0.93 for polyps larger than 6mm and 0.89 to 0.95 for polyps larger than 10mm. The exam also has good specificity – 0.94 for 6mm and 0.89 for 10mm. In addition, CT colonography performs well with sensitivity of 0.73 to 0.98 for polyps larger than 6mm and 0.67 to 0.94 for those greater than 10mm, as well as specificity of 0.80 to 0.93 for 6-mm polyps and 0.86 to 0.98 for 10-mm polyps.

Harm to patients is possible, including perforations or major bleeding events with colonoscopy and radiation exposure with CT colonography, but they are infrequent, the Task Force said.

Importance for Health Equity

Recommending a lower screening age is a move that could help address the racial health disparity associated with colorectal cancer. Existing evidence shows Black patients have both a higher incidence of and higher mortality associated with the disease.

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According to Task Force-reported data, from 2013 to 2017, the colorectal cancer incidence in this patient group was 43.6 per 100,000 compared with 37.8 per 100,000 for white patients. The death rate was also higher – 18 per 100,000 compared with 13.6 per 100,000 for white patients.

“The USPSTF recognizes the higher colorectal cancer incidence and mortality in Black adults and strongly encourages clinicians to ensure the Black patients receive recommended colorectal cancer screening, follow-up, and treatment,” the group said. “The USPSTF encourages the development of systems of care to ensure adults receive high quality care across the continuum of screening and treatment, with special attention to Black communities which historically experience worse colorectal cancer health outcomes.”

But, in an accompanying JAMA Network Open editorial, Shivan J. Mehta, M.D., MBA, assistant professor of medicine at the Perelman School of Medicine at the University of Pennsylvania, noted that it is possible this new recommendation could have an opposite effect, exacerbating the racial disparities in screening and outcomes instead.

Given the likely increase in demand for colonoscopies or CT colonographies, if facilities do not expand their capacity, medically underserved populations who lack insurance or access could be overlooked in favor of patients who have more healthcare advantages, he said.

In addition, he said, opening the door to screening for patients ages 45-to-49 could also make it harder for patients over age 50 who are not current with their colorectal cancer screenings to get the tests they need in a timely manner.

He encouraged leaders and institutions to consider all factors that affect colorectal cancer screening as they work to accommodate this new USPSTF screening recommendation.

“This is an important moment for colorectal cancer screening. As policymakers, health care systems, and clinicians respond by designing strategies that expand screening, we urge the thoughtful incorporation of practices to ensure equity in access and facilitate learning from implementation challenges and successes across populations,” he said. “This is an opportunity to reduce the burden of colorectal cancer starting at age 45 years, but it is also a reminder to ensure the benefits are realized equitably.”

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