U.S. Task Force's colon cancer screening recommendations extended to include adults aged 45-49

Americans should begin getting screened for colon cancer at age 45, according to updated guidelines from the U.S. Preventive Services Task Force.

Published today in JAMA, the guidelines from the key panel of experts in prevention and evidence-based medicine maintain its “A recommendation” for screening among those aged 50 to 75 years that was outlined in 2016, but also add a “B recommendation” for screening those aged 45 to 49 years.

The U.S. Task Force made no changes to its 2016 recommendation that screening among those between the ages of 76 and 85 should be an individual decision (“C recommendation”) and that screening should be discontinued for those older than 85 years.

“Far too many people in the U.S. are not receiving this lifesaving preventive service,” U.S. Preventive Services Task Force (USPSTF) Vice Chair Michael Barry, M.D., said in a statement “We hope that this new recommendation to screen people ages 45 to 49, coupled with our long-standing recommendation to screen people 50 to 75, will prevent more people from dying from colorectal cancer.”

Colorectal cancer is the third leading cause of cancer death among men and women, USPSTF wrote, with an estimated 52,980 persons in the U.S. projected to die of colorectal cancer this year. Although it’s most often diagnosed among persons aged 65 to 74 years, an estimated 10.5% of new colorectal cancer cases occur in those under 50 years of age.

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USPSTF provides its recommendations to guide clinical practice, but its positions also carry weight when it comes to reimbursement and implementation—for instance, copays are waived for preventive visits and cancer screening with a USPSTF A recommendation or B recommendation under the Affordable Care Act.

The independent panel wrote that these latest recommendations specifically apply to screening strategies employing high-sensitivity stool-based tests, colonoscopy, computed tomography colonography and flexible sigmoidoscopy.

The new guidance comes after a systematic review of the benefits and harms associated with colorectal cancer screening among those aged 40 years or older, as well as a comparative modeling report estimating the benefits gained from different screening strategies, the group wrote.

With these data, USPSTF said it looked at the effectiveness of these screening strategies to reduce incidence and mortality, the accuracy of various tests and their reported harms.  

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The group also noted a “general consensus” among major professional groups around the screening recommendation for adults between 50 and 75 years, but that the guidance shifts from organization to organization for those aged 40 years and older.

Looking forward, USPSTF called for additional research into persistent evidence gaps around colorectal cancer screening. Randomized trials directly comparing screening strategies, studies on screening effectiveness among those younger than 50 years, investigations of the factors contributing to increased incidence and mortality among Black adults and other colorectal cancer research are all needed, the group wrote.

Alongside the new recommendations, JAMA also published a slew of editorials discussing the updates across its various journals.

In these, authors were generally open to expanded screening and the benefits outlined by USPSTF. Some took that momentum a bit further by highlighting the cases in even younger patients and calling for additional investigation.

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“Is starting screening at age 45 years as recommended by the USPSTF early enough?” a trio of experts wrote in a JAMA editorial. “Most young-onset colorectal cancer deaths also occur in patients aged 45 to 49. However, data from 1974-2013 suggest that the rate of increase in young-onset colorectal cancer is actually steepest in the very youngest patients, with colon cancer incidence increasing by 2% per year among 20- to 29-year-olds.

“Ultimately, optimal prevention and early detection of colorectal cancer among individuals younger than 45 years will require further research into the underlying etiology and risk factors of young-onset colorectal cancer, which thus far remain elusive but are suspected to possibly be related to environmental exposures during early life. A novel strategy that brings precision medicine principles to prevention using a risk-adapted approach could then enable the identification of young patients who are at highest risk of colorectal cancer and need earlier screening,” they wrote.

Implementation of the new recommendations will also be a hurdle, they wrote, particularly among high-risk patients who are poor, uninsured or a member of a minority. Although public awareness campaigns, quality metrics and additional accompanying guidelines can help, the editorial authors floated employer-provided “wellness days” for colorectal cancer screening or on-the-spot screening from occupational health services as potential strategies to move the needle.

“The real work lies ahead in implementing the new recommendations, ensuring equitable access and conducting research to elucidate the underlying causes of the increase in young-onset colorectal cancer,” they wrote. “Realizing the full potential of colorectal cancer screening to decrease mortality will therefore require commitment by patients and families, clinicians, payers, health systems, employers, public health agencies, scientists and funders.”