The U.S. Preventive Services Task Force has published a final recommendation statement calling for individuals to get their first colorectal cancer (CRC) screening at age 45 instead of waiting until age 50.
The new recommendation was announced in November and made in response to a nationwide increase in incidences of CRC among young adults. An independent panel of experts, the task force is appointed by the Department of Health and Human Services Agency for Healthcare Research and Quality, whose recommendations heavily influence decisions by policymakers.
The Centers for Medicare and Medicaid (CMS), which by law must pay for CRC screening for its recipients, and also insurance plans subject to rules under the Affordable Care Act, will follow the task force's recommendation and cover the screenings.
The change is categorized as a B recommendation on the five-letter classification scale used by the task force. CRC screening for patients ages 55-76 remains strongly encouraged, making it an A recommendation. While screening for those over age 76 should still be considered on a per-case basis, earning it a C recommendation.
“Far too many people in the U.S. are not receiving this lifesaving preventive service,” said Michael Barry, MD, Task Force Vice Chair and Director of the Informed Medical Decisions Program in the Health Decision Sciences Center at Massachusetts General Hospital and Professor of Medicine at Harvard Medical School. “We hope that this new recommendation to screen people ages 45-49, coupled with our longstanding recommendation to screen people 50-75, will prevent more people from dying from colorectal cancer.”
Reaching a Consensus on Screening
The decision to lower the CRC screening age also aligned the task force with the 2018 recommendation by ACS, which called for lowering the starting age to 45 for CRC screening based on an analysis of SEER data of 500 patients with the disease between 1974 and 2013.
The ACS researchers revealed CRC rates had increased 1.0-2.4 percent yearly since the mid-1980s in ages 20-39 and by 0.5 percent to 1.3 percent since the mid-1990s in ages 40-54. The age-specific relative risk for CRC by birth cohort, which fell every decade from 1890 to 1950, then increased every year through 1990.
Still another study revealed the incidence of colorectal cancer in people under age 50 had increased 2 percent every year since 1990. Among those with young-onset or early-onset disease, 75 percent were between ages of 40 and 49 (Arch Intern Med 2012; doi:10.1001/archinternmed.2011.602). Starting CRC screening at age 50 was first recommended in the 1970s, by the ACS, and remained the standard of care for decades.
Studies since have shown African-American adults consistently at higher risk for CRC than people of other races and ethnicities, and also more likely to die from the disease, as was tragically driven home by the death of actor Chadwick Boseman, who died from CRC in 2020, at age 43.
In 2005, several health care organizations, led by the American Society for Gastrointestinal Endoscopy (ASGE), began advocating for lowering the starting age to 45 for Black patients since 2005. The new recommendation applies to all races.
The task force first voiced support for lowering the CRC screening starting age to 45 for everyone in 2016, but did not have enough empirical data to support change its recommendation to begin at age 50. It did not recommend CRC screening for individuals under age 45 in the newly finalized statement, citing low incidence rates.
Ensuring Excellence in Endoscopy
Two types of tests to screen for colorectal cancer—direct visualization tests and stool-based tests—are included in the final recommendation from the task force, which strongly encouraged primary care clinicians to help patients select the test is best for them.
Or as task force member, Martha Kubik, PhD, RN, put it, “the right test is the one that gets done.” She is a professor and Director of the School of Nursing in the College of Health and Human Services at George Mason University.
Colonoscopies, of course, remain the gold standard for CRC screening, said Douglas K. Rex, MD, MASGE, ASGE President. Not only do colonoscopies have the ability to remove polyps, they also provide a careful examination of the inside of the colon that is good for 10 years if negative.
Advances in imaging technologies, meanwhile, allow endoscopists to become highly effective detectors of precancerous lesions, including those hiding in previously unviewable areas of the colon.
“We have high-definition scopes which can be combined with distal attachment devices that allow us to look behind the folds, kind of like you are reaching into the curtains or the drapes on those folded areas, and flatten them out so that we can see everything,” Rex said. “And we have learned a lot about how to improve the bowel preparation for a colonoscopy so that a higher percentage of the colons we are examining are very clean.”
It also helps when CRC screening costs are covered, he noted, pointing to a decrease in colon cancer in people over 50 since 2001 when CMS began covering colonoscopies. He expects the new task force recommendation will result in more insurance companies providing coverage for CRC screening.
Meanwhile, ASGE continues its mission to help endoscopists improve their detection skills, Rex noted. “We have a measure for endoscopists' detection skills called the Adenoma Detection Rate. We also have registries which members can participate in to get benchmarking data and long-term data to help them see how they are performing in terms of detection during colonoscopy.”
The organization also helps members educate primary care providers in their local area about the benefits of CRC screening starting at age 45.
“ASGE provides the resources to our gastroenterology members that they need to go into their medical grand rounds or medical staff meetings and give presentations to help primary care providers understand how important it is to recommend screening and make the recommendation on a consistent basis—and to make it enthusiastically,” Rex said.
Chuck Holt is a contributing writer.