Decrease in Incidence of Colorectal Cancer Among Individuals 50 Years or Older After Recommendations for Population-based Screening

Caitlin C. Murphy; Robert S. Sandler; Hanna K. Sanoff; Y. Claire Yang; Jennifer L. Lund; John A. Baron

Disclosures

Clin Gastroenterol Hepatol. 2017;15(6):903-909. 

In This Article

Abstract and Introduction

Abstract

Background & Aims: The incidence of colorectal cancer (CRC) in the United States is increasing among adults younger than 50 years, but incidence has decreased among older populations after population-based screening was recommended in the late 1980s. Blacks have higher incidence than whites. These patterns have prompted suggestions to lower the screening age for average-risk populations or in blacks. At the same time, there has been controversy over whether reductions in CRC incidence can be attributed to screening. We examined age-related and race-related differences in CRC incidence during a 40-year time period.

Methods: We determined the age-standardized incidence of CRC from 1975 through 2013 by using the population-based Surveillance, Epidemiology, and End Results (SEER) program of cancer registries. We calculated incidence for 5-year age categories (20–24 years through 80–84 years and 85 years or older) for different time periods (1975–1979, 1980–1984, 1985–1989, 1990–1994, 1995–1999, 2000–2004, 2005–2009, and 2010–2013), tumor subsite (proximal colon, descending colon, and rectum), and stages at diagnosis (localized, regional, and distant). Analyses were stratified by race (white vs black).

Results: There were 450,682 incident cases of CRC reported to the SEER registries during the entire period (1975–2013). Overall incidence was 75.5/100,000 white persons and 83.6/100,000 black persons. CRC incidence peaked during 1980 through 1989 and began to decrease in 1990. In whites and blacks, the decreases in incidence between the time periods of 1980–1984 and 2010–2013 were limited to the screening-age population (ages 50 years or older). Between these time periods, there was 40% decrease in incidence among whites compared with 26% decrease in incidence among blacks. Decreases in incidence were greater for cancers of the distal colon and rectum, and reductions in these cancers were greater among whites than blacks. CRC incidence among persons younger than 50 years decreased slightly between 1975–1979 and 1990. However, among persons 20–49 years old, CRC incidence increased from 8.3/100,000 persons in 1990–1994 to 11.4/100,000 persons in 2010–2013; incidence rates in younger adults were similar for whites and blacks.

Conclusions: On the basis of an analysis of the SEER cancer registries from 1975 through 2013, CRC incidence decreased only among individuals 50 years or older between the time periods of 1980–1984 and 2010–2013. Incidence increased modestly among individuals 20–49 years old between the time periods of 1990–1994 and 2010–2013. The decision of whether to recommend screening for younger populations requires a formal analysis of risks and benefits. Our observed trends provide compelling evidence that screening has had an important role in reducing CRC incidence.

Introduction

Colorectal cancer (CRC) incidence and mortality in the United States have changed strikingly in recent decades.[1] Overall CRC incidence declined by more than 30% from 1975 (59.5 per 100,000) to 2013 (37.9 per 100,000),[2] with particularly steep declines among those older than the age of 65. Mortality rates have similarly declined during the same period.[1]

The declines in CRC incidence have not occurred equally in all populations. In sharp contrast to the decline in CRC incidence and mortality among older individuals, incidence is actually rising in adults younger than age 50.[3–11] These findings have led to recommendations to extend screening among average-risk individuals to ages younger than 50 years.[12–14] Because blacks have higher CRC incidence than whites and the age-related acceleration in incidence starts at a younger age, calls have also been made to lower the screening age for blacks.[15–18]

At the same time, there has been controversy regarding the role of screening in the reductions in CRC incidence. Unlike screening for other cancers (eg, breast, prostate), CRC screening reduces incidence via excision of premalignant lesions. The use of CRC screening has become increasingly common in the United States since it was first formally recommended in the late 1980s (largely driven by the use of colonoscopy),[19–22] but the extent to which it explains declines in CRC incidence has been debated. Some have argued that screening accounts for much of the improvement in incidence and mortality, as observed in clinical trials of fecal occult blood testing (FOBT) and sigmoidoscopy.[23–25] However, others have suggested that screening has had only a modest impact, and changes in the prevalence of risk factors may be more important.[26,27]

The trends in CRC incidence raise 2 related questions: what is the role of screening in explaining the declining rates? Which populations should be screened? To clarify these questions and better understand the clinical and public health implications of CRC incidence trends, we examined age-related and race-related differences in incidence during a 40-year time period.

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