USPSTF Begins New Review for Colorectal Cancer Screening

Roxanne Nelson, RN, BSN

January 11, 2019

The US Preventive Services Task Force (USPSTF) issued a draft research plan for colorectal cancer screening on January 3, consisting of a proposed analytic framework, key questions, study approach, and a decision model that is designed to guide the task force's review of colorectal cancer screening research as it updates its recommendations for the screening exam.

A key issue is the age at which colorectal cancer screening should begin and whether the age should be lowered from the currently recommended 50 years to 45 years.

The current set of USPSTF guidelines on colorectal cancer screening, released in 2016, presents convincing evidence that such screening substantially reduces disease-related mortality, but it does not recommend any one screening approach over another.

The task force recommended that screening begin at age 50 years and continue until age 75 years and that the decision to continue screening past that age should be an individual one and should take into account the patient's overall health and prior screening history.

However, in guidelines released in 2018 by the American Cancer Society (ACS), the starting age was lowered. The new ACS guidelines recommend that for persons at average risk, screening should begin at age 45 rather than 50, the current standard. The change in starting age was based in part on recent data demonstrating an increase in the incidence of colorectal cancer among younger populations.

A few months after the ACS guidelines were released, 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. A review was scheduled for 2021, but the coalition is asking for earlier action.

Accelerated Review?

Although there is some speculation that the task force had accelerated its review of the latest research in response to the request by the coalition, that is not the case. According to the USPSTF, this topic review is not taking place early and that it is on the standard timeline. To publish final recommendations that are 5 to 6 years apart, the task force needs to start work on the updated recommendation 2 to 3 years after the most recent final recommendation was published.

"The task force aims to keep all recommendations current, publishing a new final recommendation approximately every 5 to 6 years," Susan J. Curry, PhD, chair of the USPSTF, told Medscape Medical News. "Once the task force begins reviewing a topic, it takes a few years to develop the new or updated recommendation."

Curry explained that the colorectal cancer screening guideline is currently in the draft research plan stage, which is the first step in the multiyear process of issuing a recommendation statement on a topic. "In general, all topics are prioritized based on several criteria, including relevance to prevention and primary care, importance for public health, potential impact of the recommendation, and whether there is new evidence that may change a current recommendation," she told Medscape Medical News.

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 City and chair of the American College of Radiology Colon Cancer Committee.

"Right now it is very confusing to physicians and to the public," Yee told Medscape Medical News. "Right now the USPSTF and the ACS differ as far as the age to begin screening," she said, adding that insurers may not cover the cost of colorectal cancer screening before age 50.

Another issue is reimbursement for virtual (CT) colonoscopy.

Despite getting a thumbs up from the USPSTF, the Centers for Medicare & Medicaid (CMS) has refused to reimburse beneficiaries for colorectal screening by CT colonography (CTC).

However, proponents of the "virtual" exam are hopeful that CMS will change its stance, sooner rather than later, and believe that the USPSTF will continue to support CTC as a valid option.

"The American Cancer Society also supports CTC as a screening option," Yee told Medscape Medical News.

"The perspective from CMS is that they want more research and evidence for CTC before they will decide to reimburse for it," she said.

There is already ample evidence, Yee argued. "When you look at the evidence for screening methods, there are more data supporting CTC in terms of efficacy and safety than for other methods that they reimburse for. It is puzzling and a true disservice to patients," she said.

Several private insurance payors in the United States already reimburse for CTC screening.

In addition, the CT Colonography Screening for Colorectal Cancer Act of 2018 has been introduced in Congress. This bill would amend title XVIII of the Social Security Act to cover screening CTC as a colorectal cancer screening test under the Medicare program.


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