Now USPSTF Also Suggests Start CRC Screening at Age 45

Roxanne Nelson, RN, BSN

October 27, 2020

Screening for colorectal cancer (CRC) should begin at age 45 years instead of 50 years, as recommended in the current guideline, the US Preventive Services Task Force (USPSTF) says in a draft recommendation that is open for public comment.

"This is the only change that was made," said Task Force member Michael Barry, MD, director of the Informed Medical Decisions Program in the Health Decision Sciences Center at Massachusetts General Hospital, Boston.

The recommendation is that all adults aged 45 to 75 years be screened for CRC.

This is an "A" recommendation for adults aged 50 to 75 and a "B" recommendation for adults aged 45 to 49. Barry explained that the reason for this difference is that the benefit is smaller for the 45 – 49 age group. "But there's not much difference between A and B from a practical standpoint," he explained.

For adults aged 76 to 85, the benefits and harms of screening need to be weighed against the individual's overall health and personal circumstances. This is a "C" recommendation.

Barry emphasized that the USPSTF document is not final. The draft recommendation and supporting evidence is posted on the Task Force website and will be available for public comments until November 23.

Mounting Pressure

The move comes after mounting evidence of an increase in CRC among younger adults and mounting pressure to lower the starting age.

Two years ago, the American Cancer Society (ACS) revised its own screening guidelines and lowered the starting age to 45 years. Soon afterward, 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 (which recommends starting at age 50).

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 Colon Cancer Committee of the American College of Radiology.

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

Barry said that the Task Force took notice of recent data showing an increase in the incidence of CRC among younger adults. "The risk now for age 45 to 49 is pretty similar to the risk for people in their early 50s. So in some ways, today's late 40-year-olds are like yesterday's 50-year-olds," he commented.

The Task Force used simulation models that confirmed what the epidemiologic data suggested and "that we could prevent some additional colorectal cancer deaths by starting screening at age 45," he said.

The rest of the new draft recommendation is similar to the 2016 guidelines, in which the Task Force says there is convincing evidence that CRC screening substantially reduces disease-related mortality. However, it does not recommend any one screening approach over another. It recommends both direct visualization, such as colonoscopy, as well as noninvasive stool-based tests. It does not recommend serum tests, urine tests, or capsule endoscopy because there is not yet enough evidence about the benefits and harms of these tests.

"The right test is the one a patient will do," Barry commented.

Defining Populations

CRC in young adults made the news a few months ago when Chadwick Boseman, known for his role as King T'Challa in Marvel's "Black Panther," died of colon cancer. Diagnosed in 2016, he was only 43 years old.

"The recent passing of Chadwick Boseman is tragic, and our thoughts are with his loved ones during this difficult time," said Barry. "As a Black man, the data show that Chadwick was at higher risk for developing colorectal cancer."

Unfortunately, there is currently not enough evidence that screening Black men younger than 45 could help prevent tragic deaths such as Chadwick's, he commented. "The Task Force is calling for more research on colorectal cancer screening in Black adults," he added.

Limit Screening to Those at Higher Risk

In contrast to the USPSTF and ACS guidelines, which recommend screening for CRC for everyone over a certain age, a set of recommendations developed by an international panel of experts suggests screening only for individuals who are at higher risk for CRC.

As previously reported by Medscape Medical News, these guidelines suggest restricting screening to adults whose cumulative cancer risk is 3% or more in the next 15 years, the point at which the balance between benefits and harms favors screening.

The authors, led by Lise Helsingen, MD, Clinical Effectiveness Research Group, University of Oslo, in Norway, say "the optimal choice for each person requires shared decision-making."

Such a risk-based approach is "increasingly regarded as the most appropriate way to discuss cancer screening." That approach is already used in prostate and lung cancer screening, they note.

Agency for Healthcare Research and Quality. Evidence Synthesis No. 202.

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