USPSTF Final Recommendation on CRC Screening: 45 Is the New 50

Pam Harrison

May 18, 2021

Screening for colorectal cancer (CRC) should now begin at the age of 45 and not 50 for average-risk individuals in the United States, notes the final recommendation from the United States Preventive Services Task Force (USPSTF).

The recommendation finalizes draft guidelines issued in October 2020 and mandates insurance coverage to ensure equal access to CRC screening regardless of a patient's insurance status.

The USPSTF's final recommendations also now align with those of the American Cancer Society, which lowered the age for initiation of CRC screening to 45 years in 2018.

"New statistics project an alarming rise in the incidence of young-onset colorectal cancer, projected to be the leading cause of cancer death in patients aged 20 to 49 by 2040," commented Kimmie Ng, MD, MPH, director, Young-Onset Colorectal Cancer Center, Dana-Farber Cancer Institute, Boston, Massachusetts, and lead author of a JAMA editorial about the new guideline.

"We must take bold steps to translate the lowered age of beginning screening into meaningful decreases in CRC incidence and mortality," she emphasized.

The USPSTF recommendations and substantial evidence supporting them were published online May 18 in JAMA.

Risk Factors for CRC

As USPSTF authors note, age is one of the most important risk factors for CRC, with nearly 94% of all new cases of CRC occurring in adults 45 years of age and older. Justification for the lower age of CRC screening initiation was based on simulation models showing that initiation of screening at the age of 45 was associated with an estimated additional 22 to 27 life-years gained compared with starting at the age of 50.

The USPSTF continues to recommend screening for CRC in all adults between 50 and 75 years of age, lowering the age for screening to 45 years in recognition of the fact that, in 2020, 11% of colon cancers and 15% of rectal cancers occurred in patients under the age of 50.

The USPSTF also continues to conclude that there is a "small net benefit" of screening for CRC in adults between 76 and 85 years of age who have been previously screened.

However, the decision to screen patients in this age group should be based on individual risk factors for CRC, a patient's overall health status, and personal preference. Perhaps self-evidently, adults in this age group who have never been screened for CRC are more likely to benefit from CRC screening than those who have been previously screened.

Similar to the previous guidelines released in 2016, the updated USPSTF recommendations continue to offer a menu of screening strategies, although the frequency of screening for each of the screening strategies varies. Recommended screening strategies include:

  • High-sensitivity guaiac fecal occult blood test or fecal immunochemical test (FIT) every year

  • Stool DNA-FIT every 1 to 3 years

  • CT colonography every 5 years

  • Flexible sigmoidoscopy every 5 years

  • Flexible sigmoidoscopy every 10 years plus annual FIT

  • Colonoscopy screening every 10 years

"Based on the evidence, there are many tests available that can effectively screen for colorectal cancer and the right test is the one that gets done," USPSTF member Martha Kubik, PhD, RN, said in a statement.

"To encourage screening and help patients select the best test for them, we urge primary care clinicians to talk about the pros and cons of the various recommended options with their patients," she added.

An accompanying review of the effectiveness, accuracy, and potential harms of CRC screening methods underscores how different screening tests have different levels of evidence demonstrating their ability to detect cancer, precursor lesions, or both, as well as their ability to reduce mortality from cancer. 

Eligible Patients

Currently, fewer than 70% of eligible patients in the United States undergo CRC screening, Ng points out in the editorial. In addition, CRC disproportionately affects African American patients, who are about 20% more likely to get CRC and about 40% more likely to die from it compared with other patient groups. Modeling studies published along with the USPSTF recommendations showed equal benefit for screening regardless of race and gender, underscoring the importance of screening adherence, especially in patient populations disproportionately affected by CRC.

"Far too many people in the US are not receiving this lifesaving preventive service," USPSTF Vice-Chair Michael Barry, MD, 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," he added.

Ng echoes this sentiment in her editorial: "The USPSTF recommendation for beginning colorectal cancer screening for average-risk adults at age 45 years has moved the field one step forward and indicates that '45 is the new 50,' " she observed.

"Lowering the recommended age to initiate screening will make colorectal cancer screening available to millions more people in the United States and, hopefully, many more lives will be saved by catching colorectal cancer earlier as well as by preventing colorectal cancer," Ng affirmed.

All members of the USPSTF received travel reimbursement and an honorarium for participating in USPSTF meetings.

Ng has reported receiving nonfinancial support from Pharmavite as well as grants from the Evergrande Group, Janssen, Revolution Medicines, Genentech, and Gilead Sciences. She has also reported receiving personal fees from Seattle Genetics, Array Biopharma, BiomX, and X-Biotix Therapeutics.

JAMA. 2021;325:1943-1945, 1965-1977, 1978-1997, 1998-2011. Statement, Review, Study, Editorial

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