'Alarming' CRC Screening Preferences Among Younger Patients Should Be Wake-up Call for Us

David A. Johnson, MD


September 21, 2022

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

The ultimate goal of screening for colon cancer is to prevent it. Over the past several decades, we've certainly seen an increasing emphasis on colon cancer screening. That's led to related benefits when it comes to colonoscopy and risk reduction, primarily driven through adenoma detection and the decreased risk for interval colon cancer. Yet during that same period, we've also seen an incremental rise in cancers among younger patients.

This rise in early-onset cancer in those younger than 50 years of age was recently highlighted in a paper published in Nature Reviews Clinical Oncology. The authors noted that the increase is being seen not only in colon cancer but also in breast, renal, pancreatic, and esophageal cancers, a trend which they describe as a global epidemic.

Why is this happening? Well, there are lots of reasons beyond the scope of today's discussion, including diet, obesity, sleep, and a variety of other epidemiologic exposures. Regardless of the cause, though, we must recognize that cancers are increasingly evident in a younger population whom we didn't previously screen.

This observation led the American Cancer Society in 2018, followed by the [US Preventive Services Task Force] and the American College of Gastroenterology in 2021, to change their recommendations regarding colon cancer prevention screening from an average-risk age of 50 to 45 years. This certainly opened up a large new avenue for screening of another 19 million or so patients in the 45- to 49-year age range.

What Screening Methods Do Patients Prefer?

We can strive to apply the best recommendations, but ultimately a large factor in our screening practices will come down to what our patients prefer.

We now have an answer to this in the form of a somewhat alarming new study just published from a group of researchers at the University of California, Los Angeles. They conducted an online survey of 1000 patients who were stratified into cohorts of those aged 40-49 years and ≥ 50 years. These patients were asked about their preferences among the five US Multi-Society Task Force (US-MSTF) recommended colorectal cancer screening tests, including fecal immunochemical test (FIT) every year, FIT-fecal DNA every 3 years, colon video capsule every 5 years (not available for screening in the United States), CT colonography every 5 years, or colonoscopy every 10 years.

They found that the preference was consistent for multitargeted FIT-fecal DNA testing in both the 40-49 years and ≥ 50 years cohorts (34.6% and 37.3%, respectively).

Comparatively, colonoscopy every 10 years, which we would accept as the gold standard for prevention, had a preference rate of 13.7% and 13.6% in these cohorts, respectively.

In another sign that patients are perhaps starting to acquiesce to convenience over efficacy, in a comparison of the US-MSTF's tier 1 tests — colonoscopy every 10 years or the stay-home FIT test every year — participants uniformly preferred the latter. Annual FIT testing was preferred by 68.9% in the 40-49 years cohort and 77.4% in those aged ≥ 50 years, compared with only 31.1% and 22.6%, respectively, for colonoscopy.

Something Is Amiss With Younger Screening

I think these results mean that we're losing some ground when it comes to our messaging. We can't base everything on one study, but it certainly is a wake-up call to clinical practices, national societies, and medical organizations.

We need to be reaching out to millennials and certainly to the patients who are not yet screened. We need to make sure that they understand that colonoscopy is the only test that we have that's preventive. Even the multitargeted stool DNA test misses 60% of advanced lesions, and FIT misses 95% of advanced lesions as it relates to sessile serrated polyps. When you talk about a 5% detection rate, that's within the element of chance.

We need to start looking at what we've done in the past and reassess our messaging going forward. I'm not sure that the conventional wisdom that patients will come to us for a colonoscopy because it's the best test will sustain our screening strategies going forward.

The best screening strategy, obviously, is the one that gets the test done. But the one that results in the best screening is the one that prevents colon cancer. We need to start looking at this very strongly and revise our marketing messages, our social media, and our educational campaigns around some of these new perspectives.

Some of these findings may be tainted a little bit by the effects of COVID-19 and roughly 2 years of staying at home and away from elective procedures. But regardless, it's a wake-up call and we need to take perspective and put some plans into action. Otherwise, we're going to lose further ground. I'm concerned about this information, and hopefully you understand that you should be too.

I'm Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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