Colon Cancer Screening Should Start at Age 45, According to New Guidelines

• Earlier colorectal screening could save lives by cancer when it is easier to treat, according to new guidelines.
• This move reflects a rise since the 1980s in colon and rectal cancers in Americans, with a sharper increase in younger age groups.
• Colorectal cancer is the third leading cause of cancer-related deaths in women and in men in the United States, with 53,200 Americans expected to die this year from this type of cancer.

Adults should be routinely screened for colorectal cancer starting at age 45, instead of the current 50, a U.S. public health task force recommended on Tuesday.

This move reflects a rise since the 1980s in colon and rectal cancers in Americans, with a sharper increase in younger age groups.

The new guidelines could make millions of Americans eligible for earlier screening — along with mandatory coverage of the cost by most health insurance plans.

However, more work would need to be done to ensure that people actually get screened and that the change doesn’t worsen screening rates among minorities.

Millions more Americans could be screened

Colorectal cancer is the third leading cause of cancer-related deaths in women and in men in the United States, with 53,200 Americans expected to die this year from colon or rectal cancer.

Over the past 2 decades, rates of colorectal cancer diagnosis has been decreasing among people 65 years and older, according to the American Cancer Society (ACS).

But the rates of new diagnoses have been going up in younger age groups. Twelve percent of colorectal cancer cases diagnosed this year are expected to be in people under age 50.

“Given the alarming increase in colorectal cancer rates in people under the age of 50 in recent years, along with other supporting data, starting screening at an earlier age will likely save lives,” said Dr. Divya Mallam, a gastroenterologist with Torrance Memorial Medical Center.

The U.S. Preventive Services Task Force’s proposed recommendations still need to be finalized and are open for public comment until Nov. 23.

During the last review of its guidelines, about 5 years ago, the task force stuck with age 50 for the start of routine screening, something that Dr. Folasade P. May, a gastroenterologist and researcher at UCLA, found surprising at the time.

“All of the modeling data they use definitively showed that when we start screening at 45 we save more lives,” she said.

The task force’s last review also contrasted with the ACS, which updated its guidelines in 2018 to say routine screenings should start at age 45.

While some physicians were following the ACS guidelines, an update to the task force’s recommendations would ensure that most health insurance plans would cover the cost of the screening.

The task force assigns letter grades to its recommendations, with private insurance plans required to cover the full costs of services that receive either an “A” or “B” grade, with no copay for patients.

Colorectal screening for people ages 45 to 49 years received a “B,” meaning there is moderate or high certainty of benefit to patients. Screening for people ages 50 to 75 years received an “A” grade.

For people over age 75, the task force recommends that patients talk to their physician about the risks and benefits of screening.

May estimates that if the new recommendations are finalized, an additional 21 million Americans would be eligible for colorectal cancer screening.

Screening people at a younger age would also help groups that have been disproportionately affected by colorectal cancer.

“We do think that this will help Black people, especially young Blacks who are getting colon cancer early,” said May.

Black Americans have the highest rate of colorectal cancer, according to the Centers for Disease Control and Prevention (CDC) — 40.4 percent compared to 36.3 percent for white people. Black people are also more likely to die from colorectal cancer.

“Even when you look at the early onset group — the younger people with this condition — Blacks are most affected,” said May.

Plan needed to ensure that people get screened

While updating the screening guidelines can catch more cases of colorectal cancer earlier — when it is easier to treat — May says the change would still present challenges.

“We were already bad at [colorectal cancer] screening in the United States,” she said. “So as a public health person who’s also a physician, I’m concerned about how we’re going to screen millions more.”

In 2018, 68.8 percent of Americans aged 50 to 75 years were up to date with colorectal cancer screening, according to the CDC.

May thinks shifting the focus to younger adults might have the unintended consequence of diverting healthcare resources from those 50 and over. This could impact some groups more than others.

“In doing that, we actually might worsen some of the health disparities that we see in older African Americans, Latinos, Asians, and Native Americans, who already have lower screening rates,” said May.

While people with private health insurance would be able to get screened for free, millions of Americans were still uninsured or underinsured even under the Affordable Care Act (ACA).

These people, who would have to pay out of pocket for colorectal screening, have much lower screening rates.

The fate of the ACA also hangs in the balance, with Republicans continuing to push for its elimination and the U.S. Supreme Court hearing arguments on its legality starting Nov. 10.

May says what’s needed going forward is a real public health strategy for how to ensure that everyone eligible for colorectal screening actually gets screened.

“We could make recommendations all day,” she said, “but if we don’t have a clear plan for how we’re going to provide this service to people, I don’t know how much those recommendations help.”

Advances in technology in recent years may also help — by increasing the healthcare system’s screening capacity and relieving people’s anxiety about screening.

”Some people shy away from colon cancer screening until it’s too late and they have developed a cancer,” said Mallam, “because they are worried about undergoing colonoscopy, and they don’t know there are other screening options available to them.”

These options include stool tests and a virtual colonoscopy using a CT scan. While these procedures are less invasive, they need to be done more frequently than a colonoscopy, which should be done every 10 years.

People should also be alert to signs of colorectal cancer, such as blood in the stool, rectal pain, or changes in bowel habits or stool consistency.

“If you have any of these symptoms — even prior to age 45 — you should undergo a colonoscopy now and not wait,” said Mallam, “as these symptoms may be signs of colon cancer.”

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