Revised American Cancer Society guidelines call for colorectal screenings at earlier ages

In May 2018, the American Cancer Society (ACS) updated its guidelines for colorectal screening, lowering the recommended age at which adults at average risk should start having screenings from 50 to 45. This change is a result of recent data showing that while screening has helped reduce the rates of colorectal cancer in older adults, incidence rates are increasing in young and middle-aged adults.

While the new guidelines are certainly noteworthy, as with any revised recommendations it will be some time before any significant change is seen in the readiness of health insurance providers to cover screenings for average-risk individuals before age 50, said Reid Ness, MD, MPH, associate professor of Medicine.

“To date, the American Cancer Society is the only organization which has changed its recommendation in this area,” said Ness. “The ACS made their new recommendations in keeping with their mission statement to support strategies that will decrease the cancer burden on society. It will take changes in government opinion and policy before these changes represent strategies that are covered by Medicare and by third-party payers.”

Recommendations in the new ACS guidelines include:

• Beginning at age 45, individuals with an average risk of colorectal cancer should have a regular screening with one of six different tests depending on patient preference and availability. These include a FIT (fecal immunochemical test) or FOBT (fecal occult blood test) every year, a stool DNA test every three years, a CT colonography or flexible sigmoidoscopy every five years, or colonoscopy every 10 years. The recommendations do not prioritize any test over another.
• Following a positive result from a non-colonoscopy screening test, a follow-up colonoscopy should be performed.
• Average-risk adults in good health should continue colorectal cancer screening through age 75.
• For those between 76 and 85, screening decisions should be made jointly with clinicians based on patient preference, life expectancy, health status and prior screening history.
• Individuals over age 85 should be discouraged from continuing screening,

Ness and Robert Dittus, MD, MPH, executive vice president for Public Health and Health Care at VUMC, were co-authors of a computer model published in the early 2000s that examined the economics and health benefit of colorectal cancer screenings. Their model was used, along with others, in the formulation of previous recommendations from the U.S. Preventive Services Task Force, the ACS and other public health agencies that colorectal screening should begin at age 50.

In light of reports that colorectal cancer is appearing earlier than age 50, the ACS worked with key modeling groups to reanalyze the expected effectiveness of colorectal cancer screening at age 45 compared to age 50. They found a small benefit in cancers averted and lives saved that they concluded justified the investment of additional screening resources.

As they have in previous versions of their guidelines, the ACS continues to recommend an array of possible screening modalities. This allows patients and clinicians to work together to choose the best screening option, ranging from the most invasive and costly screening, a colonoscopy, to the least invasive and often least expensive FIT, which detects the presence of blood in the stool.

“If your goal is to screen at younger ages, locking yourself into colonoscopies as the primary screening methodology is much more expensive for very little gain in terms of new diagnoses,” Ness said. “Moving toward using other screening tools, such as FIT, which is used as the primary screening modality in much of Europe, or even sigmoidoscopic screening, which is used in England, may provide almost the same benefit at a much lower cost.”