USPSTF Recommends Lowering CRC Screening Age to 45

For the first time, the US Preventive Services Task Force (USPSTF) has posted a draft recommendation statement on screening for colorectal cancer (CRC) which recommends that screening begin at age 45.¹

Importantly, this is a B recommendation, meaning there is a high certainty of at least a moderate benefit for the service. The task force also still strongly recommends screening individuals who are aged 50 to 75 years as an A recommendation. Overall, it is recommended that people ages 45 to 75 be screened to reduce their risk of dying from CRC.

“New science about colorectal cancer in younger people has enabled us to expand our recommendation to screen all adults starting at age 45, especially Black adults who are more likely to die from this disease,” task force member Michael Barry, MD, director of the Informed medical Decisions Program in the health Decision Sciences Center at Massachusetts General Hospital, professor of medicine at Harvard Medical School, and clinician at Massachusetts General Hospital, said in a press release. “Screening earlier will help prevent more people from dying from colorectal cancer.”

For adults ages 76 to 85, the USPSTF continues to recommend that the decision to screen be made on an individual basis. This is a C recommendation, meaning that the recommendation depends on the patient’s situation.

Notably, the collective draft recommendations all apply to adults without symptoms and who do not have a personal history of colorectal polyps, or a personal or family health history of genetic disorders that increase the risk of CRC.

In this recent draft recommendation, the task force also recommended 2 types of tests to screen for CRC, including direct visualization tests and stool-based tests. Because of limited available evidence, the USPSTF recommendation did not include serum tests, urine tests, or capsule endoscopy for CRC screening.

Stool-based tests include the high-sensitivity guaiac-based fecal occult blood test (HSgFOBT), fecal immunochemical test (FIT), and stool DNA test. Both HSgFOBT and FIT detect blood in the stool, however they each use different methods to do so. HSgFOBT is based on chemical detection of blood, while FIT uses antibodies to detect blood. Stool DNA tests detect DNA biomarkers for cancer in cells shed from the lining of the colon and rectum into stool.

Currently, the only stool DNA test approved by the FDA is a multitarget stool DNA test that also includes a FIT component, referred to as sDNA-FIT in the task force recommendation. Among the stool-based tests, screening with annual FIT or annual sDNA-FIT is suggested to provide greater life-years gained than annual HSgFOBT or sDNA-FIT every 3 years.

Further, direct visualization tests to screen for CRC include colonoscopy, CT colonography, and flexible sigmoidoscopy. All 3 screening tests visualize the inside of the colon and rectum, though flexible sigmoidoscopy can only visualize the rectum, sigmoid colon, and descending colon while colonoscopy and CT colonography can typically visualize the entire colon. For colonoscopy and flexible sigmoidoscopy, a camera is used to visualize the inside of the colon, while CT colonography uses x-ray images.

However, among the direct visualization tests, a colonoscopy every 10 years or CT colonography every 5 years have greater life-years gained than flexible sigmoidoscopy every 5 years, according to USPSTF. Additionally, unlike colonoscopy and flexible sigmoidoscopy, CT colonography may also reveal extracolonic findings that require additional work-up, which could lead to other potential benefits or harms.

“There are many tests available that can effectively screen for colorectal cancer,” task force member Martha Kubik, PhD, RN, professor and director of the School of Nursing in the College of Health and Human Services at George Mason University, said in the release. “We urge primary care clinicians to discuss the pros and cons of the various recommended options with their patients to help decide which test is best for each person.”

Of note, because the above recommendations are still a draft, insurance will not cover the change in guidelines for patients with CRC until the recommendation is officially determined.² However, this draft recommendation should be finalized next year.

References:

1. U.S. Preventive Services Task Force Issues Draft Recommendation on Screening for Colorectal Cancer [news release]. Washington, D.C. Published October 27, 2020. Accessed October 28, 2020. https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/colorectal-cancer-screening-draft-rs-bulletin.pdf

2. Colorectal Cancer Organizations Applaud USPSTF’s Draft Recommendations for Screenings to Begin at Age 45 [news release]. Minneapolis. Published October 27, 2020. Accessed October 28, 2020.