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Recommendations published in JAMA are set to change colorectal cancer screening guidance for all individuals in the United States.
An update to the U.S. Preventive Services Task Force (USPSTF) recommendations now indicate that screening for colorectal cancer (CRC) should begin at age 45 years for all patients regardless of baseline characteristics, according to guidelines published in JAMA.1
This is a follow-up to draft guidance that was issued in October 2020 amending the recommended age of screening from 50 to 45 years of age and will mandate insurance coverage of screening for CRC.
These efforts by the task force are in large part a reaction to the alarming rise in the incidence of young-onset CRC, which occurs in patients younger than 50 years of age. By 2040, this is projected to be the leading cause of cancer deaths in patients ages 20 to 49 years.
This increasing incidence has been documented since the 1990s, but the proportion of patients with young-onset disease has accelerated rapidly over the last 10 years, with 11% of colon cancers and 15% of rectal cancers occurring in patients under the age of 50 years in 2020 compared with just 5% and 9%, respectively, in 2010.
“Clearly the USPSTF recommendation to start screening at age 45 will not be enough to catch those young people who are being diagnosed, but we must take bold steps to translate the lowered age of beginning screening into meaningful decreases in CRC incidence and mortality,” Kimmie Ng, MD, MPH, director of the Young-Onset Colorectal Cancer Center at Dana-Farber Cancer Institute and author of an accompanying editorial, said in a press release.2,3 “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.”
Age 45 was selected by the task force based on evidence that averting more early deaths was possible versus starting at age 50 with a relatively small increase in the number of complications from colonoscopy. Of note, the new recommendation does not change guidance regarding screening in older individuals, with patients aged 76 to 85 years recommended for selective screening only.
In the editorial, Ng and colleagues point out that screenings at age 45 will not be enough to catch all cases of early-onset CRC, as the rate of colon cancer shows the steepest increase in patients aged 20 to 29 years at 2% versus 1.3% in those 40 to 49 years. Corresponding rates in rectal cancer were 3.2% and 2.3%, respectively.
“We are now seeing patients even younger than 45—in their 20s and 30s—who are being diagnosed with this cancer and often at very late stages,” Ng said. “Clearly the USPSTF recommendation to start screening at age 45 will not be enough to catch those young people who are being diagnosed.”
With the prior recommendations, less than 70% of patients who were eligible for screening received the preventative benefit, with patients who are uninsured or underinsured, those with lower incomes, and racial and ethnic minorities being disproportionately underserved. CRC is a disease that disproportionately affects African Americans, as they have a 20% greater likelihood of developing the tumor and a 40% greater risk of dying from it. As such, Ng and colleagues said addressing these public health barriers will be necessary to raise screening adherence.
1. US Preventive Services Task Force. Screening for Colorectal CancerUS Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965-1977. doi:10.1001/jama.2021.6238
2. Ng K, May FP, Schrag D. US Preventive Services Task Force Recommendations for Colorectal Cancer ScreeningForty-Five Is the New Fifty. JAMA. 2021;325(19):1943-1945. doi:10.1001/jama.2021.4133
'45 is the new 50' as age for colorectal cancer screening is lowered. News release. Dana-Farber Cancer Institute. May 18, 2021. Accessed May 18, 2021. https://bit.ly/3bBK1DT