Commentary

Guest Commentary: Physicians must rise to the need for younger CRC screening

Paul Limburg
Paul J. Limburg

In this guest commentary, Paul J. Limburg, MD, discusses the need for increased awareness of colorectal cancer incidence among the younger population and the newer methods available for screening within this newly at-risk group.

When I started my career, the traditional school of thought was that colorectal cancer (CRC) only affects “older” people. Unfortunately, recent national trends in CRC incidence demonstrate a different picture.

While remaining the second leading cancer killer in the United States, CRC is also on the rise in younger people, many of whom are being diagnosed at an advanced stage of the disease. While the reasons for the observed increase in early-onset CRC incidence are not fully known, the medical and scientific communities agree the result must be addressed.

Based on compelling data demonstrating a 51% relative increase in CRC incidence among those younger than 50 years, the American Cancer Society (ACS) recently issued a qualified recommendation to lower the age to begin average-risk CRC screening from 50 to 45 years.

‘Life-changing impact’

As a practicing gastroenterologist of more than 20 years, I’ve too frequently witnessed the life-changing impact that CRC can have on patients and families when forced to face the reality of an unexpected diagnosis and an uncertain future.

Patients with early-onset CRC and those diagnosed before age 50 represent a particularly challenging population for many reasons. These patients have often experienced symptoms for some time that have either been downplayed or attributed to a less serious condition without a timely, comprehensive diagnostic evaluation.

Consequently, these younger patients can present with late-stage cancers, which are associated with a poorer prognosis. In fact, over half of the more than 130,000 patients under age 50 diagnosed with CRC from 2004 to 2015 were diagnosed with more advanced stages of cancer.

In talking to young patients with CRC and their family members, breaking the news that the available treatment options may not be curative is especially difficult when the diagnosis was already such a shock. Because of my personal experiences, along with my interpretation of the scientific literature, I strongly support the ACS initiative to lower the age for baseline CRC screening to 45 years.

An ‘important opportunity’

I view the updated ACS guidelines and the chance to screen for CRC in average-risk individuals starting at age 45 as an important opportunity to detect more early-stage CRC and prevent more CRC deaths, especially in those who might otherwise put off screening. The updated ACS recommendations endorse structural examinations including colonoscopy, CT colonography, and flexible sigmoidoscopy, as well as highly sensitive stool-based tests (FIT; guaiac-based FOBT and the multitarget stool DNA test, mt-sDNA). Having several available screening options provides patients with an opportunity to choose whichever test is right for them and has also been shown to increase adherence to screening guidelines.

Breaking down barriers that keep people from participating in CRC screening is vital to diminishing the negative impact of this preventable disease. Finding a screening test that patients will complete can be challenging, but there are more options now than ever before. When it comes to at-home screening options, CRC screening tests must be easy to use and provide accurate information to the provider and the patient.

Take up the ‘worthy challenge’

Importantly, with the expanded target population for CRC screening, it’s imperative that we do not divert resources from screening the estimated 30 million people aged 50 and older who remain unscreened for CRC.

According to the Cancer Intervention and Surveillance Modeling Network’s simulation modeling data used to support the ACS guidelines, lowering the screening age from 50 to 45 years would require more than 800 additional colonoscopies per 1,000 persons screened using a colonoscopy-based screening strategy. Rather than approaching large-scale screening initiatives with a one-size-fits-all approach, we have a critical opportunity to continue offering patients a selection of CRC screening options – and I believe noninvasive testing has an important role to play.

The United States Preventive Services Task Force (USPSTF) 2016 CRC screening guidelines uphold the importance of choice, stating that, “The best screening test is the one that gets done.” As such, noninvasive screening options may be more convenient for many patients, helping to boost adherence rates.

By screening individuals in the 45 to 49 age group for colorectal cancer, we can detect more cases of early-stage CRC and potentially prevent more avoidable deaths. Working together with health care providers, patient advocacy groups, third-party payers and other key stakeholders to efficiently and effectively activate the ACS guidelines is a worthy challenge that may help reduce the emotional toll, societal loss and economic burden of this preventable disease.

References:

Annual Estimates of the Resident Population by Single Year of Age and Sex for the United States: April 1, 20110 to July 1, 2017. United States Census Bureau website: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=PEP_2017_PEPSYASEXN&prodtype=table. Accessed October 15, 2019.

Bibbins-Domingo K, et al. JAMA. 2016;315(23):2564-2575.

Centers for Disease Control and Prevention. Quick Facts: Colorectal Cancer Screening in US—Behavioral Risk Factor Surveillance System, 2016. Website: https://www.cdc.gov/cancer/colorectal/pdf/QuickFacts-BRFSS-2016-CRC-Screening-508.pdf Accessed October 15, 2019.

Peterse EFP, et al. Cancer 2018;124(10):2964-2973.

Siegel RL, et al. CA Cancer J Clin. 2019;69:7-34.

Virostko J, et al. Cancer. 2019;0:1-8.

Wolf AMD, et al. CA Cancer J Clin 2018;68:250-281.

Inadomi JM, et al. Arch Intern Med. 2012;172(7):575–582. doi:10.1001/archinternmed.2012.332.

For more information: Limburg is a professor of medicine in the College of Medicine, Mayo Clinic and also serves as co-leader of the Mayo Clinic Cancer Center’s Cancer Prevention and Control Program and principal investigator of the NCI-funded Cancer Prevention Network. He can be reached at limburg.paul@mayo.edu.

Disclosures: Limburg serves as Chief Medical Officer for Exact Sciences through a contracted services agreement with Mayo Clinic. Limburg and Mayo Clinic have contractual rights to receive royalties through this agreement.

Paul Limburg
Paul J. Limburg

In this guest commentary, Paul J. Limburg, MD, discusses the need for increased awareness of colorectal cancer incidence among the younger population and the newer methods available for screening within this newly at-risk group.

When I started my career, the traditional school of thought was that colorectal cancer (CRC) only affects “older” people. Unfortunately, recent national trends in CRC incidence demonstrate a different picture.

While remaining the second leading cancer killer in the United States, CRC is also on the rise in younger people, many of whom are being diagnosed at an advanced stage of the disease. While the reasons for the observed increase in early-onset CRC incidence are not fully known, the medical and scientific communities agree the result must be addressed.

Based on compelling data demonstrating a 51% relative increase in CRC incidence among those younger than 50 years, the American Cancer Society (ACS) recently issued a qualified recommendation to lower the age to begin average-risk CRC screening from 50 to 45 years.

‘Life-changing impact’

As a practicing gastroenterologist of more than 20 years, I’ve too frequently witnessed the life-changing impact that CRC can have on patients and families when forced to face the reality of an unexpected diagnosis and an uncertain future.

Patients with early-onset CRC and those diagnosed before age 50 represent a particularly challenging population for many reasons. These patients have often experienced symptoms for some time that have either been downplayed or attributed to a less serious condition without a timely, comprehensive diagnostic evaluation.

Consequently, these younger patients can present with late-stage cancers, which are associated with a poorer prognosis. In fact, over half of the more than 130,000 patients under age 50 diagnosed with CRC from 2004 to 2015 were diagnosed with more advanced stages of cancer.

In talking to young patients with CRC and their family members, breaking the news that the available treatment options may not be curative is especially difficult when the diagnosis was already such a shock. Because of my personal experiences, along with my interpretation of the scientific literature, I strongly support the ACS initiative to lower the age for baseline CRC screening to 45 years.

An ‘important opportunity’

I view the updated ACS guidelines and the chance to screen for CRC in average-risk individuals starting at age 45 as an important opportunity to detect more early-stage CRC and prevent more CRC deaths, especially in those who might otherwise put off screening. The updated ACS recommendations endorse structural examinations including colonoscopy, CT colonography, and flexible sigmoidoscopy, as well as highly sensitive stool-based tests (FIT; guaiac-based FOBT and the multitarget stool DNA test, mt-sDNA). Having several available screening options provides patients with an opportunity to choose whichever test is right for them and has also been shown to increase adherence to screening guidelines.

Breaking down barriers that keep people from participating in CRC screening is vital to diminishing the negative impact of this preventable disease. Finding a screening test that patients will complete can be challenging, but there are more options now than ever before. When it comes to at-home screening options, CRC screening tests must be easy to use and provide accurate information to the provider and the patient.

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Take up the ‘worthy challenge’

Importantly, with the expanded target population for CRC screening, it’s imperative that we do not divert resources from screening the estimated 30 million people aged 50 and older who remain unscreened for CRC.

According to the Cancer Intervention and Surveillance Modeling Network’s simulation modeling data used to support the ACS guidelines, lowering the screening age from 50 to 45 years would require more than 800 additional colonoscopies per 1,000 persons screened using a colonoscopy-based screening strategy. Rather than approaching large-scale screening initiatives with a one-size-fits-all approach, we have a critical opportunity to continue offering patients a selection of CRC screening options – and I believe noninvasive testing has an important role to play.

The United States Preventive Services Task Force (USPSTF) 2016 CRC screening guidelines uphold the importance of choice, stating that, “The best screening test is the one that gets done.” As such, noninvasive screening options may be more convenient for many patients, helping to boost adherence rates.

By screening individuals in the 45 to 49 age group for colorectal cancer, we can detect more cases of early-stage CRC and potentially prevent more avoidable deaths. Working together with health care providers, patient advocacy groups, third-party payers and other key stakeholders to efficiently and effectively activate the ACS guidelines is a worthy challenge that may help reduce the emotional toll, societal loss and economic burden of this preventable disease.

References:

Annual Estimates of the Resident Population by Single Year of Age and Sex for the United States: April 1, 20110 to July 1, 2017. United States Census Bureau website: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=PEP_2017_PEPSYASEXN&prodtype=table. Accessed October 15, 2019.

Bibbins-Domingo K, et al. JAMA. 2016;315(23):2564-2575.

Centers for Disease Control and Prevention. Quick Facts: Colorectal Cancer Screening in US—Behavioral Risk Factor Surveillance System, 2016. Website: https://www.cdc.gov/cancer/colorectal/pdf/QuickFacts-BRFSS-2016-CRC-Screening-508.pdf Accessed October 15, 2019.

Peterse EFP, et al. Cancer 2018;124(10):2964-2973.

Siegel RL, et al. CA Cancer J Clin. 2019;69:7-34.

Virostko J, et al. Cancer. 2019;0:1-8.

Wolf AMD, et al. CA Cancer J Clin 2018;68:250-281.

Inadomi JM, et al. Arch Intern Med. 2012;172(7):575–582. doi:10.1001/archinternmed.2012.332.

For more information: Limburg is a professor of medicine in the College of Medicine, Mayo Clinic and also serves as co-leader of the Mayo Clinic Cancer Center’s Cancer Prevention and Control Program and principal investigator of the NCI-funded Cancer Prevention Network. He can be reached at limburg.paul@mayo.edu.

Disclosures: Limburg serves as Chief Medical Officer for Exact Sciences through a contracted services agreement with Mayo Clinic. Limburg and Mayo Clinic have contractual rights to receive royalties through this agreement.