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Updated guidelines lower colorectal cancer screening age to 45 years

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May 30, 2018

Updated guidelines from the American Cancer Society recommend that all adults at average risk for colorectal cancer begin screening for the disease at the age of 45 years.

“We knew from work that the American Cancer Society researchers had been observing that the risk for colorectal cancer has been increasing in people born more recently,” Richard C. Wender, MD, chief cancer control officer of the American Cancer Society, told HemOnc Today. “It truly is what we call a birth-cohort effect. People born in 1990 are at over four times the risk for developing rectal cancer, and double the risk for colon cancer, compared with people born in 1950. But, most trials were conducted in people beginning at age 50 years, so we did not have the empirical trial evidence for establishing 45 years as the optimal age to start.”

Wender and colleagues conducted a systematic review of literature on colorectal cancer screening, as well as analyses of microsimulation modeling that included new data showing a rising trend of colorectal cancer incidence among younger patients.

The researchers recommended that average-risk adults begin screening for colorectal cancer at age 45 years, either by colonoscopy or stool-based test. This was a qualified recommendation, meaning that although the guideline development group had identified a clear benefit from screening at a younger age, there was “less certainty about the balance of benefits and harms, or about patients’ values and preferences which could to different decisions about screening,” Wender and colleagues wrote.

Researchers maintained a strong recommendation for regular screening for adults aged 50 years and older.

The group also made qualified recommendations that all patients aged 75 years or younger with a life expectancy of at least 10 years should undergo regular screening; that patients aged 76 through 85 years should base their screening choices on personal preference, health status, life expectancy and screening history; and that patients aged older than 85 years should discontinue screening.

The American Cancer Society recommended a variety of possible screening methods. These methods were all given equal weight, Wender noted, and could be used depending on patient preferences or a patient’s access to a specific method.

The recommended methods were:

  • fecal immunochemical testing every year;
  • high-sensitivity, guaiac-based fecal occult blood testing every year;
  • multitarget stool DNA testing every 3 years;
  • colonoscopy every 10 years;
  • CT colonography every 5 years; or
  • flexible sigmoidoscopy every 5 years.

“Too many people equate colorectal cancer screening with colonoscopy. Many people do not want to have a colonoscopy or have trouble accessing colonoscopy,” Wender told HemOnc Today. “We have other screening tests that are equally good as long as you do them as recommended. We support a person’s choice of any of them with confidence that they’re not inferior choices.”

The guideline specifically recommended that clinicians offer their patients their choice of testing, Wender said.

“There are numerous trials showing that offering choice to people will increase the percentage of people who get screened,” Wender said. “There’s a mantra in the colorectal cancer screening world: The best test is the one that gets done. But there’s a corollary: The tragedy is doing no test at all and missing the opportunity to completely prevent colorectal cancer.” – by Andy Polhamus

Disclosures: The American Cancer Society receives some of its funding from the CDC to support the National Colorectal Cancer Roundtable, of which Wender is the chair, and Otis Brawley, MD, also a guideline development group member, is co-chair. Please see the guidelines for a list of all other authors’ relevant financial disclosures.

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