Colorectal cancer task force ranks screening tests, suggests earlier screening in blacks
The U.S. Multi-Society Task Force on Colorectal Cancer Screening has released new recommendations that rank screening options for average-risk individuals, acknowledge the increasing incidence of CRC in younger Americans, and suggest that black Americans should begin screening earlier at age 45.
“We believe these recommendations make the presentation of screening options in the office easier for providers and patients, maximizing both effectiveness and adherence,” Douglas K. Rex, MD, FASGE, AGAF, MACG, of Indiana University School of Medicine, said in a press release. “The document also addresses important issues for organized screening programs that are sometimes used in large health plans. These recommendations are informed both by available scientific evidence, as well as practical considerations and cost data.”
Douglas K. Rex
Screening tests, ranked
After evaluating the effectiveness of seven types of screening tests for cancer and precancerous polyp detection, as well as their costs and practicality, Rex and colleagues ranked them into three tiers for screening average-risk individuals beginning at age 50.
Tier one options are considered the “cornerstones of screening” and include colonoscopy every 10 years or fecal immunochemical testing (FIT) every year. Tier two options for patients who refuse colonoscopy or FIT include CT colonography every 5 years, FIT-fecal DNA every 3 years or flexible sigmoidoscopy every 5 to 10 years. Tier three options for patients who refuse all other tests include capsule colonoscopy every 5 years, if it is available. The task force did not recommend Septin9 blood testing for CRC screening due to its inferior performance compared with FIT, among other limitations.
They also emphasized that patients should know a positive result on any test other than colonoscopy requires a follow-up colonoscopy, and recommended that physicians measure the quality of their colonoscopy procedures and FIT to help ensure good technical performance.
“Screening often originates in the doctor’s office, and in that setting, colonoscopy is particularly attractive, because it needs to be performed so infrequently. However, if patients decline colonoscopy, they should be offered FIT, and if they decline FIT, a second-tier test should be offered,” Rex said in the press release. “In the doctor’s office, it’s also reasonable to present the pros and cons of both colonoscopy every 10 years and annual FIT to patients, so they can choose between the two tests. This approach provides a framework for screening that is simple and accommodates almost every health care setting. These recommendations constitute a practical approach toward the ultimate goal of maximizing screening rates, while using well accepted, effective and cost-effective tests.”
Family history recommendations
The task force also made several recommendations regarding family history as a risk factor for CRC.
Notably, for individuals with a first-degree relative diagnosed with CRC before the age of 60, advanced adenoma or advanced serrated lesions, they recommended colonoscopy every 5 years starting at age 40, or 10 years before the age of the relative’s diagnosis if that occurs sooner.
They also recommended that individuals should start screening at age 40 if they have a first-degree relative who was diagnosed with CRC after the age of 60.
Increasing incidence of young-onset CRC
While the reasons underlying the rising incidence of CRC in Americans aged younger than 50 years are currently unknown, the task force emphasized that this trend is a “major public health concern” despite the rate remaining low overall in this age group.
Considering this development, they recommended thorough evaluation of symptomatic patients with suspected bleeding, ie, those with blood in their stool, black or tarry stool with a negative upper endoscopy, or iron deficiency anemia.
Further, they recommended that physicians should make a diagnosis if bleeding symptoms are evaluated using an alternative to colonoscopy, and should follow and treat the patient until the problem is resolved.
CRC risk is comparable to asymptomatic individuals of the same age in patients with only non-bleeding symptoms like abnormal or altered bowel habits and abdominal pain, they noted.
Earlier screening for black Americans
Another notable change to the MSTF recommendations is that black Americans should begin CRC screening at age 45.
Though the task force acknowledged there is little evidence showing that screening before age 50 improves outcomes, their rationale for this recommendation is based on black Americans’ increased cancer incidence and younger mean age of onset for CRC.
They noted that “provider recommendation is key” regarding screening in this population, and added that patient navigation services are an important tool for increasing colonoscopy screening compliance. Further, they emphasized that recommendations for earlier screening in black Americans have prompted research on CRC in this population, and have helped raise awareness of racial disparities in health outcomes among physicians.
The USMSTF on CRC Screening recommendations are simultaneously published in the American Journal of Gastroenterology, Gastroenterology, and Gastrointestinal Endoscopy. – by Adam Leitenberger
Disclosures: Rex reports he is a consultant for Olympus and Boston Scientific, and has received research support from Boston Scientific, Endochoice, EndoAid, Medtronic and Colonary Solutions. Please see the full document for a list of all other task force members’ relevant financial disclosures.