1. Holt, Chuck

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Advocates for earlier colorectal cancer (CRC) screenings recently won a critical ally when the U.S. Preventive Services Task Force issued a new draft recommendation to lower the starting age from 50 to 45 in response to increased incidence rates in younger and Black adults.

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The task force is an independent panel of experts appointed by the Department of Health and Human Services' Agency for Healthcare Research and Quality whose recommendations heavily influence decisions by policymakers. The Centers for Medicare and Medicaid, which by law must pay for CRC screening for its recipients, and also insurance plans subject to rules under the Affordable Care Act, will follow the task force's recommendation and cover the screenings.


The move also aligns the task force with the 2018 recommendation by the American Cancer Society (ACS), which called for lowering the starting age to 45 for CRC screening based on an analysis of SEER data of 500 patients with the disease between 1974 and 2013. Researchers revealed CRC rates increased 1.0-2.4 percent yearly since the mid-1980s in ages 20-39 and 0.5-1.3 percent since the mid-1990s in ages 40-54 (J Natl Cancer Inst 2017;


Another study, published in 2012, revealed the incidence of colorectal cancer in people under age 50 had increased 2 percent every year since 1990. While among the patients with young-onset or early-onset disease included in that study, 74 percent were ages 40-49 (Arch Intern Med 2012; doi:10.1001/archinternmed.2011.602).


CRC is the third-leading cause of cancer death in the U.S., yet 25 percent of people ages 50-75 have never been screened, according to the ACS, which anticipates more than 147,000 new CRC diagnoses in 2020, among whom 18,000 (12%) are expected to be people under 50.


In strongly encouraging Black patients to get screened for CRC at age 45 due to higher rates of disease and death, the task force joined other medical societies and nonprofit groups that have long advocated for adjusting the starting age downward for African Americans for whom adequate care is, on average, less accessible due to racial health disparities.


The new draft recommendation is expected to be finalized in early 2021. It is designated as a B recommendation on the five-letter classification scale used by the task force. Screening for patients ages 55-76, an A recommendation, remains strongly encouraged. While screening for those over age 76 should still be considered on a per-case basis, which is a C recommendation.


The panel declined to recommend CRC screening for individuals under 45, despite increased attention drawn to the disease by the death at age 43 of actor Chadwick Boseman, star of the Black Panther films.


"For people under the age of 45, colorectal cancer is a problem, but the incidence is really low, and so we don't think recommending screening is the right thing to do unless they have a very strong family history of colon cancer or advanced polyps. But we do really emphasize that people under 45 who develop symptoms, whether it's passing blood or becoming anemic for unexplained reasons, get a colonoscopy," said Douglas K. Rex, MD, MASGE, President-Elect of the American Society for Gastrointestinal Endoscopy.


A Positive Step

The first recommendations for CRC screenings were drafted by the ACS in the late 1970s and called for a starting age of 50, which most physicians and payers followed for decades.


"Then, beginning in 2005, national organizations-first the American College of Gastroenterology, followed by the American College of Physicians, and also the OB/GYN community-recommended African-American patients start screening at age 45, because they have a high incidence of colon cancer and they get it at a younger age," noted Rex, who also is Director of Endoscopy at Indiana University Hospital in Indianapolis.


"In its 2016 guideline, the task force said that, based on their modeling, it looked like a starting age of 45 would make sense in terms of the number of life-years saved," he continued. "Unfortunately, there was very little empirical evidence on 45- to 49-year-olds because they had not been included in big screening trials. And so the task force declined to make a recommendation."


The "Qualified Recommendation" to begin screening at age 45 issued by ACS in 2018 did not sway the position of the majority of doctors, Rex noted, pointing to one recent survey showing that only 27 percent of primary care physicians altered the age at which they recommend CRC screening to their patients, and only half of those adjusted it downward. The task force recommendation should help change that, he said.


"My expectation is that a lot more insurance companies will cover it now. Plus, there are some Medicare patients who are under age 65, and so they'll have coverage," Rex explained. "We have seen over the last few decades that colon cancer incidence has been declining in people over 50. And that decline began to accelerate rapidly in 2001, probably because Medicare began to cover screening colonoscopies, and then pretty much all insurance companies did."


Observational studies published since 2018, meanwhile, have provided actual empirical evidence showing people in this age group will get screened when screening is offered, and that the yield, in terms of rates of precancerous polyps found in someone 45-49 years old, is about the same as 50-54 year olds, Rex said.


"We are kind of in this period of flux where the birth cohorts older than 50 have declining risk, partly because they have been able to get screened, and the group that is under 50 has increasing risk, which is resulting in 45- to 49-year-olds looking very similar to 50- to 54-year-olds in terms of their incidence rates," he said.


"The absolute risk of colon cancer, of course, is still very age-related-the older you are the greater your risk. However, the relative increase in risk in people currently in their 20s, compared to people in their 20s 2 or 3 decades ago, is greater than the relative increase seen in people currently in their 30s, etc.," Rex noted.


The increasing risk in young people does not appear to be primarily genetically based; rather, it's some sort of environmental influence, Rex added, noting that the increased risk may be related to factors such as increasing rates of obesity, changes in fecal microbiota, or the widespread introduction of processed foods into the American diet.


A national, organized, and free CRC screening infrastructure like those in other Western countries would be ideal, Rex said. He pointed to Kaiser Health in California, which mails at-home CRC testing kits to its members and boasts an adherence rate of 82 percent, far above the average of 60-65 percent in most U.S. states. Instead, the U.S. uses an "opportunistic" system based on patients interacting with their primary care providers "who, hopefully, will advise patients to get screened," he lamented.


Meanwhile, if a patient at average risk for CRC is afraid to get a colonoscopy due to the Covid-19 pandemic, physicians should encourage them to use an at-home test kit, Rex said. "These aren't as good as a colonoscopy, but they are much better than doing nothing."


Colonoscopies remain the gold standard for CRC due to their ability to remove polyps while enabling a slow, careful examination of the colon, Rex said. They're also performed better than ever before, he added, thanks to advances in medical imaging technologies, notably high-definition digital scopes, as well as a focus by GI societies on improving the detection skills of endoscopists.


"One of the things GI societies have done really well is promoting quality in colonoscopy, which is an operator-dependant procedure," Rex said. "For 18 years now, we've had recommendations about how to make quality measurements of detection skill. We don't have a law mandating quality measurement, but many thousands of GI doctors do it voluntarily to show they are effective at detection. Because, whether it is used for the initial screen or to evaluate somebody who has a positive stool test, you've got to have excellent colonoscopy."


Colonoscopy "is not as cost-effective in somebody who is 45 as it is in somebody who is over 50, or 60, or 70 who has not had previous screening done, but it is a cost-effective medical practice by current accepted thresholds of cost per life-years saved," Rex added. "It's going to be costly to screen 45-49 year olds-there are more than 20 million of them," he said. "But it's also cost-effective, and it will save a lot of lives of persons in a critically productive period in their lives. This group has maybe 5-7 percent of all the colon cancers, but in terms of life-years lost, they account for about twice that, so I think it's a positive step."


All for One, for All

Many have noted that lowering the CRC screening starting age is counter to women's health recommendations the task force made in 2009 when the panel recommended delaying a first Pap smear to age 21, and starting annual mammograms at age 50, up from 45. But while debate swirled following those changes, medical societies, doctors, and patient advocates lauded the new draft recommendation.


"This is the most important milestone in the past 10 years for colorectal cancer patients and their families," said Michael Sapienza, CEO of the Colorectal Cancer Alliance. "Our colorectal cancer community of patients and advocates are celebrating this draft recommendation as it will save additional lives in this group."


The Colorectal Cancer Alliance is the largest nonprofit advocacy for patients with CRC in the world, helping an estimated 325,000 patients in their time of need in 2020 alone. During the public comment period on the task force draft recommendation, the alliance submitted a letter of support co-signed by a number of other patient advocates and organizations.


Black adults in the U.S. are especially vulnerable to CRC with a 20 percent higher likelihood of getting colorectal cancer and a 40 percent higher increased risk of dying from the disease due to subpar care resulting from several factors, including racism, health care inequalities, and access to care, Sapienza said. In response, the alliance recently funded a health disparities research grant aimed at learning what is putting African Americans at increased risk.


"The increase in CRC isn't being driven by our Black and Brown communities, but it certainly is playing a part. And I think that the alliance, in particular, has put a stake in the ground and said,'We have to do a better job of reducing the rate of incidence and the mortality,'" Sapienza said.


When the COVID-19 pandemic hit and forced shutdowns, the alliance recognized it would lead to delayed diagnoses and probably costs lives. In response, a task group was formed, which issued recommendations encouraging the use of at-home CRC screening tests.


"And then we asked, 'What can we do next?'" noted Sapienza, who left his career as a professional trumpet player in 2009 to form Chris4Life Colon Cancer Foundation in memory of his mother, Chris, who died of CRC at age 59. The nonprofit merged with the Colon Cancer Alliance in 2016.


A two-pronged campaign launched by the alliance in October includes a timely slogan, "Things are different, but your risk for colorectal cancer is not," and a new interactive online tool at Patients enter basic information and get recommendations on which screening option may be best for them. At least 60,000 people clicked on the web tool within the first several weeks, of which about 15 percent completed the quiz.


The campaign is live in five cities-Washington, DC, Philadelphia, Houston, Atlanta, and Phoenix-and will expand to 15 cities in early 2021. A planned upgrade to the web tool will enable interaction with hospital EHRs, allowing patients to make doctor's appointments, and also receive alerts via text messaging, phone calls, and other digital means, to help ensure they get screened.


The campaign had about a dozen sponsors within the first 2 months with more on the horizon, Sapienza said. "We are really excited about this campaign and, hopefully, in this pandemic era it will save lives."


Chuck Holt is a contributing writer.


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