“Colorectal cancer is the third leading cause of cancer deaths, so making an impact on that third leading cause, where we think there are quite a few preventable deaths, can make a big difference,” said Michael Barry, a member of the U.S. Preventive Services Task Force and a professor of medicine at Harvard Medical School.
The draft recommendation statement, which was released Tuesday and is now open for public comment, marks a departure from its last update to the guidelines about five years ago. (Task force recommendations are typically revisited every five years.) The panel previously concluded that data on lowering the starting age was mixed and that beginning screenings before 50 would provide only a “modest” benefit. Its position stood in contrast with the American Cancer Society’s, which updated its recommendation in 2018 to say regular screenings should start at age 45.
Now, though, Barry said a review of more recent epidemiological studies on the risk of colorectal cancer increasing in younger people, coupled with simulation modeling, which suggests additional deaths could be prevented if screenings were to start at 45, led the task force to the same conclusion as the cancer society. The draft statement will be available for public comment until Nov. 23, with final recommendations expected to be released “within a few months,” Barry said.
Outside experts say the consensus among the leading organizations could have broad implications on access to care.
“These guidelines, if finalized, eventually will change standard of care for preventive medicine and how we recommend cancer screenings for average-risk Americans,” said Kimmie Ng, director of the Young-Onset Colorectal Cancer Center at the Dana-Farber Cancer Institute in Boston.
Many insurance companies, for instance, often base their coverage on recommendations from the task force, which evaluates screening tests, counseling services and preventive medications, Ng said. As it stands, the draft statement makes regular colorectal cancer screenings for people ages 45 to 75 a service that most private insurance plans are required by law to cover with no co-pay for patients, according to the task force.
“I think the result of all of this will be that lives will be saved,” Ng said.
Robert Smith, senior vice president of cancer screening for the American Cancer Society, called the proposed update a “welcome change.” Although the existing guidelines from the cancer society and the task force are “both highly respected” and used frequently by health-care providers, Smith said he hopes “removing that barrier” of insurance coverage will increase the number of referrals for people in the 45-to-49 age group.
“It may very well be that a physician, who has been shown to be sensitive to the costs of care, would choose not to recommend getting screening at age 45, because they’re concerned that the patient would get a bill that they couldn’t afford to pay,” Smith said. “We’re already seeing screening rates go up in adults at age 45, but they’ll go up a lot more now.”
Rates of colorectal cancer, which causes tumors in the colon and rectum, among people younger than 50 have been increasing by about 2 percent annually in recent years, troubling experts who have yet to figure out what is causing the steady rise. Although a March report from the cancer society indicates that the trend is largely being driven by climbing rates among younger White people, Black people have historically been hit much harder by the disease than other groups.
“It’s been shown that in the African American community, they have higher incidence and mortality of colorectal cancer, and there’s been the question whether this is due to biology or access to care,” said Robin Mendelsohn, co-director of the Center for Young Onset Colorectal Cancer at Memorial Sloan Kettering Cancer Center in New York. “More and more, we believe that it’s likely access to care.”
According to the cancer society report, Black people “are less likely to receive both timely follow-up of a positive screening test and high-quality colonoscopy, contributing to higher mortality.”
By lowering the starting age, Barry said the task force is aiming to raise awareness among everyone, especially Black people, that much can be done to detect colorectal cancers early and potentially prevent the disease.
“We didn’t find evidence that would justify a separate recommendation for Black people, but think there’s a substantial benefit of applying the screening we recommend to populations of all races and ethnicities,” he said.
Awareness that colorectal cancer can pose a risk to people under the age of 50 spiked this year following the death of actor Chadwick Boseman in August. Boseman, of “Black Panther” fame, was diagnosed in 2016 with Stage 3 colon cancer, which progressed to Stage 4 before his death. He was 43.
Though there is strong evidence that screening is effective, about a quarter of people in the traditionally screened 50-to-75 age group, where the cancer is prevalent, have never undergone testing, Barry said. Smith also noted that people often don’t immediately get screened after turning 50.
“It’s usually in their mid-50s, and with incidence increasing, that means that we’re missing opportunities to prevent the disease, and we’re missing opportunities to avert preventable deaths,” he said.
The task force’s draft statement recommends two screening methods: direct visualization tests, such as colonoscopies, which are considered the gold standard, and stool-based tests.
A colonoscopy is an invasive procedure that involves cleansing the colon beforehand and being put under anesthesia, but experts say the risk of major complications is low. And if nothing concerning is detected, people can have 10 years between colonoscopies, compared with stool-based tests, which have to be repeated much more frequently, Barry said. Mendelsohn added that if the alternative tests come back positive, people will still have to get a colonoscopy. For those who are under the age or 45 and don’t have any of the risk factors that would necessitate early screenings, Mendelsohn said it is critical to recognize common signs of colorectal cancer, such as rectal bleeding or blood in the stool, and she urged people to talk about their symptoms with a health-care provider.
“The best test is the one that gets done,” she said. “It’s important to discuss all of the options for screening with your provider so that you know the risks and benefits of the different tests.”