This story has been updated.
“Colorectal cancer is the third leading cause of cancer deaths, and we know that colorectal cancer screening can save lives,” said John Wong, a member of the U.S. Preventive Services Task Force and interim chief scientific officer at Tufts Medical Center in Boston. “When we looked at the data, we found that screening beginning at age 45 instead of age 50 would provide benefits and help save more lives.”
The final recommendation statement published Tuesday in JAMA updates guidelines from about five years ago, which had concluded that data on lowering the starting age was mixed and that beginning screening before 50 would provide only a “modest” benefit.
The task force’s recommendation is largely consistent with a draft document released in October and closely aligns with guidance from the American Cancer Society, which since 2018 has said regular screenings should start at 45, given the continuing rise in colorectal cancer cases in younger adults. A paper published in JAMA Open Network in April found that colorectal cancer was estimated to become the leading cause of cancer-related deaths in people ages 20 to 49 by 2030.
Outside experts say the consensus among the leading organizations could have broad implications for access to care. Many insurance companies base their coverage on recommendations from the task force, which evaluates screening tests, counseling services and preventive medications, said Robert Smith, senior vice president of cancer screening for the American Cancer Society.
The final recommendation would make regular colorectal cancer screenings for people ages 45 to 75 a service that most private insurance plans would be required by the Affordable Care Act to cover with no co-pay for patients.“Physicians are very mindful of the burden of care for uncovered procedures, and so they will be influenced by this,” Smith said.
The task force recommends two screening methods: direct visualization tests, such as colonoscopies, which are considered the gold standard, and stool-based tests. Kimmie Ng, director of the Young-Onset Colorectal Cancer Center at the Dana-Farber Cancer Institute in Boston, said the updated guidelines will have “a huge impact” by making these tools available “to millions more individuals in the United States.”
Rates of colorectal cancer, which causes tumors in the colon and rectum, among people under 50 have been increasing by about 2 percent annually in recent years, troubling experts who have yet to determine what is causing the 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,” Robin Mendelsohn, co-director of the Center for Young Onset Colorectal Cancer at Memorial Sloan Kettering Cancer Center in New York, said in an October interview. “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.”
The task force’s recommendation statement noted that experts looked at the potential benefits and harms of colorectal cancer screenings across racial and ethnic groups and did not find evidence to support changing guidelines for different populations. Instead, starting screening at 45 if you don’t have a family history or known risk factors should be done by everyone, according to the statement.
But given the cancer’s disproportionate impact on Black people, the task force called for more research and strongly encouraged clinicians “to especially reach out to their Black patients ages 45 to 75 to ensure that they have the opportunity to receive and benefit from our recommended effective colorectal cancer screening tests, which we hope will help reduce inequities,” Wong said.
Conversations between providers and their patients are critical in preventive health care, Smith said. “When these conversations don’t take place, then it’s kind of easy for people to think, ‘Well, this doesn’t really apply to me’ or ‘I don’t have any symptoms’ or ‘I’m not at risk,’ ” he said. “Having a guideline seems to influence some people, but other people really need this extra nudge.”
Awareness that colorectal cancer can pose a risk to people under 50 spiked in 2020 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 occurrence is most common, have never undergone testing, Wong said.
It’s critical, Ng said, for health-care providers to normalize talking about colorectal cancer, raise awareness of the importance of screening and reassure people about the general safety of colonoscopies.
“These guidelines are just words on a piece of paper or on your screen unless we have a commitment from all the different involved parties to really start to implement all of these recommendations and ensure that barriers are removed,” she said.