Earlier this week, the American Cancer Society (ACS) announced new recommendations for colon cancer screening, lowering the recommended age to begin screening for average risk individuals to 45 years old. Please note - recommendations regarding patients with high risk, such as patients with a family history of cancer or polyps were not included in this new guideline, and is beyond the scope of this article.
Why the change? While screening strategies have allowed for an overall decline in the incidence in colon cancer (as discussed in my previous blog post), we have a seen an increase in the number of individuals diagnosed before age 50, i.e. in those people who have not yet reached the age to begin screening. This is in particular regarding those patients that are considered average risk; higher risk individuals already have recommendations for earlier and more aggressive screening.
The ACS Guideline Development Group expanded on the data previously used by the US Preventive Services Taskforce (USPSTF) to create their own guidelines and recommendations. They evaluated studies aimed at screening various populations, and weighed the risks and benefits of various screening tests. As stated in the guideline paper, “The ACS recommends that adults aged 45 years and older with an average risk of colorectal cancer undergo regular screening with either a high‐sensitivity stool‐based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation.” A qualified recommendation means that there is clear evidence of benefit, but less certainty regarding the balance of benefit and risk and therefore patients may have varying individual decisions regarding the recommendation. A strong recommendation means that by following the guideline there is a clear benefit that outweighs the harms, and most patients would choose this intervention.
Does this mean that your doctor will start offering you a colonoscopy at age 45? The short answer is…… maybe.
As I mentioned above, the recommendation is for a high-sensitivity stool based test or a structural exam such as a colonoscopy. As of now, most guidelines advocate for screening to begin at age 50, with the exception of the American College of Gastroenterology’s (ACG) recommendation for African American men to begin screening at age 45 due to the higher risk in the demographic. Since publication, there has been a shift to offer these patients earlier colonoscopy, but it is not always approved by the patient’s insurance carrier. Many third-party payers will pay for screening colonoscopy based upon the guidelines, specifically the USPSTF - therefore, they reimburse for colonoscopies performed starting at age 50. Time will tell if this new recommendation from the ACS will shift the insurance/payer paradigm in the US and allow for more patients to be screened at an earlier age.
Until we see where the dust settles regarding coverage for colonoscopy at earlier ages, one option in the short-term may be to undergo an alternative test such as a stool-based test at age 45, if the test is negative it can be repeated more frequently until age 50, and if the test is positive you should schedule a diagnostic colonoscopy evaluation. Like any test there are risks and benefits, and I touched upon the various different methods for screening in my Colorectal Cancer Awareness Month blog post. As with any procedure or test, you should verify with your insurance carrier before undergoing the exam, so that you are aware of your coverage and responsibility.
I do believe this is a big step forward, and the American Cancer Society should be commended for their hard work reviewing the data, and publishing these new and updated guidelines. The rise in “young” cancers has been a hot topic of discussion in the GI world, and these are the first steps in addressing it. If you are nearing 45 years if age, or between 45 and 50, I encourage you to discuss these new guideline with your doctor and see what strategy would work best for you.
Colorectal cancer screening for average‐risk adults: 2018 guideline update from the American Cancer Society https://doi.org/10.3322/caac.21457
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