A change to address the unknown — 6 GIs react to U.S. Preventive Services Task Force's recommendation to lower CRC screening age to 45

The U.S. Preventive Services Task Force proposed lowering the colorectal cancer screening age to 45 in response to growing early-onset CRC rates Oct. 27.

Here, six gastroenterologists discuss how the change will affect their practice:

Note: Responses were edited for style and content and are presented alphabetically.

David Cave, MD, PhD, professor of medicine at University of Massachusetts Medical School in Worcester: We really make this change to screening at 45 years of age. Although not numerically large, the rate of increase of CRC cancer in patients less than 50 years of age is of great concern. This is clearly due to an environmental factor of which we know nothing. The [increase has happened] too fast for it to be a genetic issue and is analogous to the rapid rise in adenocarcinoma of the esophagus in white males.

Joseph Feuerstein, MD, associate clinical chief of gastroenterology at Beth Israel Deaconess Medical Center in Boston: The [task force] provided an important update to CRC screening by changing the recommended age of screening to 45. We know that younger patients have a rising incidence of CRC. The recommendation to start at 45 will hopefully catch those individuals who develop polyps earlier in their mid-30s to early-40s. Based on this updated guideline, insurance companies will need to update their policies to allow for earlier colon cancer screening. Determining which test is most appropriate to use for the initial screening can still be debated. However, colonoscopy is the only test that allows for the detection of polyps of any size and their immediate removal. Some of the other tests only identify advanced polyps, and this might not be enough to catch those who are developing non-advanced polyps at a younger age.

Mark Friedman, MD, gastroenterologist at Moffitt Cancer Center in Tampa, Fla.: The new guidelines are noteworthy and important. The incidence of CRC in individuals under 50 years has increased 22 percent between 2003-13. This is a trend that is very concerning for gastroenterologists. However, the majority of CRCs in these younger individuals appear to be sporadic, and we have yet to identify who is at the greatest risk and who should be screened more aggressively. As we continue to learn more about early-onset CRC, we will be able to establish evidence-based and cost-effective screening guidelines. It is certainly a step in the right direction and is acknowledging that we have a new problem in younger patients that needs to be addressed.

Shaibal Mazumdar, MD, gastroenterologist at Aurora Gastroenterology in Menomonee Falls, Wis.: I think it's a great initiative. There is an increased incidence of colon cancer in young adults, and we still do not know the reasons.

Andrew Ross, MD, gastroenterologist at Virginia Mason in Seattle: In most cases, CRC is a preventable illness when screening tests are applied to populations at risk. Based on the available data, lowering the recommended age to initiate screening in average-risk individuals from 50 to 45 is a significant step in further reducing mortality from CRC. Assuming adoption, it will be up to us as clinicians to help our patients understand the importance of and differences between all available modalities for CRC screening.

Edward Sun, MD, clinical assistant professor of gastroenterology and hepatology, assistant CMO at Stony Brook (N.Y.) University Hospital: CRC is the second most common cause of cancer death among men and women combined1, and significant costs are associated with CRC treatment. This new recommendation, if finalized, will be a consequential step toward improving CRC early identification and prevention.

As a Grade B recommendation, the USPSTF recommends "offering or providing this service," that there is a "high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial."2 Other Grade B USPSTF recommendations include well accepted practices including one-time screening for abdominal aortic aneurysm with ultrasonography in men aged 65 to 75 years who have ever smoked, and screening for hepatitis C infection in adults aged 18 to 79 years.3 Similarly, decreasing the age for CRC screening to 45 will likely be accepted by the medical community, Medicare and private payers, and most importantly, patients.

As of 2019, the resident population (men and women combined) of the U.S. age 45 to 49 was approximately 20.4 million.4 Adoption of the new USPSTF recommendation will add a considerable number of patients to the CRC screening pool. Certain institutions and GI practices that already experience a backlog of average-risk patients — patients without a personal or family history of CRC — needing colonoscopy will undoubtedly experience greater pressures on endoscopy schedules, with increased wait times as a likely result. These areas may benefit from developing a tiered approach based on assessing a patient's individual risk for CRC. In other words, there may be value in segmenting patients deemed "average-risk," with colonoscopy reserved for patients at higher risk and programmatic screening with fecal immunochemical testing or stool DNA tests applied to patients determined to be at lower risk for CRC. Various technologies in development that employ convolutional neural networks and machine learning — incorporating age, race/ethnicity, socioeconomic factors, among others — may prove key in risk-stratifying patients to their appropriate CRC screening modalities.

Decreasing the age of CRC screening to 45 is also likely to raise awareness of the importance of CRC screening. It is estimated that only 60 percent of age-eligible adults are currently up to date with CRC screening.5 Common barriers include differences in knowledge and attitudes toward CRC screening, including the belief that CRC only affects older patients or that there is a stigma attached to colonoscopy.6 The new USPSTF recommendations and the subsequent awareness efforts and conversations generated will be extremely beneficial to breaking down such barriers to CRC screening.

It is important to note that the USPSTF draft recommendation statement is available for public comments until Nov. 23. While challenges are sure to come with adopting and implementing these new recommendations, there will likely be a net positive effect with regard to public health. I'm certainly excited for this change.

1 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7-30.
2 https://www.uspreventiveservicestaskforce.org/uspstf/grade-definitions
3 https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations
4 https://www.statista.com/statistics/241488/population-of-the-us-by-sex-and-age/
5 White A., Thompson T.D., White M.C. Cancer screening test use—United States, 2015. MMWR Morb. Mortal. Wkly Rep. 2017;66(8):201–206.
6 https://centerforhealthjournalism.org/fellowships/projects/stigma-colonoscopies-and-african-american-risk-colon-cancer-part-1

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