Colorectal Cancer Screening Starting at Age 45 Years-Ensuring Benefits Are Realized by All.

Abstract

The latest recommendations from the US Preventive Services Task Force (USPSTF) represent a significant change in the scope of colorectal cancer (CRC) screening.1-3 For the first time, the USPSTF recommends initiating average-risk CRC screening at age 45 years, reduced from age 50 years in previous versions. This was a B statement, reflecting moderate certainty of moderate net benefit.1-3 The USPSTF continues to issue an A statement (reflecting high certainty of substantial net benefit) for screening adults aged 50 to 75 years.1-3 While other guidelines have recommended this younger age, the USPSTF guidelines directly inform insurance coverage and waiving of cost sharing as part of federal law. The new recommendation1 is based on a systematic review by Lin et al,2 recent epidemiology data from Siegel et al,4 and a modeling study by Knudsen et al,3 suggesting that the burden for CRC could be reduced at an acceptable burden of harms related to screening, which reflects both the established effectiveness of screening and the increase in incidence of early onset CRC (ie, diagnosis of CRC younger than age 50 years). In addition to the potential benefits of screening starting at age 45 years, an ancillary benefit could be an increase in screening rates among individuals aged 50 years and older. Still, a number of concerns and questions have been raised about implementation of population-based CRC screening beginning at age 45 years. First, given that this recommendation1 is based on a systematic review2 and modeling study3 rather than randomized clinical trials of sufficient power among participants specifically younger than 50 years, it is dependent on a few assumptions, including 100% adherence, which is not experienced in routine practice. Moreover, if there is differential uptake by healthier individuals with low risk in the younger age range, the net benefits might not be fully realized.5 Second, a significant portion of early onset CRC occurs among individuals younger than age 45 years.4 It follows that population-based screening initiation at this age is only one step in addressing early onset CRC; symptoms and family history must continue to guide diagnostic or screening examinations among younger adults.6 Third, implementation of the revised recommendations1-3 might exacerbate known racial/ethnic disparities in screening and outcomes, especially among Black, American Indian, and Alaska Native individuals, who already have worse CRC outcomes than other racial/ethnic groups.4,7,8 Implementation could reduce access among individuals who are medically underserved if capacity is not expanded, or it may simply result in improved outcomes among individuals with more advantages that are not shared by others, thus widening an existing gap. Reliance on colonoscopy for screening among individuals aged 45 to 49 years might crowd out approximately one-third of individuals aged 50 to 75 years whose CRC screening is not up-to-date, given limited endoscopy capacity in some communities.9 An estimated 10.7 million additional colonoscopies might be required as a result of this recommendation change.1-3,5 To realize the benefits of expanding the screening-eligible population, a number of approaches could be considered. While much of CRC screening is offered opportunistically during office visits to a primary care clinician, proactive and population-based approaches at a system level potentially could help to ensure equity in CRC screening.10 This should include identification of eligible individuals using system-level analytics designed with algorithms that adhere to principles of equity,11 providing direct outreach to people at home, reminders to clinicians about screening in the electronic health record, and providing navigation for those who need it.12 For example, once health systems + Related articles at jama.com, jamasurgery.com