October 29, 2020

Colon cancer screening should begin 5 years earlier, a key panel recommends

Daily Briefing

    The U.S. Preventive Services Task Force (USPSTF) on Tuesday in draft guidance recommended that people undergo screening for colorectal cancer at age 45, five years earlier than is called for in its current guidance.

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    According to STAT, the draft guidance will remain open for public comment for four weeks.

    Colorectal cancer is the third-most common cancer diagnosis among U.S. men and women, and is particularly prevalent among older adults, according to the American Cancer Society (ACS). This year, according to ACS, about 18,000 people under age 50 will be diagnosed with colorectal cancer, of whom about 3,600—or 12% of total cases—are expected to die from the disease.

    Recommendation details

    Currently, USPSTF recommends that adults without risk factors undergo colorectal cancer screenings at age 50 through age 75. If the new guidance is approved as-is, it would require insurers under the Affordable Care Act to cover colorectal cancer screenings for asymptomatic adults ages 45 to 75 at no cost to patients, according to John Wong, a physician at Tufts Medical Center and task force member.

    Specifically, the draft guidance gives the recommendation that asymptomatic adults ages 45 to 49 be screened a grade of "B," which means that the panel has "moderate certainty" of an overall benefit. Meanwhile, the recommendation for screening asymptomatic people between the ages of 50 and 75 retained its "A" grade, meaning the panel had "high certainty" that the overall benefit of such recommendations was substantial.

    The draft guidance would not change existing guidance regarding adults between the ages of 76 and 85, who are advised to consult with their physicians about whether to undergo screening, or for adults older than 85, who are advised to forgo screening.

    Under the guidance, two types of screening services are recommended, including "direct visualization tests," such as colonoscopies, as well as tests that assess stool samples for blood or other indications of cancer. According to USPSTF, once someone was screened at age 45, he or she would then undergo a colonoscopy every 10 years or submit a stool sample for testing every one to three years, pending the test used.

    According to STAT, the draft guidance does not apply to people who have symptoms of colorectal cancer, a family history of such cancer, or who present with abnormal growths, called polyps, in their colon.

    Factors behind new recommendations

    The panel made its latest recommendations based on a review of new research showing a growing number of young adults are being diagnosed with colorectal cancer. Specifically, the research that USPSTF examined indicated that adults at age 45 in 2016 had the same rate of colorectal cancer as adults who were 50 in 1992, before colorectal cancer screenings were widely available.

    In addition, the draft guidance urges clinicians to give particular attention to their conversations about screening with Black patients and calls for further research into the disproportionately high rate of colorectal cancer incidence and mortality among Black Americans—noting that that disparity is a key factor in the recommendation to expand the screening age range. Specifically, the panel noted that while the average annual death rate from colorectal cancer among U.S. adults is 12.2 deaths per 100,000 women and 17.3 per 100,000 men, it's 16.1 per 100,000 Black women and 24.4 per 100,000 Black men.

    The panel also considered the pros and cons of expanding the age range for screening. According to USPSTF, complications would likely occur for one in ever 63 to 102 adults screened between the ages of 45 and 75.

    Comments

    Otis Brawly, a professor of oncology and epidemiology at the Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health, said the new recommendations were "exciting" because "USPSTF tends to be the most conservative and orthodox group in their interpretation of the scientific literature and they rarely make a big change like this."

    According to STAT, gastroenterologists who were not part of the panel also said the new recommendations were welcome—but could create some issues.

    Fola May, a gastroenterologist at the University of California-Los Angeles, said, "What this equates to is about an additional 21 million Americans [who] will need to be screened." Citing concerns about how feasible it would be get all those additional patients screened, she added, "Colon cancer screening was just one of the measures we as a nation were always poor at and we were especially bad with ethnic and racial minorities, Blacks, Latinos, Asians, and Native Americans."

    That said, she expressed approval that stool-sample tests were also included in the draft guidance. "I hope that people will embrace that we should use even the non-invasive methods, like the stool tests, and not for everyone to get a colonoscopy because I think that would be virtually impossible."

    Adjoa Anyane-Yeboa, a gastroenterologist at Massachusetts General Hospital, who was not a part of the task force, voiced similar concerns. "I think it's important to realize that lowering the screening age doesn't necessarily increase access to screening," Anyane-Yeboa said. "But I do think that this is an important step forward and hopefully will help get more people covered and ideally will get more people screened" (St. Fleur, STAT, 10/27; Carroll, NBC News, 10/27; Sullivan, The Hill, 10/27).

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