New ACS Guidelines Lower Colorectal Cancer Screening Age to 45

In response to the increasing incidence of colorectal cancer in young and middle-aged individuals, the American Cancer Society has updated its screening recommendations.

The American Cancer Society (ACS) has updated its colorectal cancer (CRC) screening guidelines to lower the age at which individuals are recommended to begin screening due to increasing incidence in young and middle-aged populations, according to an ACS press release.1

The updated recommendations, which were published in CA: A Cancer Journal for Clinicians, advise that CRC screening should begin at age 45 for those at average risk.2

The guideline change is based on CRC incidence rates, results from microsimulation modeling that demonstrate a favorable benefit-to-burden balance of screening at age 45, and the expectation that screening will perform similarly in adults aged 45 to 49 as it does for adults for whom screening is currently recommended (50 and older).

CRC is currently the fourth most commonly diagnosed cancer among adults in the United States and the second leading cause of cancer death, with more than 50,000 deaths annually. According to the authors, CRC incidence increased 51% among adults younger than 55 years of age from 1994 to 2014 and increased 11% in mortality from 2005 to 2015.

The new recommended screening age is a qualified recommendation because there is less direct evidence of the balance of benefit and harms or patients’ values and preferences, since most studies have only included adults aged 50 years and older, according to the press release.1 The ACS recommendation for regular screening in adults aged 50 years and older is a strong recommendation.

For adults aged 45 years and older with an average risk of CRC, the ACS recommends regular screening with either a high-sensitivity stool-based test or a structural exam, depending on patient preference and test availability.

“When we began this guideline updates, we were initially focused on whether screening should being earlier in racial subgroups with higher colorectal cancer incidence, which some organizations already recommend,” Richard C Wender, MD, chief cancer control officer for the ACS, said in the press release.1 “But we saw data pointing to a persistent trend of increasing colorectal cancer incidence in younger adults, including American Cancer Society research that indicated this effect would carry forward with increasing age, we decided to reevaluate the age to initiate screening in all US adults.”

Additionally, the ACS recommends that:

  • Average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years.
  • Clinicians individualize CRC screening decisions for individuals aged 76 to 85 years old based on patient preferences, life expectancy, health status, and prior screening history.
  • Clinicians discourage individuals older than 85 years old from continuing CRC screening.

According to the authors, epidemiological trends in populations as young as those born in 1990 suggest that the higher risk of developing CRC will continue to be a concern for decades to come.

“One of the most significant and disturbing developments in CRC is the marked increase in CRC incidence—particularly rectal cancer–among younger individuals,” the authors said.2 “While the causes of this increase are not understood, it has been observed in all adult age groups below the age when screening has historically been offered and is contributing significantly to the burden of suffering imposed by premature CRC mortality.”

The authors concluded that that they hope widespread adoption of the guideline will help lower incidence, suffering, and mortality caused by CRC.

Reference

1. American Cancer Society Updates Colorectal Cancer Screening Guideline [news release]. ACS website. http://pressroom.cancer.org/releases?item=770. Accessed May 30, 2018.

2. Wolf AM, Fontham ET, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline gupdate from the American Cancer Society. CA: A Cancer Journal of Clinicians. 2018. https://doi.org/10.3322/caac.21457