ACP: Low-risk adults aged 50-75 should undergo regular screening for colorectal cancer

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Cost should also be a consideration in screening decisions

Cost-effectiveness is one more factor in the colorectal screening discussion, Michael Pignone, MD, said in an accompanying editorial.

Two studies by Ladabaum et al. reported cost-effectiveness modeling for various CRC screening techniques: “Comparative effectiveness and cost effectiveness of a multitarget stool DNA test to screen for colorectal neoplasia” (Gastroenterology. 2019;151,:427-39.e6) and “Cost-effectiveness and national effects of initiating colorectal cancer screening for average-risk persons at age 45 years instead of 50 years” (Gastroenterology. 2019;157:137-48).

These reports concluded that annual stool testing is more effective – but also more costly – than biennial testing. However, the additional cost per unit of benefit (figured in quality-adjusted life-years) is about $33,000 per life-year gained – a reasonable cost. “Hence, annual testing is a viable screening option,” wrote Dr. Pignone.

Starting screening at age 45 years instead of 50 years also produced an additional cost per life-year, but again, it is reasonable at $33,900 for colonoscopy screening and $7,700 for stool testing.

“However, for the same amount of additional resources, increasing screening rates in 55- or 65-year-olds or improving the proportion of positive stool test results that are followed by colonoscopy from 60% to 90% would yield much more benefit in life-years gained than lowering the starting age to 45 years.”

Analyses such as these conditionally support earlier colorectal cancer screening only if the universal screening rate for 50- to 75-year-olds is more than 80%, he wrote. “They also reinforce the most important point in all of the major guidelines: Any recommended form of screening in the 50- to 75-year age range is likely to be very cost-effective (if not cost-saving) compared with no screening and should be strongly encouraged.”

Dr. Pignone is director of the program on cancer prevention and control at the LIVESTRONG Cancer Institutes at the University of Texas, Austin.



Regular colorectal cancer (CRC) screenings are indicated for asymptomatic patients aged 50-75 years, according to a new evidence-based guidance statement issued by the American College of Physicians.

Regular screening can be discontinued after age 75 years, Amir Qaseem, MD, president of clinical policy and the Center for Evidence Reviews at the American College of Physicians, and colleagues wrote in the Annals of Internal Medicine.

No one test is preferred over another, according to the guidance statement. Patients and physicians can select the test type together, based on individual needs and preferences, and each test carries its own screening interval. But regular testing has been proven time and again to reduce the risk of colorectal cancer mortality, and more people should have it, according to the guidance.

“Not enough people in the United States get screened for colorectal cancer,” ACP President Robert M. McLean, MD, said in a press statement. “Physicians should perform an individualized risk assessment for colorectal cancer in all adults. Doctors and patients should select the screening test based on a discussion of the benefits, harms, costs, availability, frequency, and patient preferences.”

The guidance is an attempt to balance existing guidelines authored by the U.S. Preventive Services Task Force and the Canadian Task Force on Preventive Health Care (CTFPHC), but it also was developed following critical review of those from the American Cancer Society and other organizations.

The ACP guidance is for adults at average risk for colorectal cancer who do not have symptoms; it does not apply to adults with a family history of colorectal cancer, a long-standing history of inflammatory bowel disease, genetic syndromes such as familial cancerous polyps, a personal history of previous colorectal cancer or benign polyps, or other risk factors.

The guidance was based on evaluations of stool-based tests, including the fecal immunochemical test (FIT), also called the immunochemical-based fecal occult blood test (FOBT), and direct visualization with endoscopic and radiologic tests, including flexible sigmoidoscopy, colonoscopy, and CT colonography. The guidance includes the following recommendations:

Clinicians should regularly screen for colorectal cancer in average-risk adults between the ages of 50 and 75 years.

This recommendation is in line with those made by the U.S. Preventive Services Task Force and the CTFPHC. Data suggest that regular screening reduces colorectal cancer–specific mortality in this age group, with those aged 65-75 years likely to garner the most benefit.

The absolute risk reduction increases with age and varies with test type. For every-other-year FOBT, it rises from 0.037% in those younger than 60 years to 0.20% in those aged 60 years or older. For flexible sigmoidoscopy, the risk reduction rises from 0.05% in the younger group to 0.29% in the older group.

Data from the CTFPHC show that the net benefit in those aged 50-59 years is small, however. This may influence the decision about when to start screening.

Clinicians should select the colorectal cancer screening test with the patient based on a discussion of benefits, harms, costs, availability, frequency, and patient preferences.

The FIT or FOBT should be performed every 2 years, colonoscopy every 10 years, and flexible sigmoidoscopy every 10 years, plus FIT every 2 years.

No data suggest a benefit of one test over another; however, “all screening tests are associated with potential benefits as well as harms,” the document states. “Clinical decisions need to be individualized using patient clinical characteristics, patient preferences, and screening test frequency and availability. Because many eligible patients have never been screened and some may not adhere to recommendations about subsequent screening or follow-up of positive findings on screening tests (such as colonoscopy after a positive result on a stool-based screening test), patient informed decision making and adherence are important factors in selection of a [colorectal cancer] screening test.”

Discussions with patients should include topics like the recommended frequency of each test, bowel preparation, anesthesia, transportation to and from testing site, time commitments, and the necessary steps if a test result is positive.


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