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Research supports CRC screening at age 45


In the wake of newly issued guidance by the American College of Physicians, the American Gastroenterological Association is advising clinicians to follow the 2021 colorectal cancer (CRC) screening recommendations from the U.S. Multi-Society Task Force on Colorectal Cancer (MSTF) which recommend that average risk individuals be screened beginning at age 45.

The ACP, in a new guidance, says that “clinicians should consider not screening asymptomatic average-risk adults between the ages of 45 to 49 years. Clinicians should discuss the uncertainty around benefits and harms of screening in this population.”

The guidance is at odds with the recommendations from the task force, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The consensus was that people ages 45 and up should receive CRC screening.

“We’re disappointed that the ACP has suggested to not screen average-risk individuals between the ages of 45 to 49,” said Swati Patel, MD, MS, a member of the USMSTF, the lead author on the recent USMSTF guidance, and associate professor of medicine-gastroenterology at the University of Colorado at Denver, Aurora. “This guidance essentially contradicts these other organizations, and I think from the patient perspective, likely raises a lot of confusion.”

Barbara Jung, MD, AGAF, president of the AGA said in a written statement: “Studies show that colorectal cancer is increasing in younger patients and we have data backing screening for average-risk patients at 45. Bottomline: it saves lives. To release contradictory guidance is reckless.”

Timothy Wilt, MD, MPH, professor of medicine at the University of Minnesota, Minneapolis, and past chair of the guidelines committee at the ACP, said that a key consideration for the ACP was what they considered an “incredibly small” increase in CRC incidence in people under 50 from 2000 to 2019 – from 6.0 per 100,000 to 8.7 per 100,000.

“If I would tell my patients, your chance of colorectal cancer is 6 per 100,000 and now it’s really 9 per 100,000, they would say, ‘No thanks,’ ” he said. “I have trouble getting my patients to take a statin for heart disease when their risk of heart disease in the future is 25%.”

Dr. Patel said that these incidence numbers don’t capture the magnitude of the CRC health burden, because screening historically hadn’t been performed on those under 50. A 2020 study that broke incidence down in single-year increments found a 46% jump from age 49 to age 50, she noted.

“We only diagnose a cancer once we check for it,” she said. The dramatic jump in CRC incidence at age 50 isn’t a sign of new cancer, she said. Rather, these cancers have “been there for years and are cancers that would have been detected between 45 and 49. We just didn’t know about them because patients didn’t get the colonoscopy.”

Data show that 16% of all rectal cancer now occur in patients under 50, she said.

“That is a substantial proportion of all rectal cancers,” she said. “If these trends continue without us doing something about it, that suggests that colon cancer and rectal cancer will be the leading cause of cancer-related death in individuals under the age of 50 by 2030. That’s not that far away.”

Moreover, she said, when the ACP says in its guidance that “the small estimated benefits and harms roughly balance each other out,” it overestimates the risk of CRC screening. The first step, which includes noninvasive options such as a stool-based screen, is no-risk and needs to be followed by a colonoscopy only in a small percentage of cases, she noted. And in recent randomized controlled trials, out of more than 28,000 colonoscopies, there were two perforations, 30 bleeding events, and no deaths.

“I think the ACP statement very much overinflates the risks of screening,” she said.

Dr. Wilt suggested that guidance that flatly recommends that screening should start at age 45 is an overly blunt strategy, not accounting for lower CRC rates among women and varying risk for different races and ethnicities – information that patients should be given in order to make decisions.

“What I would say is, talk to your physicians, ask about the information, make a clinical decision that’s right for you. ... It’s your health,” he said. “We believe our guidance statements are incredibly patient-centered.”

Dr. Patel said that such an approach is not necessarily what patients look for from their physicians.

“I think in theory it’s great to have quote-unquote shared decision-making, and empower the patient to make a decision,” she said. “But generally speaking, patients seek our advice and seek our expertise to synthesize all of this complex data, to provide a recommendation that is driven by those data points.”

The ACP guidance also suggests that “opportunity costs and resources need to be weighed” and that expanding the screening population will take resources away from other medical services.

“We are the front-line docs who have to engage in these conversations,” Dr. Wilt said. “We value our GI and specialty consultants (but) they are not the ones who are there at the front line having to have these discussions.”

Dr. Patel agreed that, with expanded screening, primary care physicians need more support and that “we have a long way to go in providing those support resources.” But she added, “my perspective is that we have to look agnostically at the data.” The data the AGA cites, she added, are peer-reviewed, epidemiological data, not society-generated data.

“I don’t agree with the approach of, even though it’s an additional burden, because we don’t have the resources and time now, to just not proceed,” she said.

“I think our hope would be that practicing physicians – either within the ACP or outside – just have a clear message to patients, that colon cancer is a big deal, it’s increasing in young patients, starting at age 45 you should be screened, and you should use the test that you’re most likely to get done.”

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