USPSTF final recommendation on CRC screening: 45 is the new 50
The final recommendation from the United States Preventive Services Task Force (USPSTF) builds on draft guidelines issued in October 2020 which state that screening for colorectal cancer (CRC) should now begin at age 45 and not 50 for average-risk individuals in the United States. The recommendation also mandates insurance coverage to ensure that all individuals have equal access to CRC screening regardless of their insurance status. Since most private health insurance plans as well as Medicare and Medicaid in most states follow USPSTF recommendations, these screening changes will be incorporated in their plans. The change might not be immediate, however, since insurance carriers generally update their coverage for the following plan year or exactly one year from the issue date of the recommendations.
These recommendations align with the American Cancer Society’s 2018 recommendations to lower CRC screening to 45 years. The statistics on the alarming rise in the incidence of early age onset CRC have provided the substantial evidence for the change in recommendations, with CRC projected to be the leading cause of cancer death in patients aged 20-49 by 2040.
CRC risk factors
The USPSTF authors note that age is an important risk factor for CRC, with almost 94% of all new cases occurring in adults 45 years and older. Simulation models showed that beginning screening at 45 years of age was linked to an estimated 22-27 additional life years gained compared with starting at 50 years.
Screening recommendations
The updated USPSTF guidelines offer a variety of screening strategies, each associated with a different frequency of screening. These include:
• High sensitivity guaiac fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year
• Stool DNA-FIT every 1-3 years
• CT colonography every 5 years
• Flexible sigmoidoscopy every 5 years
• Flexible sigmoidoscopy every 10 years plus annual FIT
• Colonoscopy screening every 10 years
To best encourage screening and help patients select the best test, primary care clinicians play a critical role. They can help patients understand the pros and cons of various recommended options and ensure that patients seek out screening at the right time.
Current screening uptake
In the US, fewer than 70% of eligible patients currently undergo CRC screening. Lowering the recommended age to 45 is an important step forward in detecting CRC at an earlier stage and helping to direct patients to receive timely and appropriate treatments. With hope, many more lives can be saved by identifying the disease earlier when it most treatable. For young adults at a higher risk of developing CRC, such as those with a personal or family history of CRC or polyps or with Lynch syndrome, should talk to their doctor about their eligibility to start screening earlier than 45.
Take-home message:
The United States Preventative Services Task Force’s final recommendation on CRC screening suggests that among average-risk adults, screening should begin at 45 instead of 50. Informed by the statistics on the rising rates of early age onset CRC, this recommendation is an important step toward increasing the availability of screening to younger individuals so that the disease can be detected at an earlier stage when it is most treatable.
