Support grows for colorectal screenings at 45

The number of health organizations urging most Americans begin screening for colorectal cancer at age 45, rather than at 50, continues to grow. The American College of Gastroenterology (ACG) this year followed suit with the American Cancer Society (ACS) in recommending that screening start for all American at the age of 45. The ACS made the recommendation in 2018.

Screening should start earlier for higher-risk individuals, the AGS said in its advisory.

Colorectal cancer is the second-highest cause of death from cancer, according to the American Cancer Society, and the fourth most-often diagnosed cancer in adults. While overall rates of occurrence and death have dropped since the 1980s, numbers have climbed for adults younger than 55. From 1994-2014, incidence for this younger group rose 51 percent, and from 2005-2015, deaths rose 11 percent.

Despite the rise in deaths and incidence among younger adults, screenings have dropped in recent years. The U.S. Multi-Society Task Force reports the amount of eligible people who’ve never been screened grew from 25.6 percent in 2016 to 31.2 percent in 2018.

“The national goal is to have 80 percent eligible people screened,” said Hyannis gastroenterologist Aaron M. Dickstein, MD. “We are now only at 60 percent, unfortunately.”

Previously, in 2008, the ACG recommended that Black Americans begin screening at 45, in recognition of their higher incidence rate. For average-risk Americans, screening was to start at 50. In 2017, the U.S. Multi-Society Task Force also recommended screening start at 45 for Black Americans and 50 for average-risk Americans, and 40 or younger for people with a family history of colorectal cancer.

Now, with more health organizations backing screenings at 45 for all average-risk Americans, more insurance companies will be willing to pay for earlier tests, Dr. Dickstein said. This is important, he added, as patients are more inclined to get tested if the procedure is covered.

The Affordable Care Act requires insurers to cover colorectal screenings, but health plans created before 2010 are exempt, according to the American Cancer Society. However, other state and federal laws may govern coverage.

Colonoscopy is Preferred

Colonoscopy remains the preferred one-step method for screening, according to Dr. Dickstein, because “in one procedure we can both detect cancerous lesions as well as precancerous polyps that can be removed before they advance. Other forms of screening, such as stool tests, are two-step, in that they are only diagnostic and require prompt follow-up with a colonoscopy if the result is abnormal.”

Furthermore, colonoscopy can often find cancer earlier than stool tests, such as the FIT (fecal immunochemical test) or multitarget stool DNA test. Earlier detection means better outcomes for patients, he said.

Most colorectal cancer starts as adenomatous polyps. A less common form that can become cancer is sessile serrated polyps.

“We can find polyps that probably would become cancerous,” he said. “In particular, Sessile serrated polyps, the less common precancerous polyp, can only be identified with colonoscopy,” he said.

No one likes getting a colonoscopy, but it’s not the procedure, but the prep that turns people off, Dr. Dickstein said. Traditionally, it has required drinking a large container of salty water, often with lemon flavor added. The salty water causes diarrhea that flushes out the intestines so that the doctor performing the colonoscopy can get a clear view of the colon’s walls. Unfortunately, the large volume of water and its taste can be gag-inducing and a big challenge to swallow it all.

Now there are alternative options including a pill form that can replace the salty water, making the experience more comfortable, he said. Once done, most people don’t have to undergo another colonoscopy for 10 years.

Recommendations

The American College of Gastroenterology recommends:

• People with average risk of colorectal cancer be screened from ages 45-75.
• Decision to continue screening for people 75 and older should be based upon the individual’s health.
• Colonoscopy every 10 years and FIT (looks for blood in stool) annually are the preferred screening procedures.
• For people who refuse or can’t do these procedures, other options are flexible sigmoidoscopy (using an inserted scope to see only the lower colon and rectum), multitarget stool DNA test (detects some mutations, hemoglobin and other cancer indicators), CT colonography (X-ray imaging of the colon that’s less invasive than colonoscopy) and colon capsule (a capsule containing cameras is swallowed to see inside the colon). Flexible sigmoidoscopy, CT colonography and colon capsule require patients to first cleanse their colon, as they would to prepare for colonoscopy. Each of these tests has its own limitations, and recommended rates of how often they should be done.

Risk Factors

Of all ethnic and racial groups in the United States, Black Americans have the highest colorectal cancer rates. Black men have 24 percent higher incidence than white men, and Black women have a 19 percent higher incidence than white women. The American College of Gastroenterology (ACG) urges more outreach to Black Americans, who have lower rates of screening and treatment. Native Americans, Alaskan natives and Ashkenazi Jews also have higher incidence rates.

If you have a parent or sibling (blood relation) with colorectal cancer, your risk increases, and it increases with the affected relative’s youth. The ACG recommends screening for these people to start at age 40 or 10 years below the age of the youngest affected relative.

According to the American Cancer Society, other risk factors include:

• History of colorectal polyps or cancer.
• Inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis.
• Diabetes.
• Some genetic conditions, such as Lynch syndrome, familial adenomatous polyposis (FAP), MUTYH-associated polyposis (MAP) and Peutz-Jeghers syndrome (PJS).
• Age – risk rises as you get older.
• General health and habits: Obesity, smoking, inactivity and alcohol consumption are all linked to colorectal cancer.

Now’s the Time

During the first months of the pandemic, colonoscopies and other non-emergency procedures went on hold at Cape Cod Healthcare, but doctors have been working through the backlog.

“We’re getting closer to getting over that hump,” Dr. Dickstein said.

The value of early detection is catching cancer before it starts or progresses. That makes treatment simpler and the chance of death less likely. If you’re 45 or older, or younger with an affected close relative, don’t put off getting screened, he urged.

“People born in 1990 or so, compared with people born around 1950, have two times the chance of developing colon cancer in their lifetime,” Dr. Dickstein said, adding that many believe the trend is due to diet, obesity, and Western lifestyle.

Indeed, according to the World Cancer Research Fund and American Institute for Cancer Research, the colon cancer rate per 100,000 people in highly developed countries is 18.9 and the rate for rectal cancer is 10.8. The rates for less developed nations are 3.5 for colon cancer and 2.7 for rectal cancer.