On October 27, 2020 The United States Preventive Services Task Force (USPSTF) released draft guidelines recommending that colorectal cancer (CRC) screenings begin at 45 years old for average-risk individuals, a shift from the current USPSTF guidelines that recommend beginning at age 50. This was in direct response to the increase in incidence of early age onset colorectal cancer (EAO CRC) and aligns with the American Cancer Society’s 2018 recommendation that screening begin at age 45. 

Please note, the CRC screening recommendations are still in draft form. Insurance will not cover the change in guidelines and clinicians may not recommend screening for those under age 50, until the guidelines are finalized.

Fight CRC provided feedback on the draft guidelines during the public comment period with input from members of the Medical Advisory Board and Early-Age Onset Workgroup.

Fight CRC also worked in collaboration with the Colon Cancer Coalition (CCC) and Colorectal Cancer Alliance (CCA) to gain support and comments from the colorectal cancer community regarding the proposed guidelines. 

We received an overwhelmingly positive response from the colorectal cancer community, with nearly 1,600 signatures in support of this recommendation from patients, their loved ones, and medical professionals. These advocates also provided over 1,100 comments explaining why they support lowering the screening age to 45 for average-risk individuals. 

"I was diagnosed to Stage IIIb cancer at 48 years old. I had no symptoms that would have indicated colon cancer prior to discovering a bulge in my lower abdomen myself. If I had been screened at 45 the disease would have been detected at an earlier stage and I would not be dealing with Stage IV cancer now, as my disease has progressed. Prevention is the key."

Tayde Castro, Stage IV Survivor

The bottom line is clear: lowering the screening age for average-risk individuals will save lives.

However, it’s important to note these guidelines alone are not a silver bullet for solving the rise in EAO CRC and there is still room for improvement. If and when the updated USPSTF guidelines are adopted, the colorectal cancer advocacy community will need to keep the following considerations in mind:

• The USPSTF guidelines were developed for average-risk patients. Other Several professional organizations have developed separate guidelines for those at a higher risk of colorectal cancer due to a family history, genetic mutation, or personal history of colorectal cancer. It is important to know your risk of colorectal cancer, as you might need to be screened even before 45 years old if at increased risk.
• Education about what the guidelines mean and who they apply to will be essential for successfully reaching average-risk patients aged 45 and older who have not yet been screened. 
• Knowing the signs and symptoms of colorectal cancer are critical. No matter your age, it is extremely important to talk to your healthcare provider about any signs and symptoms you are experiencing. If you feel like your provider is not taking you seriously about signs or symptoms, advocate for yourself and if needed, find another provider.
• The scientific community does not yet know why rates of colorectal cancer among young adults (under age 50) without a familial or genetic risk are rising. Researchers are working quickly to answer this question. Fight CRC is supporting a collaborative approach to this effort through the Early-Age Onset Colorectal Cancer Workgroup.

Learn more about early age onset colorectal cancer and what you need to know about prevention and identifying symptoms.

What are the next steps for the draft guidelines?

• The USPSTF will review the public comments, including ours, and consider any final changes to the guidelines based on the feedback.
• In order to finalize the recommendations, the task force will conduct a vote to approve the guidelines.
• After approval, the final recommendation and evidence summary will be published in the Journal of the American Medical Association (JAMA) and copies of the final recommendations and evidence reports will be posted on the task force website.
• Insurers and healthcare providers will go through their own processes to adopt and begin implementing the updated guidelines. Private insurance plans subject to the Affordable Care Act (ACA) and Medicare plans are required to provide coverage all preventive screenings with an A or B recommendation without any co-pay or out-of-pocket costs to the patient.

As always, Fight CRC will continue to push for the policies and research that benefit our community the most.

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Fight Colorectal Cancer's Public Comment to the USPSTF

November 20, 2020

Dear United States Preventive Services Task Force Members:

Fight Colorectal Cancer (Fight CRC), along with our Medical Advisory Board, appreciates the opportunity to submit the following comments to USPSTF regarding the Colorectal Cancer Screening Draft Recommendations. Fight CRC is the leading patient-empowerment and advocacy organization in the United States, providing balanced and objective information on colon and rectal cancer research, treatment, and policy. We are relentless champions of hope, focused on funding promising, high-impact research endeavors, while equipping advocates to influence legislation and policy for the collective good.

After review of the updated recommendations by members of our Medical Advisory Board and our staff, we would like to submit suggestions in response to the proposed USPSTF recommendations:

• We commend the Task Force for updating its stance on colorectal cancer screening for average risk individuals to include those 45 to 49 years in response to the alarming growth of early age-onset colorectal cancer (EAO CRC). This recommendation aligns with the American Cancer Society (ACS) guidelines from 2018 and is supported by the literature.
• While we appreciate that all guidelines that receive an A or B grade are subject to insurance coverage under the Affordable Care Act, Fight CRC recommends that the USPSTF consider recommending colorectal cancer screening for those age 45 to 49 years at an A grade, in alignment with the current recommendation for those age 50 to 75 years.  Though randomized control trials are considered stronger evidence, the modeling studies incorporate empirical data and, as such, the available empirical data should be further considered for an A grading.  For example:
  • Multiple studies have found that the majority of early age onset CRC cases are diagnosed between ages 40-49^1,2.
  • A recent study demonstrated a steep increase in CRC incidence between patients ages 49 and 50. In that study, most of the cases diagnosed at age 50 were caught at an invasive stage. This suggests that these cancers were developing undetected for several years prior to the diagnosis at age 50³.
• Follow-up colonoscopy for evaluation of abnormal results of stool-based and other non-colonoscopic screening tests is necessary for screening completion.  We urge the Task Force to specify that these colonoscopies are a necessary component to complete the screening process, rather than a separate diagnostic procedure. The current practice of coding these follow-up colonoscopies as diagnostic procedures creates barriers for underserved populations to complete this critical step due to out-of-pocket costs.
• We are concerned with the real-world implications resulting from the 100% screening compliance rates used by the current modeling studies, as a 100% patient compliance rate is not realistic or feasible in the general population. For stool based-screening tests to be effective in reducing mortality, it is essential that these screening tests are completed according to the recommended intervals (i.e. annually for FIT tests)⁴.  In regard to FIT-DNA, the results of the CISNET modeling outcomes have yielded a lack of clear recommendations for the appropriate interval of screening (one vs three years) that must further be examined. One of the prime advantages of the FIT-DNA test compared to FIT or FOBT, with respect to adherence, is the appeal of a less frequent screening interval of three years. The USPSTF should make clear the timing intervals for each screening method, as a strategy to improve overall CRC screening adherence from the current rate of 68%.⁵
• We recognize that the USPSTF is tasked with providing guidelines for the average risk population.  To prevent a potential increase in disparities based upon access to screening services, we suggest that USPSTF further examine factors associated with a variance in incidence, mortality and screening rates for the Black American, Latinx, and Indigenous populations in order to make specific considerations for these subpopulations.
• Currently, the USPSTF guidelines do not include considerations of essential factors for adaptability and application, such as cost, resources needed, and potential barriers to implementation, access, and feasibility.  It is our recommendation that before health systems and public health agencies launch large-scale implementation, an agency or task force should provide an intermediate step of review focused on implications of the guidelines within real word settings and populations, as a complement to the USPSTF review.

By lowering the screening age to age 45, approximately 19 million additional Americans will be eligible for colorectal cancer screening in 2021, and the final USPSTF guidelines will have a significant impact on how many of those patients ultimately receive a colorectal cancer diagnosis or die due to the disease⁶.  Thank you for the opportunity to provide comments and we urge you to further strengthen and finalize these proposed guidelines.

Fight CRC discloses the following sponsorships and/or educational grants from companies who have an interest in novel screening methods for colorectal cancer: Exact Sciences, Epigenomics, Quest Diagnostics, Endochoice, Clinical Genomics, and Medtronic. Neither these companies nor any of our corporate supporters have influenced our comments on these draft recommendations.

References

¹ You YN, Xing Y, Feig BW, Chang GJ, Cormier JN. Young-Onset Colorectal Cancer: Is It Time to Pay Attention? Arch Intern Med. 2012;172(3):287–289. doi:10.1001/archinternmed.2011.602

²Low EE, Demb EE, Liu J, et al. Risk Factors for Early-Onset Colorectal Cancer. Gastroenterology. 159(2):492-501.e7. doi:10.1053/j.gastro.2020.01.004

³Abualkhair WH, Zhou M, Ahnen D, Yu Q, Wu XC, Karlitz JJ. Trends in Incidence of Early-Onset Colorectal Cancer in the United States Among Those Approaching Screening Age [published correction appears in JAMA Netw Open. 2020 Feb 5;3(2):e201038]. JAMA Netw Open. 2020;3(1):e1920407. Published 2020 Jan 3. doi:10.1001/jamanetworkopen.2019.20407

⁴D'Andrea E, Ahnen DJ, Sussman DA, Najafzadeh M. Quantifying the impact of adherence to screening strategies on colorectal cancer incidence and mortality. Cancer Med. 2020;9(2):824-836. doi:10.1002/cam4.2735

⁵QuickStats: Percentage of Adults Aged 50–75 Years Who Met Colorectal Cancer (CRC) Screening Recommendations — National Health Interview Survey, United States, 2018. MMWR Morb Mortal Wkly Rep 2020;69:314. DOI: http://dx.doi.org/10.15585/mmwr.mm6911a7external icon

⁶Piscitello A, Edwards DK 5th. Estimating the Screening-Eligible Population Size, Ages 45-74, at Average Risk to Develop Colorectal Cancer in the United States. Cancer Prev Res (Phila). 2020 May;13(5):443-448. doi: 10.1158/1940-6207.CAPR-19-0527. Epub 2020 Feb 6. PMID: 32029430.

Appendix 1

Upon release of the USPSTF draft guidelines for colorectal cancer screening, Fight Colorectal Cancer partnered with the Colon Cancer Coalition and the Colorectal Cancer Alliance to solicit comments of support for USPSTF’s recommendation to lower the screening age to 45 from our collective colorectal cancer communities. We received an overwhelmingly positive response, with nearly 1600 signatures in support of this recommendation.

Of the 1575 who signed (as of 11/19/20):

●       376 are patients/survivors

●       102 are caregivers

●       319 are family members/relatives

●       287 are friends of patients

●       248 are medical professionals

We received 1161 comments from this group, explaining why they support lowering the screening age to 45 for average-risk individuals. The bottom line: lowering the screening age will save lives.

“As a gastroenterologist on the front lines of the fight against colorectal cancer, I have noticed firsthand the increased incidence of colorectal cancer in patients younger than 50. The data is now clear regarding the increased incidence of colorectal cancer in younger patients. My colleagues and I are in full support of the life-saving changes in societal guidelines recommending that colorectal cancer screening in average risk patients begin at age 45. Thank you for your consideration.”

“A dear friend whom I’ve known since we were children was diagnosed with advanced colon cancer at her age 50 colonoscopy. Thanks to excellent medical care she is alive and well and cancer free ten years later. Her treatment would have been much easier if she’d been diagnosed earlier.”

“A friend was diagnosed at 48. She would be alive if she had been screened at 45.”

“As an African American gastroenterologist, I've diagnosed colon cancer in a significant number of African American patients less than the age of 45.  The recommendation was made in 2009 by the American College of Gastroenterology that screenings for colon cancer should be initiated at age 45 for people of African American descent. In May 2018, the American Cancer Society made a recommendation modification that all people regardless of race began screenings at 45. We are now seeing a rise in colon cancer in millennials, which is alarming. This is a good thing to have the USPSTF agree with the same recommendations as other societies. Progress and impact in decreasing occurrence and death is expected.”

“Cases of young-onset colorectal cancer are on the rise and show no sign of stopping. If the screening was lowered to 45, my mom would have been diagnosed earlier with the possibility of the cancer being caught at a lower stage. That means everything for patients and family members. Colorectal cancer is not an old person's disease and the screening guidelines need to reflect that.”

“I am 46 and just finished chemo, chemo + radiation following the resection of my colon that removed 12 inches of cancerous tumor.  I was run down and thankfully presented with blood in stool that merited a screening- if I had waited until age 50, it would have been too late.”

We congratulate the USPSTF for updating its stance in response to the alarming growth of young-onset CRC. Lowering the recommended age for screening is supported by both the science and a moral obligation to save lives. Therefore, we applaud the USPSTF for its recommendation to reduce the age of screening for those at average risk of colorectal cancer to 45.