Colorectal Cancer Screening Guidelines Address Rising Incidence in Younger Adults

While colorectal cancer incidence has declined over the past two decades due to screening in people 55 and over, there has been a 51 percent increase in those under 50 since 1994, according to the American Cancer Society (ACS).

Therefore, the society issued an updated guideline recommendation that now calls for screening to begin at age 45 for individuals at average risk for colorectal cancer.

While incidence rates among those who are 45 to 49 years of age are lower than those 50 to 54 years, the ACS attributed this partially to the uptake of screening at age 50, which leads to an increase in the incidence rate due to detection of prevalent cancers before symptoms arise.

“This is something that is important, and we need to pay attention to,” Susan K Peterson, Ph.D., M.P.H., from the Department of Behavioral Science in the Division of Cancer Prevention and Population Sciences at the University of Texas MD Anderson Cancer Center, said in an interview with CURE.

“This is a way to prevent this disease from happening in younger persons by implementing guidelines like the ACS has just announced, (and it is) one way we can potentially stem both the occurrence of these cancers and the morbidity and mortality from them as well,” she added.

ACS Recommendation

The ACS based its recommendation on colorectal cancer incidence rates, results from microsimulation modeling that demonstrated a favorable benefit-to-burden balance of screening beginning at age 45, and the expectation that screening will perform similarly in these adults as it does in adults aged 50 and older.

The guidelines, recently published in CA: A Cancer Journal for Clinicians, recommend the following:

• Adults aged 45 and older with an average risk for colorectal cancer should undergo regular screening — either with a high-sensitivity stool-based test or a structural exam, depending on patient preference and test availability.
• All positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy.
• Average-risk adults in good health with a life expectancy of greater than 10 years should continue colorectal cancer screening through age 75; for those 76 to 85 years, clinicians should individualize colorectal cancer screening decisions based on patient preferences, life expectancy, health status, and prior screening history; and those over age 85 should be discourages from continuing colorectal cancer screening.

Patients can be screened using a fecal immunochemical test annually; high sensitivity guaiac-based fecal occult blood test annually; multi-target stool DNA test every three years; colonoscopy every 10 years; CT colonography every five years; and flexible sigmoidoscopy every five years.

“The guidelines do not recommend only going colonoscopy, which is often times considered the gold standard of screening tests, so patients have a choice of what test they can use,” said Peterson. “Sometimes, a colonoscopy can be a bit off-putting … many people don’t really look upon a colonoscopy as favorably as something that is less invasive. So, the guidelines do allow for a variety of screening tests.”

What to Know

Now that these guidelines have been issued, it is important for patients to learn about their family history of any cancer type.

“If you have a family history of colon cancer you may benefit from being testing for an inherited gene mutation that indicates you have one of the known hereditary cancer syndromes,” Peterson said. “But even if you don’t have a risk for having a hereditary cancer syndrome, having a family history of colon cancer still puts you at increased risk for developing the disease by virtue of having a first degree relative who was diagnosed with colorectal cancer.”

“So, it is important. Everyone should know their family history, be aware of it and share that information with their doctors,” she added.

In addition, patient discussions with their doctor should start before the age of 45 — even if it is just to determine when screening should start. “It sometimes happens that a person doesn’t know when to see their doctor or they put off screening for a year or two, and then they are already behind the curve a bit in terms of getting screened,” Patterson said.

In addition, for any young to middle-aged individuals who present with symptoms, but are dismissed by a health care professional because of their age, should seek a second opinion.

“As a patient, if you go to a doctor presenting with symptoms and the doctor does not explore them and try to diagnose what is going on, go see someone else,” Peterson said. “Be your own best advocate. Talking about this, although uncomfortable, and becoming aware and to find out what is going on is really important.”

Young Enough?

At the GI Cancer Patient Summit — recently held on June 16 – John Marshall, M.D., chief of the division of hematology/oncology at Medstar Georgetown University Hospital and director of the Otto J. Ruesch Center for the Cure of Gastrointestinal Cancer, noted that while screening is helpful, the risk for those under 45 is still alarming.

“Three weeks ago, I had a 17-year-old patient of mine die of metastatic colon cancer the day after he received his high school diploma. The number of patients I have now who are in their 20s, 30s and 40s is through the roof. More than half of my clinic now is under the age of 50. And just moving it down to 45 is not going to pick up all of those people,” he said.

However, Donald B. Colvin, MD, FACS, FASCRS, founder of Fairfax Colon & Rectal Surgery and associate professor of surgery for the Medical College of Virginia, who was also a speaker at the summit, acknowledged these guidelines can help push research further.

“Some of those (young adults) have familial histories or syndromes, which years ago we didn’t really know much about. Years ago, we didn’t screen or pay much attention to that. Certainly, the biggest factor for controlling colorectal cancer is early detection and screening,” he said.

Peterson agreed, highlighting the importance of family history. “Families really are their best and secret weapons in terms of raising awareness and becoming aware of their risks for colon cancer and the importance of screening.”

“Boiling it down, this should be a wakeup call that if you are younger than 45 and are identifying symptoms that might be related to colorectal cancer, go see your doctor and do not put it off,” she added.