Updates on Age to Start and Stop Colorectal Cancer Screening
Publication Date: November 15, 2021
Last Updated: March 14, 2022
Key Points
Although there are no clinical data on the impact of CRC screening in individuals under age 50 on CRC incidence or CRC-related mortality, there are sufficient supportive data for the MSTF to suggest average-risk CRC screening begin at age 45. As outlined in detail above, this recommendation is supported by the following:
- Increasing CRC incidence and mortality, such that incidence rates for 45- to 49-year-olds now matches incidence in populations that are already eligible for average-risk screening. Incidence in 45- to 49-year-olds is similar to the incidence observed in 50-year-olds in 1992 when CRC screening was first recommended for those ages 50 and older. Incidence in all 45- to 49-year-olds is currently similar to incidence in black Americans ages 45 to 49, for whom the MSTF recommended average-risk screening in 2017.
- Emerging data show that the rate of advanced colorectal neoplasia in average-risk individuals ages 45 to 49 is similar to advanced neoplasia rates observed in screening cohorts of those ages 50 to 59.
- Modeling studies that show benefits of screening outweigh harms in average-risk 45-49 year olds. Although not specific to a screening population, data show that colonoscopy is safe in 45- to 49-year-olds.
- Modeling studies demonstrate acceptable cost-effectiveness of average-risk screening to start at age 45.
Summary of Professional Society Recommendations on CRC screening
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| CRC screening start age | CRC screening stop age | |
|---|---|---|
| MSTF, 2021 | “We suggest that clinicians offer CRC screening to all average-risk individuals age 45-49 (weak recommendation; low-quality evidence).” | “We suggest that individuals who are up to date with screening and have negative prior screening tests, particularly high-quality colonoscopy, consider stopping screening at age 75 years or when life expectancy is less than 10 years (weak recommendation, low-quality evidence).” |
| “For average-risk individuals who have not initiated screening before age 50, we recommend that clinicians offer CRC screening to all average-risk individuals beginning at age 50 (strong recommendation, high-quality evidence).” | “We suggest that persons without prior screening should be considered for screening up to age 85, depending on consideration of their age and comorbidities (weak recommendation, low-quality evidence).” | |
| NCCN, 2021 66 |
“Average risk: age ≥45. The panel has reviewed existing data for beginning screening of average-risk individuals at age <50 years. Based on their assessment, the panel agrees that the data are stronger to support beginning screening at 50 years but acknowledges that lower-level evidence supports a benefit for screening earlier. When initiating screening for all eligible individuals, the panel recommends a discussion of potential harms/risks and benefits, and the consideration of all recommended CRC screening options.” |
Not provided |
| American College of Gastroenterology, 2021 67 |
“We recommend CRC screening in average-risk individuals between ages 50 and 75 years to reduce incidence of advanced adenoma, CRC, and mortality from CRC.” Strong recommendation; moderate-quality evidence “We suggest CRC screening in average-risk individuals between ages 45 and 49 years to reduce incidence of advanced adenoma, CRC, and mortality from CRC.” Conditional recommendation; very low-quality evidence |
“We suggest that a decision to continue screening beyond age 75 years be individualized (conditional recommendation strength, very low-GRADE quality of evidence).” |
| USPSTF, 2021 90 |
Grade A: “The USPSTF recommends screening for colorectal cancer in all adults ages 50 to 75 years.” Grade B: “The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years.” |
Grade C: “The USPSTF recommends that clinicians selectively offer screening for colorectal cancer in adults aged 76 to 85 years. Evidence indicates that the net benefit of screening all persons in this age group is small. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the patient's overall health, prior screening history, and preferences.” |
| ACP, 2019 91 |
“Clinicians should screen for colorectal cancer in average-risk adults between the ages of 50 and 75 years.” | “Clinicians should discontinue screening for colorectal cancer in average-risk adults older than 75 years or in adults with a life expectancy of 10 years or less.” |
| ACS, 2018 52 |
“The ACS recommends that adults aged 45 and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, 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 continue CRC screening through the age of 75 years (qualified recommendation).” |
| “The recommendation to begin screening at age 45 is a qualified recommendation.” | Clinicians should “individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history (qualified recommendation).” | |
| “The recommendation for regular screening in adults aged 50 y and older is a strong recommendation.” | Clinicians should “discourage individuals over age 85 years from continuing CRC screening (qualified recommendation).” |
MSTF, Multi-Society Task Force; NCCN, National Comprehensive Cancer Network; USPSTF, U.S. Preventative Services Task Force; ACP, American College of Physicians; ACS, American Cancer Society; CRC, colorectal cancer; GRADE, Grading of Recommendations Assessment, Development and Evaluation.
Areas of Future Work to Refine CRC Screening Recommendations
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| Areas | Recommendations |
|---|---|
| Patient selection | Starting age: Should age to start be the same for general population or determined by precision screening? Stopping age: Relative impact of age, prior screening history, CRC risk. patient preference, and comorbidities |
| Provider acceptance | Provider attitudes and behaviors regarding starting screening earlier, test selection, and stopping screening |
| Screening test selection | Menu of equivalent options vs tiered approach vs hybrid approach |
| Access, equity, compliance | Track disparities in access to and use of screening tests, diagnostic tests, and treatment Interventions to address screening underuse in medically underserved populations |
| Primary prevention | Populations that benefit from chemoprevention Optimal dietary and lifestyle recommendations |
Comparing Changes to CRC Screening Recommendations
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| Recommendations | |
|---|---|
| Updated | We suggest that clinicians offer CRC screening to all average-risk individuals ages 45 to 49 (weak recommendation; low-quality evidence). For average-risk individuals who have not initiated screening before age 50, we recommend that clinicians offer CRC screening to all average-risk individuals beginning at age 50 (strong recommendation, high-quality evidence). |
| Unchanged | We recommend high-quality colonoscopy every 10 years or an annual FIT as first-tier options for screening of colorectal neoplasia (strong recommendation; moderate-quality evidence). We recommend flexible sigmoidoscopy every 5 to 10 years (strong recommendation; high-quality evidence), CT colonography every 5 years (strong recommendation, low-quality evidence), or FIT–fecal DNA every 3 years (strong recommendation, low-quality evidence) in individuals who decline colonoscopy and a FIT. We suggest that capsule colonoscopy (if available) is an appropriate screening test every 5 years when individuals decline colonoscopy, FIT, FIT–fecal DNA, CT colonography, and flexible sigmoidoscopy (weak recommendation, low-quality evidence). We suggest that individuals who are up to date with screening and have negative prior screening tests, particularly high-quality colonoscopy, consider stopping screening at age 75 years or when life expectancy is less than 10 years (weak recommendation, low-quality evidence). We suggest that persons without prior screening should be considered for screening up to age 85, depending on consideration of their age and comorbidities (weak recommendation, low-quality evidence). |
Recommendation Grading
Overview
Title
Age to Start and Stop Colorectal Cancer Screening
Authoring Organizations
American College of Gastroenterology
American Gastroenterological Association
Society of American Gastrointestinal and Endoscopic Surgeons
Publication Month/Year
November 15, 2021
Last Updated Month/Year
June 9, 2022
Document Type
Guideline
Country of Publication
US
Target Patient Population
Adults aged 45 or greater
Target Provider Population
Gastroenterologists, primary care, internal medicine and more
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Prevention
Diseases/Conditions (MeSH)
D003113 - Colonoscopy, D015179 - Colorectal Neoplasms
Keywords
colorectal cancer, colonoscopy, CRC, CRC Screening, colorectal cancer screening
Source Citation
Patel SG, May FP, Anderson JC, Burke CA, Dominitz JA, Gross SA, Jacobson BC, Shaukat A, Robertson DJ. Updates on Age to Start and Stop Colorectal Cancer Screening: Recommendations From the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2022 Jan;162(1):285-299. doi: 10.1053/j.gastro.2021.10.007. Epub 2021 Nov 15. PMID: 34794816.