New Recommendations: Start Screening People at Average Risk for Colorectal Cancer at Age 45

Tips for counseling patients included throughout new guidelines

The American Cancer Society updated its recommendations for colorectal cancer screening for the first time in a decade, and the most notable change is a lowering of the minimum age for screening from 50 to 45 years among people at average risk.

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There is also a greater emphasis on patient preferences for screening and guidance on when physicians can consider discontinuing screening based on patient age.

Screening efforts among those 50+ have been largely successful in reducing incidence of colorectal cancer. However, the American Cancer Society (ACS) updated their recommendations because of a growing incidence of colorectal cancer and related mortality among younger people.

“It seems that we’re doing a really good job in terms of having people get appropriate screening tests — thus lowering the overall incidence of colorectal cancer — in those older than 50 years old,” says Scott R. Steele, MD, Chairman of the Department of Colorectal Surgery at Cleveland Clinic. “But what we need to do now is say: ‘What’s going on with these patients younger than 50?’”

Physicians continue to play an essential role in counseling patients and encouraging screening. Colon cancer is the fourth most common cancer diagnosed in adults and the second leading cause of cancer-related death in the United States, the ACS notes.

However, colorectal cancer remains largely preventable with regular screenings.

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Of all the GI cancers, “colorectal cancer can be one that through an intervention, we can detect it early — even in the pre-cancerous stage — and intervene before it gets to cancer, at that polyp stage, and take care of it,” Dr. Steele says.

Offer patients multiple options

The ACS recommends physicians discuss screening options with patients and consider their preferences to boost adherence. “Ascribing to the adage that the best CRC screening test is the one that gets done, and done well, the ACS recommends that patients initiating screening or previously non-adherent with screening be offered a choice of tests based on availability of high-quality of options,” the authors wrote. A multidisciplinary ACS Guideline Development Group drafted the 32-page updated recommendations published in CA: A Cancer Journal for Clinicians.

Offering a choice among one or two stool-based tests and one or two structural examinations (such as colonoscopy) would be practical. However, “clinicians should be prepared to … introduce additional options if the patient does not appear to be accepting of the tests initially presented.” The recommendations outline six testing options but do not endorse any strategy above the others.

Insurance coverage could present challenges

Ensure patients know that an initial, positive stool-based screening test will necessitate a confirmatory colonoscopy, the ACS wrote. In some states, insurers consider this follow-up colonoscopy diagnostic, thereby exposing a patient to more financial responsibility for the examination.

In addition, most insurers follow current recommendations from the United States Preventive Services Task Force to start screening at age 50. It is likely in the near term, the authors noted, that younger patients will also face challenges regarding insurance coverage.

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“The ACS and other organizations are working aggressively to educate insurers and policymakers on the rising rates of CRC among younger individuals, the evidence in support of screening for individuals aged 45 to 49 years, and the importance of expanding screening coverage to this group.”

More research needed

Unlike the “strong recommendations” for screening at age 50+, the guidance in patients 45 to 49 years old remains “qualified recommendations” at this time, primarily because of less evidence in the literature addressing outcomes among patients younger than 50. Going forward, researchers should include more younger patients in clinical trials, the ACS stated.

In the meantime, current capacity for CRC screening could handle an increase in demand from the expanded age recommendations, the authors noted. In addition, overall earlier screening could benefit patient subpopulations considered at higher risk for CRC as well, including blacks, Alaska natives and American Indians.

The ACS provides clinical tools, including decision aids, to help physicians effectively counsel their patients about the importance of colorectal cancer screening. These materials are online at