Cancer Group Calls for Colorectal Cancer Screening Starting at Age 45

A prominent cancer organization is for the first time recommending Americans initiate colorectal cancer screening at age 45 instead of waiting until age 50, a threshold long endorsed by many other medical groups. The new guidelines, from the American Cancer Society, would extend routine colorectal cancer screening to an additional 22 million American adults between the ages of 45 and 49 and send a clear message that colorectal cancer, which has been rising in young adults, is no longer just a disease of older people. Dr. Thomas Weber, who is the co-chairman of an early-age onset colon cancer task group for the National Colorectal Cancer Roundtable but who was not involved in writing the new recommendation, called lowering the age for first screening “a game changer” that could save thousands of lives.

“This is a very, very big deal,” said Dr. Weber, who is director of surgical oncology for the northwest region of Northwell Health. “Solid epidemiological data from our national cancer registries documents a dramatic increase in the incidence of colon and especially rectal cancer among individuals under the age of 50, and the vast majority of those cases are in the 40- to 49-year-old age bracket.” The guidelines, released Wednesday, were published in CA: A Cancer Journal for Clinicians, a peer-reviewed journal of the American Cancer Society. They do not call for everyone to have a colonoscopy, the gold standard of colon cancer screening. Rather, to maximize the chances that people will take up screening, the cancer society wants physicians to offer patients a choice of six different screening options, from the most invasive procedure, colonoscopy, which can be done every 10 years, to lab tests done on stool samples that can be collected at home, which must be repeated more often and followed by colonoscopy if results are positive. The group estimates some 16,450 new cases of colon or rectal cancers will be diagnosed this year in Americans under 50. In 2014, 43 percent of colorectal cancer cases in those under 50 were in adults aged 45 to 49, according to Rebecca L. Siegel, an epidemiologist with the American Cancer Society and the lead author of several reports showing a rise in colorectal cancers in adults as young as their 20s and 30s.

The group does not recommend routine screening for those under 45 because the absolute rates of cancer in those age groups are still very low and there are risks associated with procedures like colonoscopies, including a perforated bowel. Over 140,000 Americans are expected to be given a diagnosis of colon or rectal cancer this year. The disease leads to over 50,000 deaths annually, making it the second leading cause of cancer fatalities among American adults. The vast majority of colorectal cancers are still found in older people, with nearly 90 percent of all cases diagnosed in people over 50. But while incidence and deaths among those 55 and older have been declining in recent decades, at least in part because of screening that results in removal of precancerous polyps and early detection of cancer, recent analyses have documented a 50 percent rise in colorectal cancer rates among adults under 50 between 1994 and 2014. While colorectal cancer rates dropped steadily for people born between 1890 and 1950, they have been increasing for every generation born since 1950. A recent American Cancer Society study by Dr. Siegel found that adults born in 1990 have twice the risk of colon cancer and four times the risk of rectal cancer compared to the risk adults born in 1950 faced at a comparable age.

For younger adults like Gale Fritsche, now 55, of Allentown, Pa., existing recommendations fell short. Mr. Fritsche went in for his first screening colonoscopy at 50 but discovered he already had advanced colon cancer. “I went in there not thinking there’s going to be a problem, and I wake up with two doctors standing over me saying, ‘We have an issue,’” said Mr. Fritsche, a competitive athlete who said he follows a healthy diet and has no family history of colon cancer. “If screening had started five years earlier, my cancer might have been caught at the really early stages and not been as advanced as it was.” The new guideline puts the American Cancer Society at odds with other national organizations that recommend starting screening at 50, and raises questions about whether health insurers will pay for the earlier tests. The influential Preventive Services Task Force decided against lowering the screening age to 45 when it updated its recommendations in 2016, and continues to recommend starting routine screening at 50. The Multi-Society Task Force on Colorectal Cancer, which includes representatives from several gastroenterology groups, urges African- Americans to start routine screening at 45 because they carry a higher burden of colorectal cancer but advises others at average risk to start screening at 50.

The American Cancer Society acknowledges that the evidence for screening in those under 50 is not as robust as for those 50 and older, but say it is compelling nonetheless. The group also says that screenings should continue through age 75 but that decisions for those over 75 should be individualized based on patient preference, life expectancy and health status. The message to both the general public and to physicians is that “colorectal cancer can occur at any age,” even among teenagers, said Dr. Richard C. Wender, chief cancer control officer for the American Cancer Society. “If you’re losing weight or have bowel changes or have symptoms like blood in your stool, you need an answer as to why.” He noted that though hemorrhoids are one cause of rectal bleeding, they are less common in younger people and “there’s no such thing as normal rectal bleeding.” “What’s really important is for physicians to be aware,” said Dr. Robin Mendelsohn, a gastroenterologist who is co-director of the Center for Young Onset Colorectal Cancer at Memorial Sloan Kettering Cancer Center, which is dedicated solely to treating patients under 50. “Many of our young patients say, ‘Well I saw five doctors who said it was hemorrhoids and thought I was too young to have cancer.’ One of our main goals is to get the word out to all the physicians who are seeing these people first.”