New colorectal screening guidelines include younger patients

Based on increase in colorectal cancer in younger patients

The American Cancer Society (ACS) has released updated colorectal screening guidelines for adults that now recommend screening to begin at age 45, not age 50 as recommended by the U.S. Preventive Services Task Force (USPSTF). Although the recommendation to begin screening at age 45 is a “qualified” one based on the limited evidence available for this age group, ACS noted a marked increase in colorectal cancer, particularly rectal cancer, in younger patients. Therefore, ACS’s assessment concluded that the benefit–burden balance of colorectal screening is improved by lowering the initiation age by 5 years.

The majority of ACS recommendations align with the USPSTF recommendations from 2008, except for the new lower age group. Specifically, ACS recommends that adults aged 45 years and older with an average risk of colorectal cancer undergo regular screening (qualified recommendation).

An “average risk” is defined as a person without a history of the following: adenomatous polyps or colorectal cancer, a family history of the disease, a confirmed or suspected hereditary colorectal cancer syndrome, a personal history of abdominal or pelvic radiation from a previous cancer, or a personal history of inflammatory bowel disease.

A “strong” recommendation is given to screening patients aged 50 years and older, with screening recommended through age 75 for those in good health and a life expectancy of at least 10 years (qualified recommendation).

For older patients (76–85 y), decisions should be made on an individualized basis, considering factors such as health status, life expectancy, and prior screening history. Screening is discouraged in those older than 85 years.

Options for screening include one of three stool-based tests: a yearly fecal immunochemical test; a yearly high-sensitivity, guaiac fecal occult blood test; or a multitarget stool DNA test every 3 years. In addition to the stool-based tests, other screening options include a colonoscopy every 10 years, a CT colonography (also known as a virtual colonoscopy) every 5 years, or a flexible sigmoidoscopy every 5 years.

Colorectal cancer is the second leading cause of cancer-related deaths and the fourth most commonly diagnosed cancer in the United States. Approximately 140,000 Americans will be diagnosed this year, and 50,000 patients will die from the disease. Risk factors such as smoking, obesity, excessive consumption of red/processed meat and poor intake of fruits and vegetables, and physical inactivity all increase the risk of colorectal cancer.

Colorectal screening has reduced the mortality associated with colorectal cancer in adults 55 years and older; however, for younger adults (<55 y), data have shown a 51% increase in the incidence of colorectal cancer over a 20-year period (1994–2014) along with an 11% increase in mortality from 2005 to 2015.

CDC reported that in 2016, 67.3% of U.S. adults aged 50 to 75 years were up to date with their colorectal cancer screening, defined as a fecal occult blood test (FOBT) within 1 year, colonoscopy within 10 years, or flexible sigmoidoscopy with a FOBT within 3 years.

This means that almost one-third of patients are not up to date with screening or have never been screened, and more of these patients are aged 50 to 64 years, are uninsured, and/or are in a minority group.

Therefore, interventions aimed at increasing colorectal screening rates are essential to reduce the burden of disease.

For the full article, please visit www.pharmacytoday.org for the August 2018 issue of Pharmacy Today.