Updates on Age to Start and Stop Colorectal Cancer Screening

Publication Date: November 14, 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
“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
“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
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
“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
“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 14, 2021

Last Updated Month/Year

May 8, 2024

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.

Methodology

Number of Source Documents
94
Literature Search Start Date
March 5, 2014
Literature Search End Date
March 5, 2021