Physicians debate CRC guidelines, available screening options for younger patients

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In a new Annals of Internal Medicine “Beyond the Guidelines” feature, a primary care physician and a gastroenterologist discuss the recommendation to begin colorectal cancer (CRC) screening at age 45, review options for CRC screening, and discuss how to choose among the available options. All “Beyond the Guidelines” features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine. 

CRC is the third leading cause of cancer death for men and women in the United States. It is diagnosed most frequently among persons aged 65 to 74 years. However, among persons younger than 50 years, incidence rates have been increasing since the mid-1990s. In 2021, partially because of the rising incidence, the United States Preventive Services Task Force (USPSTF) recommended CRC screening for adults aged 45 to 49 years. The USPSTF does not recommend a specific screening test, but both stool-based and direct visualization tests are available and cost-effective.

BIDMC Grand Rounds discussants, Carol M. Mangione, MD, MSPH, Chair of the U.S. Preventive Services Task Force, as well as Chief of the Division of General Internal Medicine & Health Services Research and a Professor of Medicine at David Geffen Medical School, and David S. Weinberg, MD, MSc, Chair of the Department of Medicine at Fox Chase Cancer Center and a Professor of Medicine at Temple University Medical School recently debated the case of Ms. N., a 44 year-old woman deciding possible CRC screening options after receiving a recommendation from her doctor.

In their assessments, Drs. Mangione and Weinberg agree that Ms. N. should pursue the screening test she is most likely to agree to having performed. This consensus is in line with current USPSTF recommendations, but Dr. Weinberg notes that there are no age-specific empirical data regarding screening effectiveness and that in younger populations the false-positive rates, especially for stool-based testing, are likely higher and cost-effectiveness relatively lower. Dr. Mangione agrees with the USPSTF recommendation that Ms. N. should be screened at 45 rather than 50, because the Task Force determined that screening adults aged 45 to 49 provides moderate benefit for reducing the CRC mortality rate and increasing life-years gained.

However, Dr. Weinberg is concerned that there is no direct evidence to support that persons 45 to 49 years of age will derive the same benefit from CRC screening. The discussants also agree that reaching the 80% screening rate goal for persons aged 50 to 74 years is critically important as clinicians start thinking about screening those 45 to 49 years of age that we simultaneously identify and address barriers to screening the broader population.

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