Inequitable health outcomes for colorectal cancer
The purpose of screening for cancer is to reduce the morbidity and mortality associated with the disease. Based on the Surveillance, Epidemiology and End Results (SEER) national reporting system, from 2014 to 2018 colorectal death rates per 100,000 adults were 18 for Black adults; 15.1 for American Indian/Alaska native adults; 13.6 for White non-Hispanic adults; 10.9 for White, Hispanic adults; and 9.4 for Asian/Pacific Islander adults.7 Lack of access to and a lower utilization rate of high-quality colon cancer screening modalities, for example colonoscopy, and a lower rate of optimal colon cancer treatment may account for the higher colorectal death rate among Black adults.8,9
Colorectal cancer screening should begin at age 45
In 2015 the Agency for Health Research and Quality (AHRQ) published data showing that the benefit of initiating screening for colorectal cancer at 45 years of age outweighed the additional cost.10 In 2018, the American Cancer Society recommended that screening for colorectal cancer should begin at age 45.11 In 2021, after resisting the change for many years, the US Preventive Services Task Force (USPSTF) also recommended that screening for colorectal cancer should begin at 45.7 The new recommendation is based on statistical models that showed a significant increase in life-years gained at a small incremental cost. The USPSTF also recommended that clinicians and patients could consider discontinuing colorectal cancer screening at 75 years of age because the net benefit of continuing screening after age 75 is minimal.
Prior to 2021 the USPSTF recommended that screening be initiated at age 50. However, from 2010 to 2020 there was a significant increase in the percentage of new cases of colorectal cancer detected in people younger than 50. In 2010, colon and rectal cancer among people under 50 years of age accounted for 5% and 9% of all cases, respectively.12 In 2020, colon and rectal cancer in people younger than age 50 accounted for 11% and 15% of all cases, respectively.3
Options for colon cancer screening
There are many options for colorectal cancer screening (TABLE 2).10,13 Experts conclude that the best colorectal cancer screening test is the test that the patient will complete. Among options for screening, colonoscopy and the multitarget stool FIT-DNA test (Cologuard) have greater sensitivity for detecting colorectal precancer and cancer lesions compared with fecal immunochemical testing (FIT), computed tomography colonography imaging (CTC), and stool guaiac testing (see TABLE 1).
In my practice, I suggest patients use either colonoscopy (every 10 years) or the multitarget stool FIT-DNA test (every 1 to 3 years) for screening. Most of my patients select colonoscopy, but some prefer the multitarget stool FIT-DNA test because they fear the pre-colonoscopy bowel preparation and the risk of bowel perforation with colonoscopy. Most colonoscopy procedures are performed with sedation, requiring an adult to take responsibility for transporting the patient to their residence, adding complexity to the performance of colonoscopy. These two tests are discussed in more detail below.
Colonoscopy
Colonoscopy occupies a unique position among the options for colorectal cancer screening because it is both a screening test and the gold standard for diagnosis, based on histologic analysis of the polypoid tissue biopsied at the time of colonoscopy. For all other screening tests, if the test yields an abnormal result, it is necessary to perform a colonoscopy. Colonoscopy screening offers the advantage of “one and done for 10 years.” In my practice it is much easier to manage a test that is performed every 10 years than a test that should be performed annually.
Colonoscopy also accounts for most of the harms of colorectal screening because of serious procedure complications, including bowel perforation (1 in 2,000 cases) and major bleeding (1 in 500 cases).7
Continue to: Multitarget stool FIT-DNA test (Cologuard)...