New guidelines on screening for colorectal cancer, second deadliest cancer

colonoscopy graphic

Colorectal cancer is the second leading cause of death from cancer in the United States, after lung cancer, yet many Americans are still loathe to be screened for the disease.

The U.S. Preventive Services Task Force strongly recommended adults ages 50 to 75 to be screened for colon cancer and suggested adults 76 to 85  make individual decisions about whether to be screened, depending on their overall health and prior screening history. The recommendation and several accompanying editorials were published Wednesay in the Journal of the American Medical Association (JAMA).

The independent body of national experts in prevention and evidence-based medicine emphasized colonoscopy is not the only valid test out there. There are multiple screening options available to the one-third of Americans over 50 who have never been screened.

We pose five key questions about the Task Force recommendations to Douglas K. Owens, the Henry J. Kaiser, Jr., Professor of Medicine at Stanford and director of the Center for Health Policy and Center for Primary Care and Outcomes Research. He is an author of the recommendation and was a member of the Task Force when the guidelines were developed.

What is the most significant finding of this final recommendation?

Colorectal cancer is the second leading cause of death from cancer in the United States. The good news is that evidence convincingly shows screening for colorectal cancer works. The Task Force strongly recommends screening adults 50 to 75 for colorectal cancer, as it reduces the risk of dying from the disease. Unfortunately, one-third of people 50 to 75 have never been screened, so we are missing an important opportunity to prevent deaths from colorectal cancer.

There are multiple screening options for colorectal cancer. What are they and how should individuals decide which is best for them?

What really matters is that people get screened. There are several options that are effective, so we recommend that people discuss the options with their clinician. There are direct visualization tests, like colonoscopy, and stool-based tests, like fecal immunochemical testing (FIT). Each test has different strengths and limitations, and people may prefer one approach over another. For example, colonoscopy can be done every 10 years, but FIT testing should be done every year. But the real message is, choose an approach in consultation with your clinician and get screened.

The Task Force found that once adults reach 76 years old, the benefits of screening become smaller and the potential for harm is greater. Why is this and how should older Americans determine which test is best for them?

We recommend individual decision making for patients 76 to 85. The benefits are smaller because a person’s chance of dying of other causes goes up as they get older. The harms are still small but increase with age, primarily because the risks of the potential complications of colonoscopy (bleeding, perforation, and infection) go up with age. Still, some people in this age group will benefit from screening. People most likely to benefit are those who have not been screened before, people who are healthy enough to undergo treatment for CRC should it be found, and people who do not have other diseases or conditions that limit their life expectancy substantially.

Owens explains the Task Force's recommendations to JAMA

Headshot of Owens


JAMA Network | JAMA | USPSTF Recommendation Statement: Screening for Colorectal Cancer


African-Americans have the highest incidence of and mortality rates from colorectal cancer among all racial and ethnic subgroups. Why are African-Americans more susceptible and does this mean that the screening recommendations differ for them?

The Task Force recognizes the burden that colorectal cancer has on African-Americans, who are at higher risk of being diagnosed with and dying from the disease than other racial/ethnic subgroups. We don’t know why this is — more research is needed in this area. The Task Force did not find enough evidence to conclusively support that making a different recommendation specific to African-Americans would result in a greater net benefit for this population. So our recommendations are intended to apply to all racial/ethnic groups. More robust efforts are needed to ensure that at-risk populations actually receive the screening tests and the follow-up treatments or interventions they need, as people are dying unnecessarily from this disease.

What data did the Task Force use to come to its conclusions?

The Task Force commissioned a comprehensive systematic review of the available evidence on the benefits and harms of colorectal cancer screening. The Task Force also commissioned a modeling study from the Cancer Intervention and Surveillance Modeling Network (CISNET) to help it better understand different screening strategies, such as the optimal age to start or stop screening, and the length of time between screenings. The evidence is convincing that screening reduces the risk of dying from colorectal cancer.

Who is at high risk for colorectal cancer?

The Task Force’s recommendation is for people at average risk of colorectal cancer.  People at high risk include those with a history of genetic predisposition to colorectal cancer (including people with Lynch syndrome and familial adenomatous polyposis), and people with a personal history of inflammatory bowel disease, a previous adenomatous polyp, or previous colorectal cancer.  Other groups have developed guidelines for people a high risk, including the U.S. Multisociety Task Force and the American Cancer Society.

How can precision health help colorectal cancer prevention?

The Task Force did not address how precision health might play a role in the future. However, we do know that although most cases of colorectal cancer are sporadic, with about 75 percent developing in average risk persons, there are inherited syndromes that increase the risk of colorectal cancer. The inherited familial syndromes, defined by a mutation in a known high-risk cancer susceptibility gene, that increase the risk of colorectal cancer include Lynch syndrome and familial adenomatous polyposis. Family history that is not linked to a known inherited risk syndrome is also a risk factor for colorectal cancer, with an average two- to four-fold increase in risk compared to those people who do not have a family history of colorectal cancer. Understanding more about the causes of this increase in risk is an important area for future research.   

What can help reduce one’s risk for colorectal cancer? 

The Task Force released a final recommendation in April 2016 on the use of aspirin to prevent colorectal cancer in people with an elevated risk of cardiovascular disease. For adults ages 50 to 59 years with a greater than 10 percent risk of a cardiovascular event, a life expectancy of at least 10 years, who are not at increased risk for bleeding, and who are willing to take a daily aspirin for at least 10 years, the Task Force recommends the daily use of low-dose aspirin. In this group, aspirin reduces both the risk of cardiovascular disease and the risk of colorectal cancer. It’s important to recognize that the Task Force’s recommendation on colorectal cancer screening is a complement to this recommendation, but neither is a replacement for the other. The Task Force is not suggesting that anyone should use aspirin in place of colorectal cancer screening. Colorectal cancer screening is an important, well-proven preventive intervention that reduces the risk of dying from colorectal cancer.

What symptoms usually present for patients with polyps or colorectal cancer?

It’s important to understand that people with colorectal cancer may have no symptoms whatsoever, and the Task Force’s recommendations are for people without symptoms. Symptoms can include blood in the stool or a change in bowel habits. If people have such symptoms, they should discuss them with their clinician.

What treatment options are available for people diagnosed with colorectal cancer? How have these options changed over time?

The Task Force did not examine treatment options in its final recommendations, as its focus is solely on preventive services such as screening. However, based on my professional experience I can attest that treatment depends on the extent of cancer and may involve surgery, chemotherapy, and radiation therapy.