The AAFP recommends screening for colorectal cancer in all adults starting at age 50 years and continuing until age 75 years. The risks, benefits, and strength of supporting evidence of different screening methods vary. (2021) A recommendation
The AAFP 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. (2021) C Recommendation
The AAFP concludes that the evidence is insufficient to assess the benefits and harms for screening for colorectal cancer in adults aged 45 to 49 years. (2021) I Statement
Clinical considerations from USPSTF: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening#bootstrap-panel--5
Rationale:
The AAFP has reviewed the US Preventive Services Task Force recommendation for colorectal cancer screening in adults. The AAFP agrees with the USPSTF that screening should be recommended for adults aged 50-75 based on substantial net benefit for this age group.
Screening in this setting refers to asymptomatic individuals using fecal immunochemical tests (e.g. high sensitivity gFOBT, FIT, and sDNA-FIT), flexible sigmoidoscopy, computed tomography colonoscopy, or colonoscopy. The decision of which screening modality to use should be based on a shared decision-making discussion of the benefits and harms of each modality. Patient preferences and values as well transportation, access to healthcare services, and other social determinants of health are all necessary in the shared decision-making process. The USPSTF has provided a summary of characteristics for each screening modality here: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening#bootstrap-panel--8
These recommendations do not apply to individuals who are symptomatic or at increased risk for colorectal cancer (e.g. family history, prior diagnosis of colon cancer, adenomatous polyps, or inflammatory bowel disease).
The AAFP also agrees with the USPSTF that screening for colorectal cancer in adults 76 years and older should be selectively offered as the net benefit in this age group is small and will be dependent on patient screening history, overall health status and individual preferences.
The AAFP does not agree with the USPSTF that there is sufficient evidence for screening for colorectal cancer in adults aged 45 to 49 years. The USPSTF recommendation for this age group centered on indirect evidence from modeling studies. Many of the trials did not include individuals under age 50 or did not provide these data separately decreasing the confidence in the data inputs. Additionally, the modeling studies assumed 100% adherence to screening and follow up protocols which may artificially elevate life years gained from earlier screening.
The AAFP noted that while the incidence of colorectal cancer in younger individuals is increasing,1 it is still relatively small and that the increased risk in this age group may be overestimated. There was also concern that there is no evidence that tumors in younger adults behave similarly to tumors in older adults and that early detection would be as beneficial.
These concerns decrease the confidence that the balance of benefits and harms is moderate in this age group. Further, decreasing the age for onset of screening may exacerbate disparities due to differences in access to healthcare and screening facilities. Studies have shown that disparities in colorectal cancer mortality are driven by differences in screening rates and not in true incidence of disease.2
The AAFP recognizes the increased incidence and mortality rates of colorectal cancer in Black individuals due to health disparities arising from systemic racism in the healthcare system. To reduce disparities, family physicians should have a standardized screening protocol and monitor their practices for disparities. Family physicians must be aware of the role of systemic racism in healthcare and work within their practices to develop anti-racism policies and practices. AAFP has provided resources on social determinants of health and implicit bias as part of The EveryOne Project (www.aafp.org/everyone).
In addition to strongly encouraging more data for screening individuals under age 50, the impact of social determinants including systemic racism, the AAFP continues to advocate for more research on the efficacy and harms of the newer screening modalities.
1. Siegel RL, Miller KD, Fedewa SA, et al. Colorectal cancer statistics, 2017. CA Cancer J Clin. 2017;67(3):177-193.
2. Rutter CM, Knudsen AB, Lin JS, et al. Black and white differences in colorectal cancer screening and screening outcomes: a narrative review. Cancer Epidemiol Biomarkers Prev. 2021 Jan;30(1):3-12.
These recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient's family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These recommendations are only one element in the complex process of improving the health of America. To be effective, the recommendations must be implemented.