The American Cancer Society in 2018 lowered the recommended age to start screening for colorectal cancer from age 50 to 45 for people with an average risk, due to an increasing number of patients developing colorectal cancer at younger ages. But that advice has been largely ignored.
Less than 20 percent – fewer than 4 million of the 19 million adults affected by the recommendation – were up to date with recommended screening in 2021, the most recent year for which stats are available.
As reported in the American Cancer Society 2024 Cancer Facts & Figures, there’s been a corresponding rise in colorectal cancer diagnoses among people younger than 50. In the late 1990s, colorectal cancer was the fourth leading cause of cancer death in both men and women in this age group. Now, it’s the primary cause of cancer death in men younger than 50 and the second leading cause in women that age.
Many people avoid the procedure because of discomfort – that yukky colon cleanse ahead of time – or embarrassment, but colorectal cancer often develops without noticeable symptoms, which makes early detection challenging without screening. A colonoscopy allows doctors to examine the inner lining of the colon and rectum, identifying any abnormal growths or changes before they become life-threatening.
“Honestly, the procedure itself is always comfortable because the patient is sedated the whole time, so he won’t feel any pain or wake up during the procedure,” said Michelle Likhtshteyn, MD, a gastroenterologist at Cleveland Clinic Indian River Hospital. “The prep practice (colon cleanse!) is not great but it’s really not that bad. True, you’ll be up all night going to the bathroom, but you’ll have a nice nap during the procedure. I tell my patients you only have to do it once and you’re good for many years.”
Other medical organizations have mimicked ACS’ 2018 recommendation and age 45 is now the recommended time to start screening for colorectal cancer among all average-risk adults according to prevailing guidelines.
“If a first-degree relative had colon cancer, meaning your mother, father or sibling, you should potentially get your first colonoscopy at age 40, or 10 years younger than the age at which your family member was diagnosed,” said Dr. Likhtshteyn.
Colonoscopy is considered the gold standard for screening with a 95 percent efficacy rate and is recommended every 10 years for average-risk individuals. While the patient is sedated, the doctor inserts a long, thin, flexible, lighted scope into the rectum and checks for polyps or cancer inside the rectum and the entire colon. During the procedure, the doctor can remove most polyps and some cancers. If polyps are detected and removed your doctor will recommend more frequent screenings depending on the number, type and size of the polyps.
Colon cancer tests taken at home have some advantages and some disadvantages compared to a colonoscopy. They are generally free if you have health insurance and don’t require a doctor visit or any messy preparation.
“At-home stool tests are a less invasive option for screening, but their efficacy is only about 60 percent,” Dr Likhtshteyn explained. “And if the home test result is positive or abnormal, a colonoscopy screening is needed to complete the screening process anyway. The multi-targeted DNA test is a bit more sensitive than the specific tests, but it might have to be done every year. So you’re doing something every year verses just getting a colonoscopy once every 10 years if everything is normal.”
The CDC lists three types of at-home stool tests:
- The guaiac-based fecal occult blood test (gFOBT) uses the chemical guaiac to detect blood in the stool. It’s done once a year. You receive the test from your provider and use a brush or stick to obtain a small amount of stool which you then return to the doctor or lab to be tested for the presence of blood.
- The fecal immunochemical test (FIT) uses antibodies to detect blood in the stool. It is also done once a year.
- The FIT-DNA test combines the FIT with a test that detects altered DNA in the stool. For this test you collect an entire stool sample and send it to a lab where it is tested for altered DNA and the presence of blood. It is done every three years.
It is important to note that if your result is positive or abnormal on a home screening test, a colonoscopy is still needed for a diagnosis. Talk to your doctor about which test is right for you.
“I believe that home tests are really only for very healthy patients with no family history of colon cancer,” Dr. Likhtshteyn said. “And anyone who has had a colonoscopy and had polyps removed should definitely not do a home stool test. The risk of missing some polyps is just too high.
Ultimately that’s what will lead to colon cancer. If polyps go undetected for 10 or 20 years, then you are at the point where you’ve got a very large cancer and that’s unfortunate. By removing the polyps you remove the risk of cancer.”
The testing picture continues to change with the advent of artificial intelligence in medical practice.
“In terms of advancement, AI is coming into play,” Dr. Likhtshteyn noted. “AI algorithms are trained to identify and highlight colonoscopy results, acting as a second set of eyes for the physician. It can pick up really small polyps that I might not detect with the naked eye. It also helps determine what level it is. It ultimately will lead to earlier and more accurate diagnosis.”
The most common cause of post-colonoscopy colorectal cancer is doctors missing polyps that have the potential to become cancerous during screening. Mayo Clinic Gastroenterology and Hepatology found that using AI in colorectal cancer screening produced a 50 percent reduction in that miss rate.
Colonoscopies are also used to diagnose various gastrointestinal conditions, such as inflammatory bowel disease, Crohn’s disease and ulcerative colitis. Anyone who is experiencing abdominal pain, rectal bleeding or chronic diarrhea may need to have a colonoscopy to diagnose the condition.
Colorectal cancer remains the second deadliest cancer worldwide, yet it is almost entirely preventative with proper screening. Colonoscopies are safe, painless and typically take less than an hour to perform. Most patients are able to resume their daily activities the same day, feeling reassured about their health and risk of colon cancer.
Michelle Likhtshteyn, MD, is a gastroenterologist at Cleveland Clinic Indian River Hospital, specializing in cancer screening, clinical gastroenterology, colonoscopy, esophagogastroduodenoscopy, general gastroenterological disorders and outpatient care. She completed her fellowship and residency in gastroenterology and internal medicine at SUNY Downstate Medical Center in Brooklyn, N.Y., where she treated a wide range of gastrointestinal conditions. She sees patients at the Rosner Family Health and Wellness Center, 3450 11th Court, Vero Beach, 877-463-2010.
