Frequently Asked Questions About the American Cancer Society’s Colorectal Cancer Screening Guideline

On May 30, 2018, the American Cancer Society updated its colorectal cancer screening guideline for people at average risk. These answers to common questions provide additional information.

How does this guideline differ from previous ACS guidelines?

In the new guideline, the American Cancer Society recommends that people at average risk of colorectal cancer start regular screening at age 45, instead of starting at age 50 as recommended in the previous guideline. This can be done either with a test that looks for signs of cancer in a person’s stool (a stool-based test), or with a visual exam of the inside of the colon and rectum (also called a structural exam).

People who are in good health and with a life expectancy of more than 10 years should continue regular colorectal cancer screening through the age of 75. For people ages 76 through 85, the decision to be screened should be based on a person’s preferences, life expectancy, overall health, and prior screening history. People over 85 should no longer get colorectal cancer screening.

The previous guideline recommended some screening tests over others, but the new guideline does not. However, the new guideline no longer includes double-contrast barium enema as an acceptable screening option. Also, the new guideline stresses that when a screening test other than colonoscopy has an abnormal result, that test must be followed with a timely colonoscopy, in order to complete the screening process.

What tests does ACS recommend in the new guideline?

The American Cancer Society recommends that any of the following screening test options be used:

Stool-based tests:

• Fecal immunochemical test (FIT) every year, or
• High-sensitivity guaiac-based fecal occult blood test (HSgFOBT) every year, or
• Multi-target stool DNA test (MT-sDNA) every 3 years

Visual (structural) exams of the colon and rectum:

• Colonoscopy every 10 years, or
• CT colonography (virtual colonoscopy) every 5 years, or
• Flexible sigmoidoscopy every 5 years

If a person chooses to be screened with a test other than colonoscopy, any abnormal test result should be followed up with a timely colonoscopy in order to complete the screening process.

Why did ACS lower the recommended age to start screening at 45 instead of 50?

ACS lowered the age for people of average risk to start screening after looking closely at evidence that new cases of colorectal cancer are occurring at an increasing rate among younger adults. That evidence includes a major analysis led by ACS researchers. After reviewing this data, experts on the ACS Guideline Development Committee concluded that a beginning screening age of 45 for adults of average risk will result in more lives saved from colorectal cancer.

Will my insurance company cover colorectal cancer screening before age 50?

Health insurance plans may or may not yet cover the screening test for those in the new age range. This could result in out-of-pocket expenses. Before scheduling a screening test, it’s important to check insurance coverage for each test option. There are several screening options, and some may be more affordable than others, particularly when paid out of pocket.

ACS and its advocacy affiliate, American Cancer Society Cancer Action Network (ACS CAN) are working aggressively to educate insurers, lawmakers, and other stakeholders about the rising rates of colorectal cancer among younger adults, the evidence in support of screening for those ages 45-49, and the importance of expanding insurance coverage of screening for this age group.

Why doesn’t ACS say screening should start even earlier? Wouldn’t that save even more lives?

ACS analyzed the benefits and risks of starting screening at age 40, taking into account that screening can sometimes result in harm to an otherwise healthy person. The rate at which people ages 40 to 44 develop colorectal cancer is much lower than those ages 45 to 49, which means they are much less likely to benefit from screening. ACS will continue to watch for trends in new colorectal cancers and colorectal cancer deaths, as well as additional evidence on screening in younger populations for consideration in future guideline updates. The higher a person’s risk for cancer – due to age, family history, or other factors – the more likely the benefits of screening will outweigh the risks.

Why doesn’t ACS recommend colonoscopy over the other test options? Isn’t colonoscopy the best test?

The most important thing is to get screened, no matter which test you choose. Because people have different personal preferences, a choice of tests means more people are likely to get the screenings and follow-ups they need. In addition, if people stay up-to-date with annual FOBT with a high sensitivity test, long-term outcomes are similar to those that are estimated to be achieved with colonoscopy.

Why does ACS recommend a screening cut off age?

ACS set the screening cut-off age recommendation after looking at the benefits and risks for available screening tests. The risk of harm is greater in the elderly and people with certain health problems. People ages 76-84 should discuss the pros and cons of screening with their health care provider and make a decision based on their personal preferences and their health. After age 85 years, the potential harms of screening outweigh the potential benefits.

This guideline is for people at average risk for colorectal cancer. What about people who are at higher risk?

People at increased or high risk of colorectal cancer might need to start colorectal cancer screening before age 45, be screened more often, and/or get specific tests. This includes people with:

• A strong family history of colorectal cancer or certain types of polyps
• A personal history of colorectal cancer or certain types of polyps
• A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
• A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome (also known as hereditary non-polyposis colon cancer or HNPCC)
• A personal history of radiation to the abdomen (belly) or pelvic area to treat a prior cancer

Anyone with these risk factors should speak with their health care provider about when they should begin screening and how often they should be screened.