The Best Test Gets Done: Options Become Available for Colorectal Cancer Screenings

In 2021, the USPSTF changed guidance on colorectal cancer screenings, reducing the recommended age of a colonoscopy from 50 to 45 years.

Despite colon cancer being among the leading causes of death in the US, preventive screenings fall by the wayside for many at-risk patients.

Whether it is fear of the unknown, concerns over invasive procedures, or a lack of awareness, the suggestion to get a colonoscopy remains just a suggestion.

But options and alternatives to standard screening are now available and more may be on the way.

For individuals who want to avoid an invasive procedure like a colonoscopy, there are now stool-based options and may soon be blood-based tests for colorectal cancer screenings.

While colonoscopies are still considered the gold standard for colorectal cancer screenings, stool-based tests like FIT-DNA and Cologuard have emerged in recent years and have already captured an, albeit small, portion of the market.

However, there are access, coverage, and expense issues that do prevent better utilization of these diagnostic tools.

In an interview with HCPLive®, Mark B. Pochapin, MD,Director of Gastroenterology and Hepatology at NYU Langone Health, said the best test is the “1 that gets done” and having options is a good thing.

“It's really important to have choices, I think that's one of the things we've learned is that choices are really necessary,” Pochapin said.

He generally gives patients the choice of either 1- or 2-step process. The 1-step process is the colonoscopy, which is still considered the goal standard for colorectal cancer screenings.

“You go and you look, if you find a polyp, you remove it, when we by removing the polyp to prevent the cancer and one step we're done,” Rao said. “It's not pleasant, not so much because of the procedure because I can tell you even being on the receiving end of this procedure, it's actually wonderful. You get the sedation, you fall asleep. Next thing you know it's done. The bowel prep is just no fun.”

The 2-step process starts with a non-invasive stool-based option and if those tests are positive, it is crucial for the patient to then have a colonoscopy.

While the rates for colorectal cancer screenings increased in the last year, there still remains a gap in identifying high-risk patients and promoting screenings for them. 

Screening Rates are Bouncing Back

Despite a drop in colorectal cancer screenings during the COVID-19 pandemic, the numbers have increased in 2022, partly because of a multi-pronged campaign aimed at getting adults aged 45 years and older to come in for a colonoscopy.

“Surprisingly, we're quite pleased,”Pochapin said. “In fact, the numbers are even higher than they were prior to the pandemic. So, we've not only bounced back to where we were—we've actually gone above and beyond, I think part of that is a lot of people did not get screened during the height of the pandemic.”

The pool of potential screening applicants has expanded in recent years.

In 2021, the US Preventative Services Task Force (USPSTF) recommended reducing the age of initial colorectal cancer screenings from 50 years to 45 years.

The new guidance come at a time when colorectal cancer is the third leading cause of death for both men and women, amassing over 50,000 deaths annually in the US in recent years.

And while colorectal cancer is most frequently diagnosed in individuals aged 65-74 years, anecdotally doctors have said patients are presenting younger and younger in recent years. The incidence of colorectal cancer, especially adenocarcinoma, increased in adults aged 40-49 years by nearly 15% from 2000-2002 to 2014-2016.

In 2022, approximately 71% of all US residents aged 50 years or older are screened, compared to 67% in 2021. So, the rates are increasing but remain below the 80% benchmark many are hoping for.

Since the decision to reduce the age of recommended initial screenings, Pochapin said there is a concerted effort to reach both individuals in the 45-49 group and individuals in their early 50s to get screened.

Who Delivers the Message?

Getting the message out is of utmost importance, but it is also a challenge when talking about preventative care.

For example, who is supposed to be the 1 to give that message? Is it primary care doctors?

Pochapin said the problem is many people, particularly younger men, do not often see their primary care doctors for regular check-ins until they reach the age of 50. And while primary care and gastroenterologists doctors should promote cancer screenings, how do you reach a group of people who do not visit doctors?

He said celebrity messaging can actually have an impact. Both journalist Katie Couric and actor Ryan Reynolds have publicly promoted colonoscopies, something Pochapin said will have a lasting impact.

Identifying Risk

While the current guidance calls for everyone aged 45 years to be screened, the recommendations for high-risk people are a little murkier.

Right now, the best gauge as to whether an individual is considered high-risk for colon cancer and should be screened early, some by age 25, is a family history of the disease.

However, while this is well-established, the guidance on what to do about environmental and other non-genetic risk factors, such as history of inflammatory bowel disease (IBD), obesity, and tobacco and alcohol use is unclear.

Reducing the age to 45 for screening low-risk individuals is seen as a positive, 1 unfortunate issue is that patients who are presenting at health care facilities and getting diagnosed with colon cancer seem to be getting younger and younger in recent years.

And one way to counteract that is by doing a better job of identifying high-risk individuals and constantly reevaluating what the risk factors are.

“We know that there are certain risk factors associated with colorectal cancer,” Pavan K. Rao, MD, Alleghany Health Network said. “I think the most prevalent one these days, in our society in America is obesity. But for those patients that don't have a genetic predisposition but have some of these other high-risk factors. I know we don't have like great guidelines for when do we start? Unfortunately, we're only begin to understand the complex sort of role that these risk factors play in the development of cancer.”

Concerns Over a Lack of Providers

While there will be a continued push to screen as many people as possible for colorectal cancer, a major concern is many gastroenterologists have retired in recent years.

“As it stands now if all eligible patients performed their age-appropriate screening for colorectal cancer, we don't have enough providers nationally to meet that burden to do their colonoscopy,” Rao said. “S,o adding an additional 5 year’s worth of patient population to that is certainly not going to make our shortage of access to care any better nationwide.”

However, unfortunately increasing the numbers of doctors able to perform colonoscopies is not as easy as flipping a switch. Rao said the obvious solution is to promote more people into those fields, but that requires admitting more into medical school and having those individuals choose to matriculate into gastroenterology. Not something that can be done overnight.

While this is a generational fix, once again non-invasive screenings like mail-in stool tests, can help close some of these gaps and reduce the burden on gastrointestinal providers.

This allows doctors to become more selective on who should receive a colonoscopy without yielding worse outcomes for patients.

Closing Future Gaps

While the numbers for colorectal cancer screenings are increasing, there are some gaps in care that Aasma Shaukat, MD, MPH, Director of Research Outcomes, Division of Gastroenterology and Hepatology, NYU Langone, hopes are closed in the near future. For example, Black Americans are still much more likely to have a higher incidence and a higher mortality rate.

“I think focusing on is actually making a difference, I'd like to see the disparities really continue to disappear,” Shaukat said. “And we're definitely making some good progress in that realm.”

One trend that has emerged is some geographic variation in backlogs of screening.

“There's areas in the US where there is a backlog, and particularly healthcare systems in smaller rural areas, smaller towns, and they are unable to increase the capacity,”Pochapin said. “And they're still trying to catch up on the backlog and the more urgent things that have been brewing over the last few years.”

The backlog exists for a multitude of reasons, including a shortage of gastroenterologists, a shortage of nurses, and a lack of facilities available.

Other factors that can lead to individuals being unscreened include not having health insurance and surprisingly not having a healthcare provider, even for people who are insured.

“That's a big factor for 45- to 49-year-olds because they tend to generally be healthy, they don't really go to doctors,” Shaukat said. “So even if they have health insurance, they're unlikely to see a primary care doctor.”

And the major theme of the year is to give patients options as to what test to take because the “best test is the 1 that gets done.”

That may become even more of a prominent notion as Shaukat hopes 1 or 2 blood-based tests are on the horizon, maybe as soon as 1 year down the line.

And ultimately, despite a scare from COVID-19 and a backlog of available doctors, progress continues to be made.

“Considering that we had quite a backlog going into this year, I think we've caught up pretty well,” Shaukat said. “Large challenges remain in our healthcare system. But I would say we've done better than most healthcare systems around the world.”