At what age should colon cancer screening start?

Colorectal Cancer Screening Age Recommendations

Colorectal cancer screening should begin at age 45 for average-risk individuals, as recommended by the US Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS). 1

Screening Recommendations by Age Group

Ages 45-49

• The US Multi-Society Task Force on Colorectal Cancer suggests offering CRC screening to all average-risk individuals ages 45-49 (weak recommendation; low-quality evidence) 2
• This represents a change from previous recommendations that started screening at age 50, reflecting increasing rates of colorectal cancer in younger adults 1

Ages 50-75

• For average-risk individuals who have not initiated screening before age 50, screening is strongly recommended beginning at age 50 (strong recommendation, high-quality evidence) 2
• Screening should continue through age 75 for those in good health with life expectancy greater than 10 years 1

Ages 76-85

• Screening decisions should be individualized based on:
  • Prior screening history
  • Overall health status
  • Life expectancy
  • Patient preferences 1
• Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities (weak recommendation, low-quality evidence) 2

Age >85

• Screening should be discontinued as the benefits are outweighed by the risks 1

Special Populations

African Americans

• Current guidelines recommend screening beginning at age 45 for all populations, including African Americans 1
• This represents a change from older guidelines that had recommended earlier screening specifically for African Americans 3

Higher-Risk Individuals

• Those with a first-degree relative diagnosed with CRC or advanced adenoma before age 60 should begin screening at age 40 or 10 years before the youngest affected relative's diagnosis (whichever is earlier) 1
• Screening should be performed by colonoscopy every 5 years for these higher-risk individuals 1

Recommended Screening Modalities

Tier 1 (Preferred Options)

• Colonoscopy every 10 years (strong recommendation; moderate-quality evidence) 2, 1
• Annual fecal immunochemical test (FIT) (strong recommendation; moderate-quality evidence) 2, 1

Tier 2 Options

• CT colonography every 5 years (strong recommendation, low-quality evidence) 2, 1
• FIT-fecal DNA test every 3 years (strong recommendation, low-quality evidence) 2, 1
• Flexible sigmoidoscopy every 5-10 years (strong recommendation, high-quality evidence) 2, 1

Tier 3 Option

• Capsule colonoscopy every 5 years (weak recommendation, low-quality evidence) 2, 1

Important Clinical Considerations

• All positive results on non-colonoscopy screening tests must be followed up with timely colonoscopy 1
• Patients with symptoms such as colorectal bleeding should undergo diagnostic colonoscopy regardless of age or screening status 1
• Consider stopping screening when persons up to date with screening and negative prior screening tests (particularly colonoscopy) reach age 75 or have <10 years of life expectancy 2
• The predominance of right-sided procedures supports the use of full colonoscopy as the primary screening method 4

Pitfalls to Avoid

• Failing to recognize that colorectal cancer incidence is rising in persons under age 50, requiring thorough diagnostic evaluation of young persons with suspected colorectal bleeding 5
• Neglecting to follow up positive non-colonoscopy screening tests with colonoscopy
• Not considering family history when determining screening age and intervals
• Continuing screening in very elderly patients or those with limited life expectancy where risks may outweigh benefits