Colorectal Cancer Screening Recommendations
Colorectal cancer screening should begin at age 45 for average-risk individuals, with either colonoscopy every 10 years or annual FIT testing as preferred first-tier options, continuing through age 75 and individualizing decisions for ages 76-85 based on health status and prior screening. 1
Recommended Screening Methods and Intervals
Average-Risk Individuals (age 45-75):
First-tier options:
- Colonoscopy every 10 years
- Fecal Immunochemical Test (FIT) annually
Alternative options:
Age-Specific Recommendations:
- Ages 45-75: Regular screening recommended for all average-risk individuals 2, 1
- Ages 76-85: Individualize decision based on:
- Ages 86+: Screening not recommended as competing causes of mortality likely preclude survival benefit 2
Special Population Considerations
Black Adults:
Black adults have the highest incidence and mortality rates for colorectal cancer compared to other racial/ethnic groups (43.6 cases per 100,000 vs. 37.8 cases per 100,000 in White adults) 2. This disparity is primarily driven by inequities in access, utilization, and quality of screening and treatment rather than genetic differences 2.
High-Risk Individuals:
- Family history of CRC or advanced adenoma: Begin screening at age 40 or 10 years before the youngest affected relative's diagnosis (whichever comes first); repeat colonoscopy every 5 years 1, 3
- Inflammatory bowel disease: Begin screening 8-10 years after symptom onset; repeat every 1-3 years 3
- Hereditary syndromes:
- Hereditary nonpolyposis colorectal cancer (Lynch syndrome): Begin at age 25; repeat every 1-2 years 3
- Adenomatous polyposis syndromes: Begin at age 10 or mid-20s depending on syndrome; repeat every 1-2 years 3
- Peutz-Jeghers syndrome: Begin at age 8; if normal, repeat at age 18 and then every 3 years 3
Test Performance Characteristics
| Test | Sensitivity for CRC | Sensitivity for Advanced Precancerous Lesions | Specificity |
|---|---|---|---|
| Cologuard (FIT-DNA) | 92.3% | 42.4% | 86.6% |
| FIT | 73.8% | 23.8% | 94.9% |
Follow-Up Recommendations
- Any positive non-colonoscopy screening test: Must be followed by timely diagnostic colonoscopy 1
- Adenomatous polyps found and removed: Follow-up colonoscopy in 3-5 years, depending on size and number of polyps 1
- Personal history of CRC: Surveillance colonoscopy within 1 year of resection, then every 3-5 years if normal 1
Quality Considerations
Quality metrics for colonoscopy include:
- Cecal intubation rates
- Adequate withdrawal time (at least 6 minutes)
- Adenoma detection rates
- Appropriate bowel preparation 1
Clinical Rationale for Starting at Age 45
The USPSTF lowered the recommended starting age from 50 to 45 years in 2021 based on:
- Increasing incidence of colorectal cancer in younger adults
- Modeling data suggesting that starting screening at 45 may moderately increase life-years gained and decrease colorectal cancer cases and deaths 2
The absolute risk of developing colorectal cancer is lower in adults aged 45-49 (20.0 new cases per 100,000) compared to those aged 50-59 (47.8 new cases per 100,000), but age-period-cohort analysis indicates an increasing risk trend in younger adults 2.
Common Pitfalls to Avoid
- Failure to follow up positive screening tests: All positive results on non-colonoscopy screening tests must be followed up with timely colonoscopy 1
- Overlooking high-risk individuals: Those with family history or other risk factors need earlier and more frequent screening 3
- Continuing screening beyond age 75 without individualization: For adults 76-85, consider health status, prior screening, and preferences 2, 1
- Screening beyond age 85: Generally not recommended as risks outweigh benefits 1
- Ignoring racial disparities: Black adults have higher incidence and mortality rates and may benefit from targeted screening approaches 2