At what age should males start colonoscopy (colon cancer screening) screening?

Colorectal Cancer Screening Age Guidelines for Males

Colorectal cancer screening in average-risk males should begin at age 45, with stronger evidence supporting initiation at age 50 for those who have not yet started screening. 1

Starting Age for Colorectal Cancer Screening

Average-Risk Males:

• Most current guidelines recommend starting colorectal cancer screening at age 45 for average-risk individuals, including males 1
• The US Preventive Services Task Force (USPSTF) provides a Grade B recommendation for screening at age 45-49 and a stronger Grade A recommendation for ages 50-75 1
• The American Cancer Society (ACS) recommends screening beginning at age 45 (qualified recommendation) 1
• The National Comprehensive Cancer Network (NCCN) recommends starting at age 45, though acknowledges stronger evidence for beginning at age 50 1
• The American College of Gastroenterology suggests screening in average-risk persons aged 45-49 years (conditional recommendation) and recommends screening for ages 50-75 (strong recommendation) 1

Higher-Risk Males:

• African American males should begin screening at age 45 due to higher incidence rates (weak recommendation) 1, 2
• Males with a first-degree relative diagnosed with colorectal cancer or advanced adenoma before age 60 should begin screening at age 40 or 10 years before the youngest affected relative's diagnosis, whichever comes first 2, 3
• Males with two or more first-degree relatives diagnosed with colorectal cancer or advanced adenomas at any age should begin screening at age 40 or 10 years before the youngest diagnosis, whichever comes first 2, 3
• Males with a single first-degree relative diagnosed with colorectal cancer or advanced adenoma at age 60 or older can follow average-risk screening guidelines but begin at age 40 2

Stopping Age for Colorectal Cancer Screening

• Screening should be considered for discontinuation at age 75 for individuals who are up to date with screening and have had negative prior screening tests, particularly colonoscopy 1, 4
• For males aged 76-85 without prior screening, individualized decisions should be made based on overall health status, life expectancy, and preferences 1, 4
• Screening should be discouraged in males over age 85 as the harms outweigh the benefits 1, 4
• Males with severe comorbidities (AIDS, COPD, cirrhosis, chronic hepatitis, chronic renal failure, dementia, congestive heart failure, or combinations of moderate conditions) should stop screening at age 66 regardless of prior screening history 1, 4

Screening Modality Considerations

• Colonoscopy every 10 years and annual fecal immunochemical test (FIT) are first-tier screening options 1, 2
• Colonoscopy has advantages in the opportunistic screening setting, while annual FIT may be preferred in organized screening programs 1
• Second-tier options include CT colonography every 5 years, FIT-fecal DNA test every 3 years, and flexible sigmoidoscopy every 5-10 years 2

Evidence Quality and Controversies

• The recommendation to begin screening at age 45 is based on:
  • Increasing colorectal cancer incidence in younger adults 1
  • Similar incidence rates in 45-49 year-olds now compared to 50-year-olds when screening was first recommended 1
  • Similar rates of advanced neoplasia in 45-49 year-olds compared to screening cohorts of 50-59 year-olds 1
• Some studies have found lower but measurable risk of colorectal neoplasia in 40-49 year-olds compared to 50-59 year-olds, with the number needed to screen to detect one advanced lesion being 49 in the younger group versus 20 in the older group 5
• Other research suggests equal risk of colon polyps in screening colonoscopies for ages 40-49 and 50-59, which may warrant reconsideration of current age recommendations 6

Common Pitfalls to Avoid

• Failing to recognize higher-risk individuals who need earlier screening 3
• Continuing screening beyond age 85 when evidence shows harms outweigh benefits 4
• Stopping screening too early in healthy individuals with no prior screening history 4
• Not considering race-specific recommendations, particularly for African American males 1