At what age should I get a colonoscopy?

Colonoscopy Screening Age Recommendations

For average-risk individuals, colorectal cancer screening should begin at age 45 for African Americans and at age 50 for non-African Americans, continuing until age 75 or when life expectancy is less than 10 years. 1

Starting Age for Screening

Average-Risk Individuals

• Non-African Americans should begin colorectal cancer screening at age 50 (strong recommendation) 1
• African Americans should begin screening earlier at age 45 (weak recommendation) due to higher incidence rates and risk of advanced polyps 1, 2
• The American Cancer Society has more recently recommended screening beginning at age 45 for all average-risk individuals, though this is a qualified recommendation 2
• The USPSTF provides a Grade B recommendation for screening at age 45-49 and a stronger Grade A recommendation for ages 50-75 2

High-Risk Individuals

• Individuals 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 age of diagnosis of the youngest affected relative, whichever comes first 1, 3, 4
• Individuals with a single first-degree relative diagnosed with CRC or advanced adenoma at age 60 or older can follow average-risk screening options but begin at age 40 1, 3
• Individuals with inflammatory bowel disease (ulcerative colitis or Crohn's disease) should begin colonoscopy 8-10 years after symptom onset 1, 4
• Those with hereditary nonpolyposis colorectal cancer (HNPCC) should begin colonoscopy at age 25 1, 4
• Individuals with familial adenomatous polyposis (FAP) should begin screening at age 10-12 1

Stopping Age for Screening

• Individuals who are up to date with screening and have negative prior screening tests, particularly colonoscopy, should consider stopping screening at age 75 or when life expectancy is less than 10 years 1, 2
• Persons without prior screening may be considered for screening up to age 85, depending on their age and comorbidities 1, 2
• Screening is not recommended for adults older than 85 years 1, 2

Screening Methods

• Colonoscopy every 10 years and annual fecal immunochemical test (FIT) are first-tier screening options 1, 2
• Colonoscopy has advantages in opportunistic screening settings 1
• Annual FIT is likely preferred in organized screening programs 1
• Other acceptable methods include flexible sigmoidoscopy every 5 years (with or without annual stool testing) and CT colonography every 5 years 1

Evidence Quality and Controversies

• The recommendation to begin screening at age 45 for African Americans is based on weak evidence but serves an important role in addressing health disparities 1
• Recent studies show varying results regarding adenoma prevalence in 40-49 year olds compared to 50-59 year olds:
  • Some studies show significantly lower prevalence of adenomas in 40-49 year olds (12.1% vs 22.6%) 5
  • Other studies show similar prevalence but higher rates of advanced adenomas in those 50-59 years old 6
• The incidence of colorectal cancer is rising in persons under age 50, which has prompted reconsideration of screening age recommendations 1, 2

Common Pitfalls to Avoid

• Failing to recognize the earlier screening recommendation for African Americans 1, 2
• Continuing screening beyond age 85 when evidence shows harms outweigh benefits 1, 2
• Not considering family history when determining screening age 3, 4
• Inadequate screening of first-degree relatives younger than the conventional screening age 7
• Not verifying family history information, which is often incomplete or inaccurate 3