At what age and how often should I start colon cancer screening?

Colorectal Cancer Screening Recommendations

Colorectal cancer screening should begin at age 45 for average-risk individuals and continue through age 75, with colonoscopy every 10 years or annual fecal immunochemical test (FIT) as preferred first-tier options. 1, 2

Starting Age for Screening

• The American Cancer Society, US Preventive Services Task Force (USPSTF), and National Comprehensive Cancer Network (NCCN) all recommend beginning colorectal cancer screening at age 45 for average-risk individuals 1, 2
• The recommendation to begin screening at age 45 is based on:
  • Increasing CRC incidence in younger adults
  • Similar incidence rates in 45-49 year-olds compared to 50-year-olds when screening was first recommended
  • Similar rates of advanced neoplasia in 45-49 year-olds compared to 50-59 year-olds 1, 2
• For individuals with a family history of CRC in a first-degree relative, screening should begin at age 40 or 10 years before the age of diagnosis of the youngest affected relative, whichever comes first 1, 3
• African American individuals should begin screening at age 45 due to higher incidence rates 2

Recommended Screening Tests

• First-tier options (strongly recommended):
  • Colonoscopy every 10 years
  • Annual fecal immunochemical test (FIT) 1, 3
• Second-tier options (for those who decline first-tier tests):
  • Flexible sigmoidoscopy every 5-10 years
  • CT colonography every 5 years
  • FIT-fecal DNA every 3 years 1, 3

When to Stop Screening

• Individuals who are up to date with screening and have negative prior screening tests (particularly high-quality colonoscopy) should consider stopping screening at age 75 years 1, 4
• For persons aged 76-85 years without prior screening, decisions should be individualized based on:
  • Overall health status
  • Life expectancy
  • Patient preferences 2, 4
• Screening should not be offered to individuals age 86 and older as the risks outweigh the benefits 5, 4
• Individuals with severe comorbidities should stop screening at age 66 regardless of prior screening history 2, 4

Special Considerations

• Persons with Lynch Syndrome should begin colonoscopy 10 years before the age at diagnosis of the youngest affected relative 1
• Never delay evaluation of symptomatic individuals regardless of age, especially those with bleeding symptoms 1
• The benefits of continued screening decrease with age while potential harms increase 4, 6
• Having health insurance significantly increases the likelihood of receiving appropriate screening 7

Common Pitfalls to Avoid

• Continuing screening beyond age 85 when evidence shows harms outweigh benefits 1, 4
• Stopping screening too early in healthy individuals with no prior screening history 2, 4
• Not considering race-specific recommendations, particularly for African American individuals 2
• Not screening first-degree relatives of CRC patients beginning at age 40, as screening rates in this high-risk group aged 40-49 lag significantly behind those aged 50+ 7
• Not recognizing that any screening is better than none - patient preferences and local resource availability should be considered to increase screening uptake 8