Health Bulletin - July 2023

Colon Cancer Screening-Current Guidelines and Recommendations:

45 is the new 50!

If you are 45 years or older, the time to get screened for colorectal cancer is now.

Till recently Colon Cancer Screening used to be recommended starting at age 50 for average risk individuals.

In 2021, the U.S. Preventive Services Task Force (USPSTF) issued a new recommendation that colorectal cancer screening for people at average risk should start five years sooner starting at age 45. The change to 45 was based on the trend of growing incidence of colon cancer cases among younger adults. American Cancer Society (ACS), American College of Gastroenterology (ACG) also recommends screening age of 45. These recommendations paved way for the Health Insurance carriers to start covering Colon cancer screening starting at age 45, meaning an insured individual will be fully covered by most insurances without incurring any out-of-pocket costs for screening.

Colon cancer screening is unique in that its only screening which prevents cancer by way of early detection of polyps/growths before turning in to cancer while all other screenings such as mammogram, pap smears, prostate screenings are aimed at early detection.

What is colorectal cancer:

The colon is the large intestine or large bowel, rectum is the passageway that connects the colon to the anus. The colon, or large intestine, is about five to six feet long.

As we age abnormal growths, called polyps, form in the colon or rectum. Over time, some of the polyps may grow and turn into cancer. Screening tests can find polyps early so they can be removed before turning into cancer. Screening also helps find colorectal cancer at an early stage when treatment works best.

Colorectal cancer almost always develops from a polyp. This understanding of sequence of progression of polyp to cancer is behind the recommendations for screening so that polyps can be removed in early stages before developing into colon cancer.

Background:

In the United States, colorectal cancer (CRC) ranks second to lung cancer as a cause of cancer mortality and is the third most commonly occurring cancer in both men and women.

1 in 23 men and 1 in 26 women will be diagnosed with colorectal cancer.

There are more than 20 million Americans eligible for colorectal cancer screening who have not been screened.

Colorectal cancer is preventable with screening.

The CDC estimates that 68% of deaths from colorectal cancer could be avoided if all eligible people got screened.

A systematic review of 6 observational studies reported a pooled reduction of 69% in overall Colon cancer incidence and reduction of 68% in mortality associated with screening colonoscopy.

While rates of colorectal cancer in older adults have been decreasing over the last several decades due to various factors including effective use of colon cancer screening, early detection, the rates of colorectal cancer in young adults are increasing.

1 in 10 colorectal cancers are diagnosed in patients under 50 years of age.

Rates of early-age onset colorectal cancer have been rising steadily since the mid-1990s. There was a 51% increase in cases of colorectal cancer in people aged 20-49 from 1994 to 2012. Patients under 50 years of age are 58% more likely than older patients to be diagnosed with late-stage disease.

Less than 50% of Asian Americans are up to date with colorectal cancer screening.

Risk factors include Age, increased risk as we age which we all do, other risk factors include Dietary and Environmental factors, Diabetes, Obesity, increased consumption of processed and red meat, Tobacco and Alcohol use, Genetics and family history and most importantly is big unknown why certain individuals develops and while others in spite of risk factors and no risk factors.

What is screening:

Screening means getting checked even when you have no symptoms.

Regular screening for and removal of growths in the colon called polyps reduces risk of developing colorectal cancer- by up to 90% with colonoscopy.

Most early colorectal cancers produce no symptoms. This is why screening for colorectal cancer is so important.

Never ignore new or worrying symptoms!

Reach out to health care providers if you have any symptoms, regardless of age.

What is average risk and high risk?

For screening purposes, average risk means those without any symptoms and no high-risk factors for colon cancer.

People at increased or high risk of colorectal cancer include those with a family history of colon cancer, personal history of colon polyps and colon cancer, suspected or confirmed hereditary colon polyps and colorectal cancer syndromes, personal history of Inflammatory bowel disease such as Crohn’s and Ulcerative colitis and those with history of getting radiation to abdomen.

SCREENING RECOMMENDATIONS FROM THE AMERICAN COLLEGE OF GASTROENTEROLOGY:

Average risk adults aged 45 to 75 be screened for colorectal cancer. The decision to be screened between the ages of 76 and 85 should be made on an individual basis. If you are older than 75, talk to your doctor about screening.

People at increased risk of getting colorectal cancer should talk to their doctor about when to begin screening and could be much earlier than age 45 and which test is right for them, and how often to get tested.

Primary screening methods for patients at average risk for colorectal cancer:

Colonoscopy every ten years is preferred and allows for one step screening, direct exam, and removal of polyps in same setting, with good quality exam and if no polyps are found then good for 10 years.

Other alternative screening options, indirect tests and 2 step process and if positive then would need follow up Colonoscopy.

 FIT (fecal immunochemical test) every one year. Multitarget stool DNA test every three years (commercially available Cologuard).

Flexible sigmoidoscopy every 5 to 10 years (not being used much) CT colonography every five years (available in select centers) Colon Capsule every five years (not yet widely available)

TAKE HOME MESSAGE:

Screening saves lives. Remember, the most common symptom of early colon and rectal cancers is NO symptom, so it is important to get screened.

I have been a Gastroenterologist and performing screening colonoscopies for over 10-15 years and would readily advocate the same to friends and family members, it has been my observation that risk of polyps and colon cancer in Indians and even in lifelong vegetarians is no different from other populations in United States. Have seen close friends and family members affected with colon cancer at young age and timely screening and attention to symptoms would have had a different outcome.

Most health insurances would cover with almost no out of pocket expense for routine screening.

Learn more from The American College of Gastroenterology, https://gi.org/topics/colorectal-cancer/

Hanmanth Bejjanki, MD
Board Certified in Gastroenterology and Hepatology.
Private Practice, Texas.
Assistant Professor of Medicine.
The Anne Burnett Marion School of Medicine at TCU.
Past President OGKTMA (Osmania Gandhi Kakatiya Telangana Medical Alumni of America).

Article Coordinated by

Dr. Sujeeth R. Punnam, MD
Chair, Health Committee

(Dr. Sujeeth R. Punnam is a cardiologist in Stockton, California and is affiliated with Dameron Hospital and St. Joseph's Medical Center. He received his medical degree from Kakatiya Medical College and has been in practice for more than 20 years.)