45-Year-Olds Should Now Get Routine Colorectal Cancer Screenings: Q+A with James Church, MD

June 17, 2021

The U.S. Preventive Services Task Force (USPSTF) recently issued a statement recommending that colorectal cancer screening guidelines be lowered to age 45 from 50. Of the varying factors that led to this recommendation, the USPSTF has said that far too many in the U.S. are not receiving this “lifesaving preventative service” for a leading cancer that is largely preventable. 

Portrait of Dr. James Church with sunny and residential background.

James Church, MD, is a colorectal surgeon who cares for all aspects of colorectal disease, focusing on hereditary colorectal cancers and polyposis. (Photo courtesy of Dr. Church)

The task force is not alone in its recommendation; the American Cancer Society and American Society of Colorectal Surgery also indicated last fall that people at average risk of colorectal cancer start regular screenings at age 45.The new, final USPSTF recommendations all apply to adults 45 to 75 without symptoms who are at average risk for colorectal polyps and cancer. Factors indicating enhanced risk, such as personal or family history of colorectal polyps or cancer, warrant enhanced screening. 

“The rate of colon cancer overall is decreasing in America, because we do so many colonoscopies. We know these screenings are working,” says James Church, MD, professor of surgery at Columbia University Vagelos College of Physicians & Surgeons whose specialty is inherited colorectal cancers and polyposis. “But over the last two decades, we've become aware of a phenomenon of colorectal cancers occurring more frequently in the young.”

Colorectal cancer is the third leading cause of cancer deaths in the U.S. One in 10 colon cancer patients are being diagnosed before the age of 50, and the incidence rate has been increasing for people younger than 50 while decreasing in older individuals. Dr. Church and other experts have said that fewer older Americans are being diagnosed with colorectal cancer and that this could be in part because there is better adherence to screenings but it remains unclear as to why doctors are seeing an uptick in younger patient diagnoses. 

Dr. Church sheds light on the significance of this sweeping change in screening guidelines for colorectal cancer. 

What drove the decision to lower the colorectal cancer screening guidelines to age 45 from 50?

This decision is based on an increasing trend of younger people—younger than age 50—being diagnosed with colorectal cancer, and at times, presenting with advanced disease. It’s rare that we’ll see someone as young as 20 with colorectal cancer, but what we are talking about here is the 45-year-old woman, for instance, who is busy with her career and family life, and experiences rectal bleeding but is told by her physician that it is hemorrhoids. Symptoms may or may not persist but time goes by. She ultimately gets a colonoscopy and learns that she’s got an advanced cancer, stage four. I've seen that many times, and it seems to be happening more and more often. We're trying to figure out why. But the fact remains that young people, under the age of 50, are getting colon and rectal cancer more frequently than they used to and the data are quite clear on that. It seems to be going up in an exponential curve.

For those of us that are seeing younger patients with colon cancer, it's particularly alarming because each case is a tragedy. It’s a tragedy because they get the cancer in the first place and then because nobody is suspecting it, the diagnosis is often delayed. It allows the disease to become more advanced and so it's a much bigger problem. And, the significance of the official lowering of the screening guidelines is that colonoscopy screening for cancer is now reimbursable by insurance carriers in at least some of this younger age set. 

Who should go for routine colorectal cancer screenings? 

Everybody 45 and up should get screened in some way, whether that is a complete colonoscopy or another available test such as a stool DNA test or a stool blood test, or flexible sigmoidoscopy, which is “half” a colonoscopy that looks at the rectum and lower part of the large intestine. But the colonoscopy is the only test that will remove polyps from the entire colon and prevent cancer.

It is essential to note that Black people tend to get colorectal cancer earlier and at more advanced stage, than white people. That is data that we’ve known for some time and we’ve recommended that Black people get routine colorectal screenings starting at age 45. We also prioritize people at high risk of colon cancer, and the easiest risk factor for people to find out about is their family history. If someone in your family has had colon cancer, you are at higher risk developing the disease, and that means a father, mother, brother or sister or child, your risk is two and a half times the average population risk. At the moment in the U.S. the average population risk is 4%; you would have a 10% lifetime risk of getting colon cancer if you have this family history. 

What are the existing risk factors for colon cancer? 

A person’s biggest risk factor is family history. In this country, almost 150,000 people get diagnosed with colorectal cancer every year. Ultimately, each one of those 150,000 people has a family, and those families are instantly at higher risk. Many people aren’t aware of that. So as soon as colon cancer enters the family, it increases the risk of everyone in that family. So if you’re aware of this, you should then pay closer attention to any symptoms that might arise—rectal bleeding, a change in stool habit, or abdominal pain that doesn’t go away. And there are also lifestyle risk factors such as eating too much processed meats, or not enough fiber or vegetables, or smoking, or not getting enough exercise, or being severely overweight. These are all risk factors, not just for colorectal cancer, but for other diseases. 

What should people know about the importance of colorectal cancer screenings?

The rate of colon cancer overall is going down in America, because we do so many colonoscopies, so it's working. The peak of colon cancer incidence keeps rising with age until people are about 80 or 85 years old, and that’s because the longer you're alive, the longer the cells lining the colon have to accumulate the gene mutations that allow cells to form polyps; then some polyps turn into cancer. Every colon cancer starts with a polyp, and that's a very important principle to remember. We can potentially prevent every colon cancer by finding the precancerous polyp and removing it. If everybody got a colonoscopy, then nobody would get colon cancer, assuming we found all the polyps and got rid of them.

Then you have to ask, “Why don't people get a colonoscopy?” And there are a lot of reasons. Sometimes people can’t get access to it, sometimes they can’t afford it, and sometimes they don’t know that they should get it. Part of why the change in screening guidelines is so important is that it’s in the news which then helps raise awareness of the importance of this screening. Public awareness is so important here. It is so important to let people know that this is literally life-saving, and for the young people under age 45 that can't get screened yet, pay attention to symptoms and really understand your family history.