NCCN Guidelines Update: Initial Colorectal Screening Lowered to Age 45

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The updated colorectal cancer (CRC) screening guidelines from the National Comprehensive Cancer Network (NCCN) include a lowering of the age for initial screening for the average-risk person and for second- and third-degree family members with CRC, as well as an extension in the interval for surveillance colonoscopy for low-risk individuals. These changes were presented by Reid M. Ness, MD, MPH, Associate Professor of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, TN, at the 2022 NCCN conference.

In version 1.2022 of the NCCN CRC screening guidelines, the age to initiate screening in average-risk individuals, regardless of race or sex, has been lowered from 50 years to 45 years, following the US Preventive Services Task Force recommendation from May 2021; with the evidence to support this recommendation given a B grade.

“The first and most significant change…was a lowering of the initial screening age for average-risk individuals from 50 to 45. The second biggest change is the recommendation to extend the surveillance period from 5 to 7 years to 10 years for patients with only 1 to 2 small tubular adenomas at the index colonoscopy,” Dr Ness said. “The impetus for this recommendation change is based on well-publicized trends in CRC incidence since the implementation of CRC screening in 1980,” he added.

The incidence of CRC in the United States in people aged ≥50 years has decreased by approximately 40% over this period, and has been accompanied by a small increase in incidence in people younger than age 50 years. The cost to benefit ratio was deemed favorable for lowering the screening age, Dr Ness added.

The NCCN also recommends that patients younger than age 45 who present with alarming symptoms of CRC (ie, iron deficiency, rectal bleeding) also undergo screening colonoscopy.

For a person with ≥1 first-degree relatives with CRC at any age, the recommendation to initiate screening colonoscopy remains at age 40 years, or 10 years before the earliest diagnosis of CRC in the family. Surveillance in this scenario should be repeated every 5 years or, if positive, per the colonoscopy findings.

The age for the initiation of screening for those with a second- or third-degree family member with CRC was also lowered from age 50 to 45 years.

To achieve the best results, CRC screening should be performed as part of a population-based program, and should include direct outreach to patients and clinic-focused interventions to increase screening rates, reduce the rate of mortality, and minimize disparities by race and ethnicity, according to the guidelines.

Other than lowering the initial screening age, perhaps the biggest change to the NCCN guidelines is the recommendation to extend the waiting period from 5 years to between 7 and 10 years before surveillance colonoscopy for patients with low-risk adenomas, defined as ≤2 polyps <1 cm at index colonoscopy.

The basis for this recommendation is data showing that, compared with patients with no adenoma, those with a low-risk adenoma did not have a significantly increased risk for CRC or related death, said Dr Ness.

“Although we decided to extend the surveillance period for patients presenting with 1 to 2 low-risk adenomas, we did not extend the surveillance period for patients with only low-risk sessile serrated polyps [SSPs] at index colonoscopy secondary to a perceived paucity of data,” he said. Therefore, the surveillance colonoscopy interval after the identification of only 1 or 2 low-risk SSPs remains at 5 years.

Surveillance colonoscopy interval after the identification of most high-risk adenomas or SSPs remains at 3 years.

Any person with ≥10 adenomatous polyps at a single colonoscopy who does not have a polyposis syndrome is now recommended to do a repeat colonoscopy within 1 year, although data to inform this recommendation are limited.

“Another change to our surveillance guidelines was a shortening of our recommended surveillance interval for those patients with large colorectal adenomas or SSPs with either unfavorable risk characteristics for local recurrence or removed in piecemeal fashion from 12 to 6 months, with the second surveillance colonoscopy recommended to occur 12 months later, even without evidence of recurrence at first surveillance colonoscopy,” Dr Ness pointed out.

After the diagnosis of inflammatory bowel disease (IBD) colitis, the initiation of surveillance colonoscopy remains at 8 years, except in patients with primary sclerosing cholangitis, in whom the surveillance interval is 1 year, or when the family history recommendations supersede the recommendations based on the duration of IBD. The surveillance colonoscopy interval in patients with IBD colitis remains at 1 to 3 years, depending on the measures of underlying CRC risk.

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Last modified: August 5, 2022
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