September 1, 2021, 8:41 a.m. News Staff — The AAFP recently published an updated clinical preventive service recommendation on colorectal cancer screening that differs slightly from the U.S. Preventive Services Task Force’s final recommendation statement on the topic regarding the age at which screening asymptomatic individuals should begin.
“The USPSTF’s recommendation to lower the age of initial screening was based on modeling data that made some unrealistic assumptions,” said Alexis “Alex” Vosooney, M.D., of West St. Paul, Minn., a member of the Academy’s Commission on Health of the Public and Science. “The AAFP recommendation is still to start screening at age 50 for low-risk individuals and ensure equal access to screening (and) followup.”
This is not the first time the AAFP’s recommendation has diverged from that of the USPSTF on the topic. In 2016, the AAFP gave a “B” recommendation designation for colorectal cancer screening in adults ages 50 to 75, in contrast to the task force’s “A” recommendation for screening in the same patient population.
Both the AAFP’s recommendation and the USPSTF’s final recommendation statement contain a series of screening recommendations based on patient age.
For adults ages 76 to 85, the Academy and the task force both recommend that clinicians selectively offer screening for colorectal cancer, and that patients and clinicians should consider the patient’s overall health, prior screening history and personal preferences in determining whether screening is appropriate. This is a “C” recommendation from both organizations.
For adults ages 50 to 75, the task force recommends screening, which may include a combination of stool-based and direct visualization tests — an “A” recommendation. The Academy also gives an “A” recommendation designation for screening this patient population, with the caveat that screening should start at age 50 and continue until age 75.
The most significant difference pertains to adults ages 45 to 49. For this age group, the task force has concluded with moderate certainty that screening for colorectal cancer has moderate benefit, resulting in a “B” recommendation. The Academy, however, has concluded that the evidence is insufficient to assess the benefits and harms of screening in this population, resulting in an “I” statement. The Academy strongly encourages more research for efficacy of screening in this population. Additionally, the AAFP calls for more research on the impact of social determinants of health and systemic racism on the disparities observed in colorectal cancer screening and treatment.
The Academy explained that its disagreement with the USPSTF’s recommendation is based on a variety of factors.
“The USPSTF recommendation for this age group centered on indirect evidence from modeling studies,” the Academy stated in reference to screening adults ages 45 to 49. “Many of the trials did not include individuals under age 50 or did not provide these data separately, decreasing the confidence in the data inputs. Additionally, the modeling studies assumed 100% adherence to screening and followup protocols, which may artificially elevate life years gained from earlier screening.”
Vosooney, in an email to AAFP News, expanded on the differences between the recommendations and how those differences could affect the way family physicians provide care.
“Starting screening at an earlier age may not offer a benefit if patients don’t have appropriate access to screening and followup care,” Vosooney said. “Modeling can be a helpful tool, but it needs to have realistic inputs. Being able to tell patients why recommendations differ is good practice when helping them sort through information they have heard on the news or through their insurance company.”
The AAFP also noted that while the incidence of colorectal cancer in younger people is increasing, it is still relatively small, and that the increased risk of colorectal cancer in this age group may be overestimated.
In addition, the Academy expressed concern over a lack of evidence showing that tumors found in young adults behave similarly to those found in older adults, and that early detection would be as beneficial.
Overall, the AAFP said these concerns decrease the confidence that the balance of benefits and harms from screening is moderate in those ages 45 to 49.
The Academy also suggested that decreasing the age at which screening should begin could exacerbate health disparities among patient populations due to differences in access to care and screening facilities. To reduce this issue, the Academy recommended that family physicians have a standardized screening protocol and monitor their practices for disparities. It also directed FPs to access resources such as The EveryONE Project to learn more about social determinants of health and implicit bias.
“Health systems or insurers may be telling people to start screening at age 45,” said Vosooney. “Family medicine clinicians need to be aware of the background on the recommendations so they can have an informed discussion with their patients.”
“Ensuring that patients have access to screening and followup is a key component to ensuring they are receiving the benefit of evidence-based recommendations,” she added. “Clinicians need to assess the barriers their patients face to completing screening and followup so that they can help find solutions.”