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Am Fam Physician. 2022;105(4):343

Original Article: Should Routine Screening for Colorectal Cancer Start at 45 Years of Age? Yes: Lowering the Starting Age Is a Settled Issue [Editorial]

Issue Date: February 2022

To the Editor: We appreciate the comments outlined in the editorial by Dr. Wender. We would like to provide additional information on the process used by the American Academy of Family Physicians (AAFP) to review and develop clinical preventive services recommendations.

The AAFP has a long-standing partnership with the U.S. Preventive Services Task Force (USPSTF) and participates in all steps in the development of the USPSTF’s preventive services recommendations, including nominating task force members, providing comments on draft research plans and recommendations, and reviewing final recommendations.

The AAFP Clinical Preventive Services recommendations are developed through the AAFP’s Commission on Health of the Public and Science and are approved by the AAFP Board of Directors. The commission reviews the evidence reports, included studies, and any modeling data or other information that informed the task force. The commission then determines whether the AAFP should agree with the recommendation or develop a different recommendation based on the evidence. If there is agreement with the USPSTF recommendation, members are referred to the USPSTF website for more information. If a new recommendation is developed, the AAFP uses a grading system consistent with the USPSTF.1

In 2016, the AAFP issued a different recommendation from the USPSTF for colorectal cancer screening due to concerns with limited evidence of benefit from certain screening modalities and unknown harms.2 The updated 2021 recommendation continues to recommend screening for colorectal cancer in adults 50 to 75 years of age. However, the AAFP determined that the evidence was insufficient to recommend for or against screening in adults aged 45 to 49 (I statement). This decision was made after reviewing the modeling data provided by the evidence report, which outlined that many of the studies used as model inputs did not include individuals younger than 50 years.3

We would like to note that an I statement from the AAFP or the USPSTF is a statement of insufficient evidence and a call for more research on that topic. It is important not to confuse this with a D recommendation, which states that the evidence supports not performing the screening test. The AAFP and USPSTF I statements have stimulated research demonstrating benefit for screening, as in the case of the 2013 lung cancer screening recommendation that was recently updated from an I to a B recommendation by the AAFP.4

Email letter submissions to Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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