Overuse of Colorectal Cancer Screening and Surveillance

RB is a 57-year-old patient who comes to your office for a physical examination and hypertension follow-up. Examination results are normal, and his blood pressure is well controlled. On review of screening tests, you see that he had a colonoscopy 4 years ago, during which two small hyperplastic polyps were removed. RB informs you that he recently received a letter from his gastroenterologist stating that he is past due for follow-up of an abnormal colonoscopy. He inquires if it is necessary for him to undergo a repeat colonoscopy this year or if he is eligible for other colorectal cancer (CRC) screening tests. He says he saw a television advertisement promoting the Cologuard test and received a card in the mail offering a $50 fecal immunochemical test. He has no family history of CRC. You review his history and the pathology report from the previous colonoscopy and determine that he is at average risk for CRC.

Epidemiology

CRC is the fourth most common nonskin cancer in the United States with more than 150,000 new cases annually. Most cases occur in individuals older than 50 years.¹ It is the third most common cause of cancer death in men (9%) and in women (8%).² Over the past decade, CRC incidence has been decreasing in people 55 years and older due to the effects of screening, with removal of adenomatous polyps, earlier diagnosis, and advances in treatment.² However, CRC mortality rates in younger individuals increased by approximately 1% annually from 2011 to 2020.³ Risk factors for CRC include inflammatory bowel disease, genetic syndromes (eg, familial adenomatous polyposis, Lynch syndrome [hereditary nonpolyposis CRC]), previous radiation therapy to the abdomen or pelvis, and a personal or family history of CRC.⁴

Screening Options

Multiple societies have published screening recommendations, including the American Cancer Society, US Multi-Society Task Force on Colorectal Cancer, US Preventive Services Task Force (USPSTF), American College of Gastroenterology, and the American Academy of Family Physicians (AAFP).^5–8 All endorse colonoscopy as a first-line screening option for average-risk adults starting at age 45 or 50 years and continuing to age 75 years.^5–10

Colonoscopy is the third most common cancer screening test in the United States after mammography and cervical cytology, with more than 15 million procedures performed annually.¹¹ Advantages of colonoscopy are that it has approximately 95% sensitivity, can detect and remove precancerous adenomas, and has a longer interval between screenings than other options.^5–7

However, the test also has greater burdens and associated harms. The USPSTF concluded that the benefits outweigh the risks when the test is performed in appropriate patients (ie, average-risk individuals ages 45 to 75 years) at approved intervals.^6,12 Patients older than age 75 years benefit the least from screening and are at higher risk of procedure-related complications, including death.^13–16 The USPSTF recommendations for CRC screening are^6,12:

• 50 to 75 years: screen
• 45 to 49 years: screen
• 76 to 85: selectively offer screening ○ Evidence indicates that the net benefit of screening all persons in this age group is small

○ When making a screening decision, patients and clinicians should consider the patient's overall health, prior screening history, and preferences