Review the 2021 USPSTF Guidelines on Colorectal Cancer Screening (CRC screening) with our guest, Dr. Michael Barry (vice-chair of the U.S. Preventive Services Task Force). Topics include a breakdown of testing modalities (stool tests versus direct visualization), screening ages, what to do for patients older than 75, and more!
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The 2021 USPSTF CRC Screening guidelines recommend CRC screening for average risk adults (USPSTF 2021):
**These recommendations do not apply to patients with a prior history of CRC, adenomatous polyps or personal/family history of high-risk genetic disorders.
CRC is the third leading cause of cancer-related deaths in the United States. In 2021, 53,000 deaths due to CRC are estimated in the United States. Dr. Barry uses an example of 1000 people to describe the USPSTF analysis for the benefit of CRC screening on CRC incidence and mortality.
Example: Imagine a group of 1000 people at age 40 representing the diversity of race, ethnicity and gender in the country. Think about what might happen to them over time. If we don’t screen them our model suggests we would see about 80/1000 develop CRC and roughly 30/1000 would die of CRC. When collectively applied to the United States population this adds up to 53,000 deaths.
Dr. Barry describes three lines of evidence that led to decreasing the recommended age of screening initiation for CRC from 50 in 2016 (USPSTF 2016) to 45 in 2021.
Back to Dr. Barry’s 1000 person cohort example: With no screening, 80 cases of CRC and about 30 deaths would be expected over time. With regular screening for CRC starting at age 50, the number of cases would be expected to decrease from 50 to 30 and expected deaths would decrease from 30 to 5 out of 1000. This assumes perfect adherence to screening. By dropping the age of screening initiation to 45, the incidence would be expected to decrease by 2 to 3 additional cases and the number of deaths by one. So, most of the benefit comes from screening initiation at age 50 (grade A recommendation with high certainty of net benefit). And there is moderate certainty of a moderate benefit for screening initiation at age 45 (hence grade B recommendation). For practical purposes, A and B are the same = just do it.
The best screening method is the one the patient will complete and preferences vary. The USPSTF recommends the following screening choices (USPSTF 2021):
1) Direct Visualization: colonoscopy (every 10 years), CT colonography (every 5 years), flexible sigmoidoscopy (every 5 years), flexible sigmoidoscopy + fecal immunochemical test (FIT) (every 10 years)
2) Stool-based tests: high-sensitivity FOBT (yearly), FIT (yearly), sDNA + FIT (every 1 to 3 years)
The colonoscopy is the most sensitive option for a single test, but prevention is similar between testing methods with adherence (USPSTF 2021). Dr. Barry describes how some patients like the idea of getting a colonoscopy and not having to think about it again for 10 years. While others find a colonoscopy (and the prep!) invasive and prefer stool-based testing. It is important to ensure patients understand a follow up colonoscopy will be indicated if a stool-based test is positive. Following a positive stool-based test, a colonoscopy must be completed to ensure the benefits of screening (USPSTF 2021). With stool-based testing, <10% of patients will have a finding that requires colonoscopy. The screening method should be chosen based on patient preference, and Dr. Barry indicated that it is reasonable to switch between screening methods if necessary.
Listeners will review the updated 2021 USPSTF colorectal cancer (CRC) screening guidelines.
After listening to this episode listeners will…
Dr Barry was previously a principle investigator at Healthwise (a non-profit) supported by a grant from MGH. The Curbsiders report no relevant financial disclosures.
Gibson EG, Barry MB, Williams PN, Watto MF. “#283 CRC Screening: USPSTF Update with Dr. Michael Barry”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date July 5, 2021.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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