As colorectal cancer cases grow in younger adults, U.S. health care reaches ‘pivotal point’ in screening for it

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U.S. health care has “reached a pivotal point” in understanding early-onset colorectal cancer (CRC) and how to detect it as CRC has emerged as a health concern for more adults at an earlier age.

Three studies and an editorial in JAMA described the state of medicine around CRC, leading with a finding that more patients complete a screening when a fecal immunochemical test (FIT) simply arrives by mail.

“This study highlights that health systems can effectively engage adults aged 45 to 49 years with mailed FIT outreach, a practice already adopted by health systems for adults aged 50 years and older,” said “Population Health Colorectal Cancer Screening Strategies in Adults Aged 45 to 49 Years: A Randomized Clinical Trial.” The authors noted that the mailed FIT strategy eliminates the need for patients to log into electronic portals or make a choice, reducing friction in the screening process.

While active choice strategies allow for personalization, they may pose barriers to action, the authors wrote, and particularly in younger adults who are less accustomed to preventive care engagement. “This study offers robust evidence for how to engage this age group in CRC screening,” the study said.

A first for the efficacy of outreach

According to the authors, the study is the first to demonstrate the effectiveness of direct outreach to increase CRC screening in a younger cohort less likely to be aware of recommendations.

In 2021, the U.S. Preventive Services Task Force issued a grade B recommendation to begin CRC screening at age 45 for average-risk adults, expanding eligibility under the Affordable Care Act.3 This change followed a nearly 15% rise in CRC incidence among adults aged 50 years or younger over the past 30 years.

Despite CRC now being a leading cause of cancer death in younger adults, participation remains low. First author Artin Galoosian, MD, MA, assistant professor of Medicine at the University of Southern California, and colleagues cited a recent claims-based study that found screening uptake among 45- to 49-year-olds was just 1.51% within 20 months of the updated guidelines. While proven effective in older adults, evidence for mailed outreach in the younger, newly eligible population was lacking, authors said.

Studying screening

A randomized clinical trial of more than 20,000 adults aged 45 to 49 found that unsolicited mailing of fecal immunochemical test (FIT) kits directly to individuals without requiring active choice significantly outperformed three other strategies for initiating CRC screening.

The study highlights a practical and effective population health approach to improving early CRC detection in younger adults, a group at increasingly greater risk for the disease and for whom screening rates remain suboptimal despite recent guideline changes lowering the recommended starting age from 50 to 45.

The trial was conducted at UCLA Health between May and November 2022 and included 20,509 average-risk adults from primary care settings who were randomly assigned to one of four outreach strategies:

• FIT-only active choice
• colonoscopy-only active choice
• dual-modality (FIT or colonoscopy) active choice
• usual care default mailed FIT outreach

The mean age of participants was 47.4 years, approximately half were women (54%) and half (50.8%) self-identified as non-Hispanic White. Galoosian and colleagues measured screening uptake over six months following the intervention. Overall screening participation was 18.6%, according to the study.

Galoosian and fellow researchers reported that screening participation was highest, 26.2%, in the group that received unsolicited mailed FIT kits. In contrast, they found significantly lower rates in the three “active choice” arms:

• 17.4% for those offered a choice between FIT or colonoscopy
• 16.4% for FIT-only
• 14.5% for colonoscopy-only

‘A pivotal point’

While incidence of CRC increased, the USPSTF recommendation was “initially met with skepticism,” and raised important questions about how to reach nearly 45 million U.S. adults newly eligible for screening, said “Younger Adults, Earlier Screening — What We Are Learning About Colorectal Cancer and What Comes Next,” an editorial by Caitlin C. Murphy, PhD, MPH; Ami E. Sedani, PhD, MPH; and Bijal A. Balasubramanian, MBBS, PhD.

The study and two others published Aug. 4 in JAMA begin addressing those issues, the authors said.

“We have reached a pivotal point in our understanding of early-onset colorectal cancer,” they said. “Existing, evidence-based interventions such as a mailed FIT effectively increase screening participation among younger adults, and expanding eligibility to younger adults does not diminish participation among older adults. Examining trends in incidence rates and stage at diagnosis can provide insight into whether screening translates into earlier detection of asymptomatic cancers.”

An encouraging trend

Meanwhile, “Trends in Colorectal Cancer Screening in U.S. Adults Aged 45 to 49 Years,” evaluated changes in CRC screening uptake among those adults from 2019 to 2023. Researchers found:

• Up-to-date CRC screening prevalence grew from 20.8% in 2019, and 19.7% in 2021, up to 33.7% in 2023.
• Colonoscopy prevalence rose from 19.5% in 2019 and 17.8% in 2021, to 27.7% in 2023.
• Stool-based testing grew from 1.3% in 2019 and 2.7% in 2021 to 7.1% in 2023.

“This trend is encouraging because screening reduces CRC mortality, mostly through the detection and removal of potentially precancerous lesions,” the study said.

CRC incidence

As for CRC, in “Colorectal Cancer Incidence in U.S. Adults After Recommendations for Earlier Screening” researchers sought to examine whether earlier detection or increased disease occurrence would explain the growth in CRC incidence in adults 45 to 49. Those patients had CRC incidence rise 1.1% a year from 2004 to 2019. That incidence rate jumped to 12.1% a year from 2019 to 2022, driven by local-stage tumors.

“The sudden uptick in incidence among adults aged 45 to 49 years in 2021 may reflect a rebound of missed diagnoses in 2020 because of (COVID-19) pandemic-related disruptions,” the study said. “However, the increase was unique to early-stage disease in the newly eligible screening age group and accelerated in 2022, and USPSTF recommendations did not change until 2021.”

A version of this article appeared on Patient Care, a sister publication of Medical Economics.