This article originally appeared in the spring 2023 edition of the Minnesota Family Physician magazine.
The U.S. Preventive Services Task Force (USPSTF), American College of Gastroenterology and American Cancer Society are among the groups with updated recommendations on screening for colorectal cancer, lowering the age to begin screening to age 45.
We asked James Hougas III, MD, FAAFP, assistant professor at the University of Minnesota, to share his thoughts on the updated recommendations on colorectal cancer screening and about his experience as a family physician who performs colonoscopies in practice.
HOW DO YOU FEEL ABOUT THE RECOMMENDATION TO EXPAND COLORECTAL CANCER SCREENING?
Hougas: I think reducing the age to start screening is a good idea. People are developing colon cancer at younger ages (12% in patients under age 50) and increased screening of average-risk patients has the potential to prevent cancer for them entirely. Considering that colorectal cancers are the third most common cancer in men and women in the U.S., these screenings can impact a lot of people.
WHAT IS THE ROLE OF FAMILY MEDICINE IN COLORECTAL CANCER SCREENING?
Hougas: Encouraging recommended follow-up makes a difference. While it may not be a surprise to anyone, the patients most likely to die from colon cancer are the ones who have fallen behind on their screenings. Overall, 1 in 23 men and 1 in 25 women will develop colorectal cancer in their lifetime.
WHAT IS THE ROLE OF FAMILY MEDICINE IN COLONOSCOPIES, AND WHAT SHOULD IT BE?
Hougas: Physicians should be able to practice the full range of their skills. If we have been adequately trained and keep up the skill sufficiently, there is no reason that we shouldn’t be able to practice that skill. Colonoscopy is no different. There are vast swaths of rural areas with limited access to endoscopy in Minnesota. Family medicine is already in those communities, providing critical access to a wide range of care. Colonoscopy can be another piece of a full spectrum practice. If you don’t personally do colonoscopy, being able to talk your patients through their concerns or worries about the procedure can improve their willingness to get it done.
CAN YOU SHARE ABOUT YOUR EXPERIENCE PERFORMING COLONOSCOPIES?
Hougas: It is one of my favorite parts of my clinical practice. It is great to be able to take a clinic patient who might not otherwise get their screening done and carry that trust into the procedure room. It also keeps variety in my week.
WHAT DO YOU THINK FAMILY PHYSICIANS NEED TO KNOW ABOUT COLORECTAL SCREENING?
Hougas: Any type of screening for colon cancer has benefit, not just colonoscopy! For your average-risk patients, encouraging FIT, Cologuard™ or colonoscopy makes a difference. If your patients are higher risk, like a first-degree relative who had an advanced adenoma or colorectal cancer, they should only be recommended for colonoscopy. The follow up (surveillance) guidelines after polypectomy were updated in 2020 and allow for increased time between colonoscopies for many patients.
PARTING THOUGHTS…
Hougas: Despite a recent New England Journal of Medicine article that was in the headlines, we still believe that colonoscopy and general screening saves lives. While that study out of Europe adds important data to medical science, there are several flaws in its interpretation. For one, only 42% of the patients in the colonoscopy study group actually had the procedure performed. Even with fewer than 50% of the invited patients completing the intervention, patients in the colonoscopy group were at lower risk of developing colon cancer.
REFERENCES
- Screening for Colorectal Cancer U.S. Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965-1977. doi:10.1001/jama.2021.6238
- American Cancer Society. Colorectal Cancer Facts & Figures 2020-2022. Atlanta: American Cancer Society; 2020.
- de Kanter C, Dhaliwal S, Hawks M. Colorectal Cancer Screening: Updated Guidelines From the American College of Gastroenterology. Am Fam Physician. 2022;105(3):327-329.
- Bretthauer M, Løberg M, Wieszczy P, et al. Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death. N Engl J Med. 2022;387(17):1547-1556. doi:10.1056/NEJMoa2208375
- Dominitz JA, Robertson DJ. Understanding the Results of a Randomized Trial of Screening Colonoscopy. N Engl J Med. 2022;387(17):1609-1611. doi:10.1056/NEJMe2211595
ABOUT THE EXPERT
James Hougas III, MD, FAAFP, is an assistant professor in the University of Minnesota Department of Family Medicine and Community Health and a faculty member at St. John’s Hospital Family Medicine Residency. His clinical and research interests include infectious diseases, antimicrobial stewardship, trauma care and systems, office-based procedures, physician leadership and colonoscopy.
AAFP Clinical Recommendation
Following review of the USPSTF recommendations, the American Academy of Family Physicians (AAFP) agreed that screening should be recommended for all adults aged 50-75 but found “insufficient evidence to assess the benefits and harms for screening for colorectal cancer in adults aged 45-49.”
View the AAFP’s recommended clinical considerations and rationale on colorectal cancer screening and other clinical topics.
