A Significant Departure: New USPSTF Colorectal Cancer Recommendations
Carol A. Burke, MD, FACG
President-Elect, American College of Gastroenterology
Screening for colorectal cancer substantially reduces colorectal cancer deaths. Yet updated recommendations by the U.S. Preventive Services Task Force (USPSTF) released last week fail to distinguish adequately between colorectal cancer screening methods and neglect to differentiate between strategies that prevent colorectal cancer versus those that merely detect it.
In a significant departure from their 2008 recommendations, this government-backed panel has unnecessarily complicated the issue for patients and payers alike and neglected to highlight one of the most unique and important elements of colorectal cancer screening – this is a cancer that is largely preventable by colonoscopy with polypectomy.
The USPSTF gives an “A” recommendation to colorectal cancer screening starting at 50 years of age and continuing until 75 years of age. They have moderate certainty (C recommendation) that the net benefit of screening for colorectal cancer in adults ages 76 to 85 years is greater in those who have never been screened versus those previously screened. The decision to screen in this age group should be individualized, taking into account the patient’s overall health.
While ACG agrees that there is much to be done to increase colorectal cancer screening rates in the United States, the College is concerned that the USPSTF’s approach leaves patients, physicians and payers in a quandary.
The USPSTF last issued guidelines for colorectal cancer screening in 2008. At that time, the panel made graded recommendations for only three approaches to screening: colonoscopy, fecal occult blood testing, and flexible sigmoidoscopy.
In its updated CRC recommendations issued last week and published in JAMA, the USPSTF departed significantly from its approach in 2008 and chose to endorse “CRC screening” by any of a variety of options, without graded recommendations for the tests:
- Flexible sigmoidoscopy
- Computed tomography colonography
- Guaiac-based fecal occult blood test
- Fecal immunochemical test
- Multi-targeted stool DNA test
- Methylated SEPT9 DNA test
Instead, based on a review of the evidence of the effectiveness of screening and the lack of head-to-head studies demonstrating that any of the screening strategies are more effective than others, the panel concluded that “multiple screening strategies are available to choose from, with different levels of evidence to support their effectiveness, risks and benefits, as well as unique advantages and limitations, although there are no empirical data to demonstrate that any of the reviewed strategies provide a greater net benefit.”
The panel relied on a report of a microsimulation modeling study to inform its screening recommendations. By failing to present the tests in any preferred or ranked order, the USPSTF implies that the tests are equivalent. While the USPSTF heralded “shared decision making” as a way for physicians and patients to navigate all the options and reach a consensus about the right test, the new recommendations mask the very real differences among the screening options. They also require substantial knowledge by the prescribing clinician of each test’s benefits, limitations and accuracy, and their ability to ensure patients’ understanding of each test, including the need that any positive screening test short of colonoscopy leads to colonoscopy, as well as the insurance impact when a positive screening test leads to a “diagnostic” rather than screening colonoscopy.
ACG Perspective: Colonoscopy as the Preferred Colorectal Cancer Prevention Strategy
In contrast, the College’s colorectal cancer screening guidelines make the distinction between screening strategies that prevent colorectal cancer versus strategies that detect colorectal cancer. This distinction is in alignment with the guidelines of the U.S. Multi-Society Task Force on Colorectal Cancer. ACG prioritizes colorectal cancer prevention over colorectal cancer detection and therefore recommends colonoscopy as the preferred colorectal cancer prevention strategy.
The aim of the American College of Gastroenterology CRC screening recommendations is to endorse high-quality colonoscopy as the colorectal cancer screening test of choice, and this is solidly based on strong clinical evidence demonstrating a decrease in both CRC incidence and mortality related to the use of screening colonoscopy. Gastroenterologists are in the best position to share the evidence supporting the benefit of colonoscopy as one of the most effective prevention tools in clinical medicine, reducing both CRC incidence and mortality.
The College stands behind enhancing CRC screening rates and our current guideline that places the highest preference on colonoscopy as the screening test of choice because it prevents colorectal cancer, not just detects it.