A professional society is not enthusiastic about lower age for colon cancer screening

August 30, 2023

Image by Dall-E

I wrote in March about colon cancer screening, including the 2021 US Preventive Services Task Force recommendation to start colorectal cancer screening at age 45 in light of the increase in colorectal cancer in those under age 50. The USPSTF recommends screening with colonoscopy, flexible sigmoidoscopy with stool tests, CT colonography, and stool tests (either for blood or genetic tests).

This month, the American College of Physicians (the specialty society of internists - I am a member) came out with its recommendations for colorectal cancer screening, which

●      Do not recommend screening those at average risk from ages 45-49

●      Do not use CT colonography or stool DNA tests (Cologuard) or any blood test for screening

●      Recommend stool testing (Fecal immunochemical test (FIT) or Stool Guaiac) every other year instead of annually.

The ACP came to its conclusions reviewing the same literature reviewed by the USPSTF. However, the ACP considered costs in its recommendation; hence, the FIT test ($3-4) is strongly preferred over the Cologuard test ($680). The ACP is skeptical of the microsimulation models which favored earlier screening. They point out finding a single case of cancer takes many more screenings given the low incidence of colorectal cancer in those under 50; this means that more are exposed to potential harm from screening. An accompanying editorial (paywalled) points out that while these guidelines recommend less screening than the USPSTF and the American Cancer Society, they are consistent with international guidelines. Internationally, the UK and Canada support colorectal cancer (CRC) screening from age 50 years. Japan offers CRC screening starting at age 40 years.

Implications for employers:

-        The highest value is in screening from ages 50-75, although members who wish to begin screening at 45 should receive coverage for this.

-        Benefit design is required to follow the USPSTF recommendations - and thus there should be no cost sharing for colorectal cancer screening starting at age 45.

-        The Affordable Care Act does not require coverage of every possible colorectal cancer screening test, so employers can choose not to cover Cologuard which if performed annually or every two years would be the most expensive screening method.

-        Employers should be cautious about carrier or vendor programs to promote Cologuard as a colorectal cancer screening test. FIT testing is available and is FAR less costly.

-        Multicancer early detection tests (such as Grail’s Gallerie) are not sensitive enough for colorectal cancer, so those having this test, which is also not recommended by the ACP, should still use other accepted screening modalities. Here is a link to WTW information on multicancer early detection tests.

Thursday: New therapeutic competition in a drug class lowers prices

Thanks for reading.  You can find previous posts in the Employer Coverage archive

Please “like” and suggest this newsletter to friends and colleagues. Thanks!