Certain birthdays bring with them exciting new privileges: At 18, you can vote. At 21, you can legally drink. At 25, you can rent a car. And of course, at 45, if you’re at average risk of colorectal cancer, you’re eligible for your first colon cancer screening. But if you’ve tried to get an appointment for a colonoscopy recently, you might have run into an unexpected speed bump: getting an appointment.
In 2021, the U.S. Preventive Services Task Force lowered the suggested age for routine colorectal cancer screening from 50 to 45 for adults at average risk, adding almost 20 million new people to the screening pool. Add to that the millions of people whose colonoscopies were either postponed or canceled during the Covid lockdown, and it’s no wonder the health care system is stretched so thin: The current annual colonoscopy capacity is estimated at only about 15 million procedures. There are simply not enough colonoscopies to go around, a limitation that’s unlikely to change anytime soon. That leaves the medical community with a big screening gap to close.
Colonoscopies are a highly regarded colorectal cancer screening option for a reason: Since the first nationally endorsed screening guidelines came out in the mid ‘90s, they remain the only screening option that lets a doctor take immediate action. According to Paul Limburg, MD, a board-certified gastroenterologist and chief medical officer of screening for Abbott’s cancer diagnostics business, “If you have precancerous polyps, an experienced colonoscopist can often find and remove them during the same procedure.”
So how do we preserve that therapeutic benefit but get more people screened? That's a problem researchers are trying to help solve. In a recent modeling study, researchers explored how we could reallocate available resources to screen all eligible individuals — and do it in a way that benefits patients, doctors and the broader health care system. This is what A. Mark Fendrick, MD, a professor of internal medicine and a professor of health management and policy at the University of Michigan, calls “a rare win-win-win.” The solution? Use more stool-based tests — an idea that may seem a little outside of the box ... until you understand the power of the test that comes in one.
That "box" is a use-at-home stool DNA test. These tests (which are available to adults 45 and older at average risk of colorectal cancer and, yes, arrive at your doorstep in a discreet box) can be completed at home and sent to the lab for results. While other non-invasive screening options, like fecal immunochemical tests (FIT) and new blood-based tests, may have limited ability to pick up signals from early-stage cancer or precancer, stool DNA tests have become a force for early detection. “In contrast to some other screening options, the next-generation stool DNA test, called Cologuard Plus, is FDA-approved for detecting both colorectal cancers and advanced precancerous lesions in average-risk individuals,” explains Dr. Limburg. Cologuard Plus launched last year and is now part of Abbott’s cancer diagnostics portfolio. Cologuard Plus builds on the success of the original Cologuard test, delivering high sensitivity for colorectal cancer detection. That said, these tests are not intended for people with symptoms or higher-risk personal or family medical histories who are generally advised to undergo colonoscopy instead.
Cologuard Plus is a highly effective noninvasive screening option—but how does it compare with colonoscopy? While a screening colonoscopy is typically repeated every 10 years, Cologuard Plus is recommended every three years. That shorter interval matters because no screening test catches every precancerous growth. Screening more often increases the opportunity to find changes before they become cancer. "Based on modeling studies, the combined effectiveness of repeated screenings with the Cologuard Plus test is on par with, if not even better than, screening with colonoscopy every 10 years," says Dr. Limburg.
Considering how many people need screening and how few doctors we have to screen them with colonoscopy, Dr. Fendrick says prescribing use-at-home colorectal cancer screening tests is an obvious solution: “If there are only 15 million colonoscopy slots, and the goal is to save as many lives as possible and screen as many eligible individuals at average risk for colorectal cancer as possible, we need to be doing a lot more stool-based tests and fewer initial screening colonoscopies. If I had it my way, on your 45th birthday everyone who is eligible would get a cupcake and a stool-based test like Cologuard Plus.”
When you follow an average-risk screening strategy with a stool-based DNA test like Cologuard Plus, “we’re dividing the screening-eligible population into two groups: those with a negative test result, who do not need a colonoscopy, and those with a positive test result, who can maximally benefit from this procedure,” says Dr. Fendrick.
In this scenario, many more of the 15 million available colonoscopies would be conducted on the patients who are more likely to have cancer or precancer, rather than on people whose exams might turn up nothing at all. “The point is that we simply do not have the capacity to do a screening colonoscopy for everyone — and even if we could, not all people are willing to get one,” Dr. Fendrick explains. “So physicians need to realize that if that’s all they’re offering, they may prescribe a test that many people won’t complete.”
While improving patient outcomes is a worthy goal, any large change in screening strategy also must make sense for the physicians performing the procedures and the insurers paying for them. Dr. Fendrick notes there’s an economic benefit to using more stool tests for initial screening. Modeling has shown that a stool-based screening strategy would lower overall colorectal cancer costs, while increasing the time doctors would spend on procedures that could benefit patients most. Any positive result from a noninvasive colorectal cancer screening test requires a follow-up colonoscopy to diagnose and potentially remove cancer or precancerous polyps. “Freeing up colonoscopy capacity for those who need follow-up or therapeutic colonoscopies would not only benefit patients, but it would also be a more effective use of physicians’ time and health care resources.”
Dr. Limburg and Dr. Fendrick aren’t suggesting we replace colonoscopy; instead, they want practitioners to use it more strategically. If the medical community can use the limited colonoscopy capacity on the patients who stand to benefit most, it could save time, money, and most importantly, lives: an outcome that would certainly be considered a win-win-win. If our health care system can simultaneously increase colorectal cancer screening rates by using more stool-based testing and reserve more colonoscopy slots for the people who truly need them, turning 45 won't just mean becoming eligible for screening — it'll mean having a better chance of actually getting screened.
Dr. Fendrick has been a consultant for Abbott but was not compensated for this article.
