The American Cancer Society has released a major update to its recommendations for colorectal cancer screening. While colonoscopies remain the gold standard for detecting the disease, the organization is now also endorsing blood and stool tests — though there's also important guidance about how these tests stack up to the tried-and-true screening method that's been recommended for years.
This is the first update the ACS has made to its guidelines since 2018, when it lowered the recommended screening age for colonoscopies from 50 to 45. Since then, the rate of younger patients diagnosed with the disease has only continued to rise; CRC is now the most deadly cancer among people under 50. But if caught early, it's highly treatable with a five-year survival rate of about 90 percent. Still, more than 20 million Americans eligible for CRC screening don't get regularly tested. The organization hopes that acknowledging the option of less invasive and more convenient tests will change that.
"We need to increase our emphasis on colorectal cancer as a highly preventable disease as much as a treatable one," said Robert Smith, Ph.D., senior vice president of early detection science at the ACS. "By offering more screening tools in our guideline update, more eligible adults will be able to participate in lifesaving colorectal cancer tests, helping to close the screening gap."
However, not all of these tests "have the same efficacy, accessibility, or coverage, so it's important that patients understand their risk factors and options when selecting a test with their doctor," says William Dahut, MD, the ACS's chief scientific officer.
Here's a closer look at the guidelines, what to know about the alternative screening tools, and more.
The new colorectal cancer screening guidelines (and their effectiveness)
The ACS still recommends that screening begin at age 45 and continue through at least age 75. Colonoscopies, in which a scope is inserted into the large intestine to search for tumors or polyps, remain the preferred method and should be performed every 10 years. What's new is that the ACS now offers guidelines for stool and blood tests.
Two types of fecal tests are being recommended. Multi-targeted stool testing, which includes Cologuard, analyzes samples for traces of blood and biomarkers associated with CRC; these tests should be performed every three years. High-sensitivity fecal testing, which includes fecal immunochemical tests (FIT) and guaiac-based fecal occult blood tests (gFOBT), detects only blood in stool and should be performed annually.
The blood tests, meanwhile, are not preferred by the ACS because they're less sensitive and don't screen for pre-cancer as the stool tests do, Arif Kamal, MD, the ACS's chief patient officer, tells us. That's why blood testing is only recommended for patients unwilling to use the other two options.
Dr. Mark Pochapin, a gastroenterologist at NYU Langone, says it's helpful to think about these newer tests as a "two-step process," because if they come back positive, a patient will need to follow up with a colonoscopy. The consensus among experts is that although stool tests are reliable and effective, colonoscopy is still superior because "it detects a high percentage of polyps and allows for their removal," he tells us.
"The concept of prevention is finding every polyp and removing them before these polyps ever have the opportunity to turn into cancer," Dr. Pochapin says.
Importantly, these recommendations are only for people of average risk for colorectal cancer. Those at high risk — including people with a family history of CRC or conditions linked to CRC, such as Lynch syndrome, and those who've had the cancer before or inflammatory bowel disease — should be getting colonoscopies more often and at a younger age. It's important to consult your doctor about your individual needs.
Will insurance cover blood and stool tests for colorectal cancer?
According to the Colorectal Cancer Alliance, two types of stool tests are widely covered by insurance: FIT tests, and a form of the multi-targeted stool testing known as an mt-sDNA test, which is used by Cologuard. These tests analyze specific DNA markers and detect 43 percent of pre-cancer, giving them an edge over the other multi-targeted stool test on the market, which looks at RNA markers and are 41.3 percent effective. This method — called mt-sRNA — is used by ColoSense, and it isn't widely covered.
Both mt-sRNA and the blood tests haven't yet been endorsed by the U.S. Preventive Services Task Force, a panel of experts that dictates what screenings and other procedures insurers must cover. However, because all of the alternatives listed by the ACS are FDA-approved, they should be largely covered by Medicare, Dr. Kamal says.
Cancer detection is a fast-moving space, with new and better tests coming to market each year, which only helps in the fight against CRC, says Richard Wender, MD, medical advisor to the Colorectal Cancer Alliance.
"Ongoing innovation is crucial to screening participation and early detection, particularly among individuals who face barriers to screening," he says. "With young-onset colorectal cancer rates and deaths continuing to rise, it's important that we continue to make advancements and prioritize screening awareness and education."
