CRC Screening Increases in Patients Aged 45 to 49 After USPSTF Recommendation

The US Preventive Services Task Force’s (USPSTF) recommendations for screening for colorectal cancer (CRC) have had an immediate effect on testing rates in patients aged 45 to 49 years, according to a study published in JAMA Network Open.¹ Screening in this age group, first recommended in the newest guidelines, can be affected by socioeconomic status and locality.

Increased screening has been associated with a decrease in both incidence and mortality related to CRC, which has led the USPSTF to expand their guidelines to encourage adults aged 45 to 49 years to get screened for CRC.² However, the association between these updated guidelines and any increased uptake of screening has not been looked into and is not understood nearly as well. This study aimed to assess privately insured individuals to evaluate the association between the updated guidelines, published in 2021, and uptake in screening for CRC.

Screening for colorectal cancer increased in patients aged 45 to 49 years after an update in screening guidelines | Image credit: © Dr_Microbe - stock.adobe.com

Deidentified commercial claims data from Blue Cross Blue Shield (BCBS) Axis were used for the retrospective cohort study. The database includes data from 92% of physicians and 96% of hospitals throughout the US. Data from January 1, 2017, to December 31, 2022, were used to evaluate differences in screening patterns before and after the guidelines were introduced. The years were separated into 2-month periods. Individuals were included if they used BCBS insurance for at least 12 months prior to the start of the period, and did not receive screening for CRC in the 12 months prior. Those who were screened more than once were regarded as 1 individual in analyses.

Colonoscopy, CT colonoscopy, stool DNA test, fecal occult blood test, fecal immunochemical test, and flexible sigmoidoscopy uptake were the tests evaluated in this study. Outpatient procedures were included in the study, and patients with gastrointestinal tract symptoms were excluded. The risk of CRC for patients was evaluated, along with demographic data collected from BCBS that included age, sex, ethnicity, and area-level deprivation measured through Social Deprivation Index (SDI).

There were 10,221,114 patients included in the study who were all aged 45 to 49 years who had a mean (SD) age of 47.04 (1.41) years; 51.04% of the participants were female. A mean of 3,304,879 (108,378) individuals were eligible for screening in each 2-month period. The database primarily did not include race and ethnicity, with 66.76% of the participants listed as unknown. For participants whose race or ethnicity was known, participants primarily reported being White (25.43%), followed by 3.86% who reported Hispanic, 2.65% who reported Black, 1.15% who reported Asian, and 0.15% who reported Native American or Pacific Islander.

Mean screening uptake in patients aged 45 to 49 years was similar in the periods of January 1, 2017, to April 30, 2018, and May 1, 2018, to December 31, 2019, (0.57% [0.03%] vs 0.58% [0.02%]). Although the screening uptake declined during the COVID-19 pandemic but increased steadily after May 2021 (range, 0.71%-2.41%), December 31, 2022, saw similar rates of screening in patients aged 45 to 49 years compared with patients aged 50 to 75 years (2.37% and 2.40% respectively).

The bimonthly mean screening increased from 0.58% (0.02%) prior to May 2021 to 1.58% (0.57%) after May 2021, when the screening recommendations were updated, or a 1.00 percentage point (95% CI, 0.62-1.38) absolute change. The relative change was not significantly changed however (171.67%; 95% CI, –20.90% to 365.71%).

The mean screening uptake increased from 0.50% (0.02%) to 1.51% (0.59%) in patients with average risk from the prerecommendation to the postrecommendation period. The high-risk group saw a more moderate increase in screening rates, changing from 2.12% (0.11%) to 2.33% (0.27%). Mean relative change in screening did not change significantly among patients at average risk (202.51%; 95% CI, –30.59% to 436.87%). Both female and male participants had a higher uptake of overall screening in the postrecommendation period compared with the prerecommendation period (1.56% vs 0.55% and 1.46% vs 0.45%, respectively).

Individuals who resided in areas that had an SDI that correlated to the highest socioeconomic status had a significantly higher screening rate among average risk beneficiaries compared with beneficiaries living in areas of lowest socioeconomic status (1.84% vs 1.19%). Higher uptake was also found in patients with average risk if they lived in metropolitan areas compared with nonmetropolitan areas (0.53% vs 0.38% before recommendations and 1.59% vs 1.11% after recommendations, respectively). Overall, screening uptake increased by 0.19 percentage points (95% CI, 0.18-0.20) every 2 months after the recommendations were published in all patients.

There were some limitations to this study. Only a subset of the population had data on race and ethnicity and health outcomes due to these factors could not be captured. Also, type of coverage was not evaluated in patients, which could have affected reasons for screening, and BCBS may not be representative of all Americans.

The researchers concluded that screening increased in patients aged 45 to 49 years after the updated guidelines were introduced. Although there was an overall increase in screening, disparities were found based on socioeconomic status and area of residence, which emphasizes a need for interventions in these areas to increase overall screening in patients of all areas and socioeconomic status.

References

1. Siddique S, Wang R, Yasin F, et al. USPSTF colorectal cancer screening recommendation and uptake for individuals aged 45 to 49 years. JAMA Netw Open. 2024;7(10):e2436358. doi:10.1001/jamanetworkopen.2024.36358

2. Colorectal cancer: screening. U.S. Preventive Services Task Force. May 18, 2021. Accessed October 7, 2024. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening