The American Cancer Society (ACS) has recently issued its first substantial revision to colorectal cancer (CRC) screening recommendations since 2018. This update addresses two key areas: the integration of novel molecular screening technologies that have received regulatory approval and the concerning, persistent rise in CRC incidence among younger demographics.
Research points to a confluence of factors, including dietary habits and environmental influences, as potential contributors to the uptick in early-onset CRC cases. Consequently, updated screening protocols are more critical than ever. Here are the five pivotal insights derived from the revised ACS guidelines.
Blood-Based Tests: A Cautious Approach
So-called “liquid biopsy” tests, also referred to as blood-based or cell-free DNA assays, have garnered considerable attention as a convenient alternative to traditional stool tests and colonoscopies. However, the ACS is advising a more conservative stance.
According to the updated guidelines, blood-based tests are currently not endorsed as primary screening methods. They are suggested only for individuals who decline or have not completed a preferred CRC screening modality.
The primary limitation of these tests lies in their sensitivity. Blood-based tests have demonstrated lower efficacy in detecting both advanced precancerous lesions (APLs) and early-stage cancers when compared to established stool-based methods. This distinction is profoundly important, as the fundamental objective of CRC screening is not solely to identify cancer but to prevent its development by detecting and removing precancerous growths before they can transform into malignancy.
The guidelines cite a modeling study indicating that approximately 80% of the long-term reduction in CRC mortality achieved through screening is attributable to the detection and removal of precancerous lesions. Blood-based tests, with their notably low sensitivity for APLs (around 13% in two extensive prospective studies), fall short of this crucial preventive goal.
Furthermore, there’s an observed decline in specificity with age. Across both the ECLIPSE and PREEMPT CRC studies, specificity decreased from over 90% in participants under 55 to approximately 80% in those aged 70 and older. This suggests that older adults may encounter a higher rate of false positives, compounding the risks associated with follow-up colonoscopies.
Nevertheless, the ACS recognizes the tangible benefit of blood-based tests for individuals who might otherwise forgo screening altogether, acknowledging that any screening is preferable to none.
Two Novel Stool-Based Tests Designated as “Preferred”
This represents the most significant modification in the new guidelines. Two recently approved stool-based tests have now been incorporated into the ACS’s list of preferred screening options:
- ColoSense (mt-sRNA): This multitarget stool test employs an algorithm that integrates eight RNA biomarkers, a fecal immunochemical test (FIT), and self-reported smoking status. Its purpose is to identify individuals at elevated risk for any abnormal cell growth within the large intestine. In the CRC-PREVENT validation study, it exhibited 94.4% sensitivity for CRC, 100% sensitivity for stage I disease, and 45.9% sensitivity for advanced adenoma. It secured FDA approval in 2024.
- Cologuard Plus (ng-mt-sDNA): This next-generation multitarget stool DNA test is an evolution of the original Cologuard. It features a refined set of biomarkers engineered to enhance specificity while maintaining high sensitivity. The BLUE-C study reported a sensitivity of 93.9% for CRC and 43.4% for APL, with improved specificity compared to its predecessor. It also received FDA approval in 2024.
Both of these tests are recommended for use every three years and join a select group of approved stool-based screening options, which also include annual high-sensitivity fecal occult blood tests and an established DNA stool test. Predictive modeling suggests that all these options offer comparable effectiveness in reducing colorectal cancer incidence and mortality.
It is also noteworthy that Medicare and Medicaid coverage for ColoSense is pending as of the publication of these guidelines, which could potentially impact patient access.
Positive Non-Colonoscopy Test Mandates Follow-Up Colonoscopy
This directive applies universally to all non-colonoscopy screening tests, encompassing both stool-based and blood-based methodologies. The guidelines are unequivocal on this matter: a positive result necessitates prompt follow-up with a colonoscopy, ideally within six months, to finalize the screening process.
This step is not optional and cannot be substituted by repeating a stool or blood test. The guidelines explicitly state that opting for another non-colonoscopy test after a positive result is deemed unacceptable.
The rationale for this stipulation stems from real-world data indicating it as a recurring issue. The guidelines highlight that self-reported screening data can be misleading, partly because individuals who receive a positive result from a non-colonoscopy screening test fail to complete their subsequent colonoscopies. Data from one randomized trial cited within the guidelines revealed that only 50% of participants with a positive blood-based test underwent a follow-up colonoscopy within six months, in contrast to 70% of those with a positive stool test result.
Therefore, it is imperative to remember that a positive screening test marks the initiation of a process, not its conclusion.
The Age-45 Screening Commencement Recommendation Remains Firm
In 2018, the ACS established a significant precedent by lowering the recommended age for initiating CRC screening from 50 to 45 for individuals at average risk. This recommendation is reiterated in the current update.
The underlying justification has not changed; if anything, the supporting data have become more compelling. CRC incidence has risen among adults under 50 at an annual rate of 3% between 2013 and 2022. Within this demographic in the United States, CRC is now the leading cause of cancer-related mortality in men and the second leading cause in women. Research has identified dietary patterns as a primary driver of this trend, particularly among women under 50.
Despite the 2018 recommendation, screening uptake among the newly eligible age group remains suboptimal. In 2023, only 37% of adults aged 45–49 reported being up-to-date with ACS-recommended CRC screening. The guidelines also point out that screening rates were lower among Hispanic (56%), Asian (58%), and American Indian or Alaska Native (59%) individuals compared to their White (67%) and Black (66%) counterparts.
Persistent Disparities Demand Urgent Attention
These disparities in early colorectal cancer screening uptake are not the sole inequities observed across racial and ethnic groups. The guidelines underscore several stark differences in the CRC burden:
- Black Individuals: Age-adjusted CRC incidence rates are estimated to be 11% higher among Black individuals, with mortality rates approximately 40% higher than those of White individuals.
- American Indian and Alaska Native Populations: Incidence rates are 48% higher, and mortality rates are about 44% higher than those of White populations.
- Alaska Native People Specifically: Exhibit CRC incidence and mortality rates more than double those observed among White populations in the United States.
These disparities are compounded by persistent gaps in screening access. Lack of health insurance and lower socioeconomic status are correlated with reduced screening prevalence. The guidelines also highlight that the anticipated high cost of newer diagnostic tests, including blood-based assays and the newly approved stool tests, is poised to create significant barriers for uninsured and underinsured populations.
Annual high-sensitivity fecal occult blood tests and older stool DNA tests remain the more cost-effective options among the recommended modalities. Modifiable lifestyle factors, such as alcohol consumption, also contribute to CRC risk and warrant attention alongside screening initiatives.
The ACS frames the inclusion of additional screening methods as a component of its commitment to promoting health equity. An expanded range of options offers increased opportunities to reach individuals facing barriers to colonoscopy or traditional stool-based testing. However, the guidelines emphasize that broadening accessibility to tests is insufficient without concurrent efforts to ensure equitable access and comprehensive insurance coverage.
The Concluding Perspective
The 2026 update to the ACS guidelines refines the CRC screening recommendations originally issued in 2018. The fundamental message remains consistent: commence screening at age 45, adhere to a chosen preferred test, and if the result is positive, proceed with a follow-up colonoscopy.
For individuals aged 45 and older who have not yet undergone screening, the most critical step is to consult with a healthcare provider to determine the most appropriate screening test. As the guidelines articulate, the most effective screening test is ultimately the one that is completed.
Business Style Takeaway: Proactive engagement with updated health screening guidelines, such as those for colorectal cancer, is crucial for maintaining executive vitality and long-term productivity. Understanding and acting upon these recommendations can prevent serious health issues, minimize potential work disruptions, and underscore a commitment to personal well-being, which directly translates to sustained performance and leadership efficacy.
Original article : www.mindbodygreen.com