The Pulse | Thursday, January 28, 2021

Colorectal Cancer Trends in 2021 and Beyond

Whitney Jones, MD

As we begin our work of preventing cancer and saving lives this year, many challenges stand before us: the impact of the COVID-19 pandemic, ensuing public health measures and the old/new challenges of delivering equitable preventative care across the populations we serve. If we are going to seize the opportunity we have to prevent the rise of colorectal cancer (CRC), then we must think and work our way out of these areas where “catch up” is needed.

Three areas in particular beg our immediate attention:

1. We must rethink how to make up the screenings, surveillance and diagnostic studies for those who have had diminished or no access to healthcare over the last year.
2. We should consider how to onboard the approximately 22.5 million people nationwide between the ages of 45-49 who have yet to be fully integrated into the health system’s screening services based on new guidelines.
3. Last and most critically, we have much room to screen more effectively those who are not yet engaged nor benefiting due to factors of race, socioeconomics/poverty, geography, sex, age and educational attainment.

These three issues in front of us are not mysteries, but puzzles to solve. We can and we must do this to save even more lives and prevent more unnecessary suffering.

Here are some trending items for your team to be aware of as we dive into 2021 and beyond.

Incidence Rates

Nationally, CRC incidence and mortality rates per 100,000 are down. We are finding and removing more precancerous adenomas, detecting CRC at earlier stages and improving our treatments for advanced disease. Our country is stuck at approximately 67% screened, leaving one-third of eligible people unscreened. There remain wide variations between states and groups with health disparities to be sure. Find your state statistics here.  

Critically, incidence rates for CRC continue to rise for all those under age 55. Two issues are contributing to this disturbing fact: early-age onset and late messaging.

Early-Age Onset

First, early-age onset (those under age 50) CRC is dramatically increasing. Those born in or after the 1980s-90s now show a 2x increased risk for colon cancer and a 4x increased risk for rectal cancers.^[1] The reasons are unknown and this is considered a worldwide phenomenon. Diet, microbiome and environmental factors are potential causes under study. One out of five CRC cases now occur under age 55.^[1] Never ignore symptoms in a person just based on their age alone.

Lead Time Messaging

Second, our current messaging starts too late. We often fail to identify and screen (at 40 or sooner) the approximately 1 in 5 persons at elevated risk due to family history of CRC or advanced adenoma. Only around half of average-risk individuals who should be screened at age 45/50 are actually getting screened before age 55. Clearly, the current CRC messaging package is delivered too late and too infrequently to achieve an on-time screening event for this under 55 cohort. Lead time messaging around CRC screening starting at age 35, repeated at least annually, will better inform and identify the high-risk pool, improve compliance among average risk persons, and address health disparities.^[2] Who does not like to keep the schedule on time? 

Age and Types of Screenings

In 2018, the American Cancer Society (ACS) changed their average age screening start age to 45. This was driven by the 10% of lives lost to CRC occurring between the ages of 45-49. Currently, the United States Preventative Task Force Service is reviewing the same recommendation to also lower the age for average-risk to 45. This age change is overdue, and your institution should prepare now to put it into action immediately or ramp it up further if your state already used ACS 45 guidelines for screening. This is critical to our mission — do not wait to prepare.

Increasing screening to the national goal of 80% in all communities will, by necessity, require increased utilization of non-colonoscopy-based screening testing for average-risk asymptomatic individuals. While it is a superb first line of screening test, we can expect colonoscopy to shift toward more diagnostic and therapeutic indications, while tools like FIT, multi-target stool DNA (including Version 2.0 of Cologuard) and others will be increasingly used for population screening. Much of the “catch up” needed can be accomplished through these two currently available options, both of which can be delivered to those still avoiding in-person visits or procedures. ^[3]

Quality Assurance Metrics

As we see shifts in average-risk screening patterns, expect to develop new quality metrics around adenoma detection rates (ADR) following a positive FIT, Cologuard or other emerging first line screening methods. Benchmarks for ADR will likely be higher in those undergoing colonoscopies after a positive first order test than in those using colonoscopy as the primary screening modality. Also, when evaluating a positive stool test, it is critical to focus on those tricky right sided/cecal flat lesions, including hyperplastic polyps and serrated adenomas.

A second and long overdue must in the endoscopy suite is universal CRC tumor testing for Lynch Syndrome (also known as hereditary nonpolyposis colorectal cancer, HNPCC). Around half of Lynch syndrome patients will present with CRC after age 45.^[4] Only by testing all tumors can we identify the 1 in 279 persons carrying genetic mutations. Tumor staining for mismatch repair (MMR) or microsatellite instability (MSI) not only identifies probable Lynch syndrome patients, but it is also helps determine the best type of treatment approach (i.e. immunotherapy). A simple endoscopy unit protocol requesting universal MMR tumor screening on every CRC by pathology is a no-brainer.

Multiomics and Artificial Intelligence

If the rapid changes in stool-based testing have been difficult to keep up with, then strap on your seatbelts for the future — the innovation train has left the station and is not slowing down.

Look for less expensive and more expansive genetic testing options to be available and family history collection tools to become integrated into EHRs. Every person we see in the office or the endoscopy suite deserves a Hereditary Cancer Risk Assessment and either a referral to a genetic counselor or a point of service genetic panel testing if criteria are met. Every person developing CRC under the age of 50 should have full gene panel testing offered in addition to universal tumor testing for MSI/MMR deficiency. Blood-based liquid biopsies that look at methylation patterns will help us identify multiple early-stage cancers, including CRC, gastric, esophageal, pancreatic, liver and others with remarkably high specificity and site of cancer accuracy.

Artificial Intelligence and informatics from multiple positions (insurers, health systems, EHRs) must help us better identify unscreened, at-risk persons — especially those with health disparities — and get them to screen. Only a few health systems use this now. If we are to catch up, we all must adopt an informatics-based system incorporating a logistical approach to screen people on time at population scale.

It’s clear that emerging biotech/technology are becoming as critical to high quality digestive disease management as endoscopes, CT scans and MRIs are today.

So, SGNA members — be ready and lead as you always have in the past. Thank you all for what you do every day!

 

Dr. Whitney Jones is a practicing gastroenterologist and a former therapeutic endoscopist and clinical professor at the University of Louisville from 1994 until 2017. He is currently an adjunct professor at the University of Louisville School of Public Health.

In 2003 Jones founded a 501C3, the Colon Cancer Prevention Project, a leading CRC information and advocacy organization focused on innovative acceleration of evidence based screening, including emerging biotech and logistics. Kentucky has since more than doubled its screening rates (now 69.7%) and reduced colon cancer deaths by a third. 

A major focus of the “Project” is advocacy through passing pragmatic state based laws, which lower barriers to access evidence based CRC screening, including a funded program for the un- and underinsured. Kentucky is the first state in the nation to mandate no cost sharing coverage for preventative evidence-based genetic panel testing for hereditary cancers, including Lynch Syndrome.  These laws have resulted in Kentucky having the lowest barriers for CRC screening in the nation. 

[1] https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21601

[2] https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.32535

[3] https://pubmed.ncbi.nlm.nih.gov/30452915/

[4] https://www.gastrojournal.org/action/showPdf?pii=S0016-5085%2814%2900448-X  (page 508)