Colorectal Cancer Screening in the U.S., 2018: The Gap Among Adults 50–64

Among cancers that affect both men and women, colorectal cancer (CRC) is the second leading cause of cancer death in the United States. In 2016, 141,270 people were diagnosed with it and 52,286 died. Screening works: there is strong evidence it reduces both new cases and deaths, and the steady decline in both over the past 30 years is partly due to more adults getting screened.

At the time of this CDC Vital Signs report, the U.S. Preventive Services Task Force recommended that adults aged 50–75 at average risk — no personal or family history of colorectal cancer or polyps, no inflammatory bowel disease, and no genetic syndromes linked to it — be screened with any of six tests:

1. fecal occult blood test (FOBT);
2. fecal immunochemical test (FIT);
3. multitarget stool DNA test (FIT-DNA);
4. CT colonography;
5. sigmoidoscopy;
6. colonoscopy.

Screening still fell short of the Healthy People 2020 target of 70.5%, and gains had not been equal across groups.

How the data were gathered

CDC analyzed the 2018 Behavioral Risk Factor Surveillance System, a state-based telephone survey of adults. Of 222,490 respondents aged 50–75, 16,127 (7.2%) who didn't answer the screening questions were excluded. "Up to date" meant having had a recommended test within the recommended interval.

What it found

68.8% of adults aged 50–75 were up to date — 79.2% of those 65–75 but only 63.3% of those 50–64, a gap of 15.9 percentage points. Screening rose steadily with age, from 50.0% at ages 50–54 to 81.3% at 70–75, and in every group studied, older adults were more likely to be up to date.

Percentage of adults up to date with colorectal cancer screening, by age, 2018 (CDC).

Among adults 50–64:

• lowest among those without a regular health care provider (32.7%) or without health insurance (32.6%);
• highest among those with household incomes of $75,000 or more (70.8%) and college graduates (70.7%);
• higher among women than men (65.4% vs. 61.1%), and in metropolitan than non-metropolitan areas (68.1% vs. 64.4%).

Among adults 65–75: lowest among those without a regular provider (45.6%) and highest among those with incomes of $75,000 or more (87.1%).

The widest gap — 54.5 percentage points — was between older adults with incomes of $75,000 or more and younger adults without insurance. Yet lack of insurance didn't explain most of the shortfall: 81% of never-screened adults aged 50–64 and 94% of those 65–75 said they had health insurance.

By state: Massachusetts had the highest rate among all adults 50–75 (76.5%) and Wyoming the lowest (57.8%). Among adults 65–75, rates topped 70.5% in 49 states and the District of Columbia; among those 50–64, only four states reached that level, and 11 were below 60%.

Why younger adults lag

Seeing a primary care provider is linked to getting screened, but visits don't guarantee it: in one study of Medicaid enrollees who turned 50, 75% had a primary care visit within a year, yet only 17% were screened. Modeling shows that starting screening at 50 rather than 55 prevents more cancers and deaths, so a slow start at younger ages blunts screening's benefit.

Other barriers include:

• no recommendation from a provider;
• being offered only colonoscopy rather than a choice of tests;
• not knowing screening is needed;
• fear, cost and competing priorities;
• being unable to take time off work for a colonoscopy;
• finding the tests unpleasant, such as collecting stool samples or doing bowel preparation.

The results have limits: people may have counted diagnostic tests as screening, answers were self-reported and not checked against medical records, and the survey's response rate was 49.9%.

What could help

Colorectal cancer screening earns the Task Force's top grade A recommendation. One modeling study found that raising screening to 80% could cut incidence by 22% and deaths by 33% by 2030 — about 277,000 cases averted and 203,000 deaths prevented — assuming people start at 50 and keep screening through 75.

Evidence-based steps from The Community Guide — provider and patient reminders, provider assessment and feedback, and removing structural barriers — can raise screening even in hard-to-reach groups. Through CDC's Colorectal Cancer Control Program, states, tribes and universities partnered with about 600 clinics, most of them Federally Qualified Health Centers, reaching about 1 million adults aged 50–75 over three years and raising screening by an average of 10 percentage points. Other ideas include teaching adults about screening well before they turn 50, explaining insurance coverage and test options clearly, and researching the barriers specific to younger adults.

Sources

• Joseph DA, King JB, Dowling NF, Thomas CC, Richardson LC. "Vital Signs: Colorectal Cancer Screening Test Use — United States, 2018," MMWR Vol. 69, No. 10, CDC; a work of the United States government in the public domain.