Why Screening for Colorectal Cancer Is Starting Younger – and What to Expect

By: Winship Cancer Institute
Date: Mar 24, 2022

“Colorectal cancer is the third leading cancer in men and women equally and the second leading cause of cancer death."

Turning 50 is a big milestone for many people — a lot happens in a half-century, after all, including major medical and technological advancements. And for some time, reaching age 50 has been associated with having your first colonoscopy.

Recently, guidelines have changed. In 2018, the American Cancer Society revised its guidelines to recommend a first screening for colon cancer at age 45 — or earlier if you have a family history. In 2021, the US Preventive Services Task Force (USPSTF) updated its recommendations to match the American Cancer Society’s guidelines, lowering the age of first screening to 45. 

Sonali Sakaria

Sonali Sakaria, MD, is the Emory Clinic clinical chief of gastroenterology (GI) at Emory Decatur Hospital and completed her internal medicine and gastroenterology training at Emory University School of Medicine. She says the main reason for the updated guidelines “is that colorectal cancer is the third leading cancer in men and women equally and the second leading cause of cancer death. Recent studies have highlighted an increased incidence of colorectal cancer in individuals younger than age 50.”

But colorectal cancer is preventable — and it’s treatable when caught early. Colon cancer screening is one of the most effective early detection and prevention services available in medicine today.

Since 2011, Sakaria explains, the rate of colon cancer has increased by roughly 1% each year in patients both under and over age 50. Modeling studies, which are simulations run using available data to make predictions, have shown that starting colonoscopies at age 45 would help save lives. During screening, it’s possible to remove polyps early — if pre-cancerous polyps are removed, they won’t turn into colon cancer later.

“It’s a screening test that’s as important as getting pap smears, mammograms and prostate cancer screening. It truly does save lives,” Sakaria says. “I think educating patients on how the procedure is done alleviates a lot of their concerns. And the more educated patients are, the more likely they are going to be willing to undergo the screening procedure.”


Is a colonoscopy the only screening option?

You may see products for colon cancer testing advertised on television that you can order for using at home. However, there are benefits of a colonoscopy over this test, Sakaria says, and the US Multi-Society Task Force on Colorectal Cancer developed a tiered system that ranks screening tests and includes a colonoscopy in its Tier 1 recommendations. “Colonoscopy is great for detection and removal of polyps and great for detection of colon cancer,” Sakaria says. “The stool tests are good for detecting colon cancer, but they’re not as good for detecting pre-cancerous polyps.”

A colonoscopy is a one-step test, Sakaria explains. “Not only does it screen for colon cancer, but it is also a therapeutic procedure, meaning during colonoscopy, we remove any polyps that could potentially turn into colon cancer in the future.” If you opt for a stool test instead and it’s positive, you’ll need a colonoscopy regardless to evaluate why your test was positive. The next question your doctor will ask is, “Does the patient have something in the colon that’s causing the stool test to be positive, and does it need to be treated?”

A colonoscopy is typically recommended for most patients first, following the Tier 1 recommendations. But if a patient refuses that screening, or if they’re not a candidate for colonoscopy, Sakaria says the stool-based test — specifically the fecal fit test — would be considered and would need to be performed annually. If a stool-based test is positive a colonoscopy would be recommended for further evaluation.


What to expect for your first colonoscopy

Preparing your body for a colonoscopy starts the day before your procedure. “We have patients start a clear liquid diet in the morning the day before the procedure. They are on clear liquids the whole day,” Sakaria explains. This includes things like broth, clear soda, apple juice, popsicles and water, as well as black coffee and jello.

Around 5:00 p.m. that day, patients will start drinking something often referred to as “prep.” Once this stage starts, Sakaria warns that patients will begin experiencing diarrhea, one of the reasons that might cause patients to avoid having a colonoscopy. However, it’s an important step, Sakaria says. “We need to clean out the colon so that when we perform the colonoscopy, we are able to properly examine the walls of the colon for presence of colon cancer or polyps that need to be removed.”

The next day, patients arrive at Emory Healthcare and meet the anesthesiologists and GI doctor who will be performing the procedure. Next, they change changing into a gown and have an IV placed for administration of IV fluids and anesthesia. “Once the patient is asleep, we introduce a long tube with a camera and a light on the end of it called a colonoscope up the patient’s rectum to examine the entire colon and look carefully for colon cancer or polyps. If we find any polyps we will remove them during the colonoscopy.”


What causes increased risk?

Reasons for increased incidence of colon cancer in younger people are multifactorial and complex, but experts suggest unhealthy diet and obesity may be contributing factors. According to the American College of Gastroenterology, some estimates say that people born in 1990 have twice the risk of colon cancer and four times the risk of rectal cancer than those born around 1950.

“One of the risk factors for colon cancer is obesity, and certainly a family history of colon cancer as well,” says Sakaria. Also, physical inactivity and smoking raise the risk of colorectal cancer. “Symptoms a person could look for, or symptoms that prompt us to evaluate for colon cancer in a patient include rectal bleeding, persistent abdominal pain, unintentional weight loss, a change in bowel habits or a change in stool caliber.“

Screening is particularly important for Black men and women. “We do know that African Americans have roughly a 20% higher incidence of colorectal cancer, and they are more likely to develop colon cancer at a younger age,” says Sakaria. “They also have the lowest five-year survival rate for colorectal cancer of any other racial group. So, it’s critical for us to be screening the African American population, men and women alike.”


Building awareness and forming relationships

Patient relationships are important to Sakaria. During her residency, she realized she loved gastroenterology for both the diversity of procedures available and the connection with patients. “We are able to build and maintain long-term relationships with patients in the outpatient clinics,” she says, in addition to treating patients in acute-care settings like the ICU.

Sakaria and other health care providers also connect with patients during Emory Healthcare’s community events, like a Colon Cancer Awareness Walk. “It’s a fantastic way for patients to be able to walk with their physicians and their GI doctors and to just talk to them and have a frank personal conversation about colonoscopies and why colorectal cancer screening is so important.”

Sometimes patients might have questions about colon cancer screening they’re afraid to ask, or don’t want to ask their primary care provider, she says. “And colon cancer is a very important topic that patients need to feel comfortable discussing.”

For Sakaria, events are one more way for the community to engage with GI doctors, and one more opportunity for a person to have a one-on-one discussion with a GI doctor and learn more about why early screening saves lives.

“The more we can reach out to and educate the community on the importance of colorectal cancer screening through colon cancer awareness walks or other methods, the better it is.”


Request an Appointment

Talk to your primary care physician about your risk of colorectal cancer and to determine if you should schedule a colonoscopy. Or call 404-778-7777 to speak with a representative and make an appointment.


Colorectal Screenings and Your Insurance Coverage

The Affordable Care Act requires health plans that started on or after September 23, 2010, to cover colorectal screening tests, which includes a range of test options. In most cases there should be no out-of-pocket costs (such as co-pays or deductibles) for these tests. Before you get a colonoscopy, ask your insurance company how much (if anything) you should expect to pay for it.

About Emory Gastroenterology

Guided by state-of-the art, leading diagnostics and current medical research, our multidisciplinary teams of physicians and advanced practice providers are available to provide expert medical consultation as well as diagnostic and therapeutic gastrointestinal procedural expertise in all areas of digestive health. Our board-certified physicians offer patients the latest, research-backed treatments and comprehensive, specialized care for all types of gastrointestinal (GI) disorders.

About Winship Cancer Institute of Emory University

Winship Cancer Institute of Emory University is Georgia’s only National Cancer Institute-designated Comprehensive Cancer Center, a prestigious distinction given to the top 3% of cancer centers nationwide for conducting cancer research and providing training that is transforming cancer care, prevention, detection and survivorship. Winship discovers, develops, delivers and teaches some of the world’s most effective ways to prevent, detect, diagnose and treat each patient’s unique cancer. Cancer care at Winship includes specialists with deep expertise and experience in cancer; multidisciplinary evaluation, treatment planning and care coordination that caters to each patient’s individual needs; therapies supported by the latest advances in cancer research; and comprehensive clinical trials and support services.

Schedule your appointment today.

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