At what age should you be screened for colorectal cancer?

After James Van Der Beek’s death, doctors say not enough younger adults are getting tested for colon cancer, even though diagnoses for people under 50 are rising.

James Van Der Beek in 2020.Michael Bukner / Penske Media via Getty Images file

The recent death of the 48-year-old actor James Van Der Beek is again highlighting how colorectal cancer is increasingly killing younger people.

Overall, cancer death rates in people younger than 50 have dropped by 44% since 1990. But after increasing for decades, colorectal cancer is now the leading cause of cancer death in people under 50. Colorectal cancer starts either in the colon or rectum.

“We anticipate that this is going to be a continued trend,” said Van Karlyle Morris, section chief for colorectal cancer at MD Anderson Center in Houston.

Federal cancer screening guidelines and the American Cancer Society recommend that people who have an average risk for colorectal cancer should begin screening at age 45 with a colonoscopy every 10 years, or a stool test every one to three years. Insurance companies use the guidelines to determine whether the screening is covered.

Most colon cancer cases still occur in people over 50. But rates among people in their 20s, 30s or 40s have been climbing dramatically in the last few decades.

Why does screening start at 45?

Colon cancer tends to be a slow growing disease which usually begins with growths, called adenomas or polyps, that can later turn into cancer.

“The fact that trends do not suggest colorectal cancer rates in young people are dropping certainly does open the door for conversations around policy change dropping the screening age again,” said Morris.

The U.S. Preventive Services Task Force, which sets federal guidelines for cancer screening, dropped the recommended age for colorectal cancer screening from 50 to 45 in 2021. Based on a growing body of evidence, the American Cancer Society had been recommending all adults to begin screening at 45 since 2018.

At the time, “there was a lot of pushback from the medical community, they thought it was too young,” said Rebecca Siegel, senior scientific director of surveillance research at the American Cancer Society. “Even today, not everyone is convinced.”

Developing cancer screening guidelines is an incredibly complex task, said Siegel. Experts comb through research, and weigh the benefits of screening against any risks, even one as seemingly small as missing a day of work. They consider granular details such as increasing risk and overall risk — two numbers that are often very different.

The risk of colorectal cancer for someone ages 40-44 is about 21 per 100,000 people. That risk more than doubles from ages 45 to 49 — to 47 per 100,000 people — after routine screening is recommended, Siegel said.

Overall, 10% of colorectal cases are in people younger than 50, according to the Mayo Clinic.

“Although colorectal cancer rates are rising among younger people, the overall incidents are still low,” said Dr. Andrew Chan, a gastroenterologist and chief of the clinical and translational epidemiology unit at Mass General Brigham in Boston.

Aside from risk, one of the factors that goes into cancer screening guidelines is how to best use resources.

“There are also only a certain number of gastroenterologists,” Siegel said, meaning the resources available to perform routine screenings are limited.

Even under the current guidelines, “it can take months to get in for a colonoscopy,” Morris said.

As is, screening is already low among younger people who have an average risk. Only about 20% of people aged 44–49, who are universally eligible for colorectal cancer screening, are up to date, according to the American Cancer Society.

“Uptake is certainly lower in younger populations, and I would expect for people who are even younger than 45, the uptake would be even lower,” Chan said.

Should I get screened earlier?

People who have a family or personal history of colorectal cancer or polyps should start screening earlier than age 45, Siegel said.

“People need to talk to their families. Even if your mom had a non-cancerous polyp at age 40, you need to start screening for colorectal cancer younger [than 45],” she said.

Once a person has symptoms, a colonoscopy is no longer considered screening. Instead, a person’s insurance should cover a colonoscopy as a diagnostic test, Siegel said.

What are the earliest symptoms of colon cancer?

In a 2023 interview with People magazine, Van Der Beek shared that his first symptoms were changes in his bowel movements, which he noticed in the summer of 2023, when he was 46.

He initially thought they were caused by drinking coffee, but the issues persisted. That is when he asked his doctor about undergoing a colonoscopy, which revealed the actor had Stage 3 colon cancer.

Research has found that there are four distinct symptoms that can appear up to two years before a diagnosis:

Abdominal pain.
Rectal bleeding.
Ongoing diarrhea.
Iron deficiency anemia. Anemia is usually found in yearly blood tests.

“It’s really important for people to know the red flag symptoms,” Siegel said, adding that many symptoms of colorectal cancer can be passed off as a more benign gastrointestinal problem.

“If it’s persistent, and especially if you have more than one of these symptoms,” action must be taken, she said. Morris added that anyone with a history of anemia or who has an unexplained low red blood cell count should promptly be screened as well.

The Food and Drug Administration has approved noninvasive stool and blood tests that can be an initial screening tool, but require a colonoscopy follow-up if signs of cancer, such as blood in the stool or DNA, are detected.

In studies, Cologuard, an at-home stool test, detected about 92% of colorectal cancers, whereas Shield, a blood test, detected about 83%. The tests are not very good at detecting precancerous polyps that show up on a colonoscopy. Shield detects just 13% of precancerous polyps, while Cologuard detects about 42%. The at-home FIT stool test has an accuracy rate of between 84% and 97% for colorectal cancer, and 12% to 15% for precancerous polyps.

What does a colonoscopy cost without insurance?

Although noninvasive stool tests such as Cologuard can make screening easier to access, colonoscopy remains the gold standard for colorectal cancer detection.

“Insurance coverage for colonoscopy and things like Cologuard really doesn’t start until age 45, unless someone has a risk that makes them eligible for getting screened earlier,” Chan said.

People at average risk, and those who do not have any symptoms but want to get a colonoscopy before age 45, can theoretically get one but will need a doctor’s referral, Morris said.

The out-of-pocket cost for a colonoscopy ranges from $1,250 to more than $4,000, according to the price comparison website GoodRx.

What can I do to protect against colon cancer?

It’s clear that colorectal cancer rates are rising among young people, but the cause is still poorly understood.

Research suggests that rising rates of obesity and declining physical activity, changes in the gut microbiome and diets high in ultraprocessed foods, which have become more common since the 1980s, are largely to blame. Some early research has also suggested that antibiotic use and having certain bacteria in the gut could also play a role.

Chan said that while screening is important, people should also focus on improving their diet and getting enough exercise, two lifestyle factors that have been shown to significantly reduce a person’s risk of colorectal cancer.

“Those types of interventions will hopefully have benefits that extend beyond screening,” he said. “Screening is important, but I don’t want us to ignore those other factors.”