Adults aged 50+ years undergo colonoscopy primarily as part of a routine exam.
Adults <50 years more likely to undergo colonoscopy for symptoms.
These proportions have remained stable over the past decade.
Full cost of colonoscopy is more likely to be paid by adults < 50 years.
Given guideline changes, continued surveillance of colonoscopy patterns needed.
In May of 2018, the American Cancer Society lowered the age of colorectal cancer (CRC) screening initiation from 50 to 45 years and in October 2020, United States Preventive Services Task Force published draft guidelines also lowering age of screening initiation to 45 years. Evaluating guideline adherence is needed; however, the majority of prior research on cancer screening do not distinguish whether colonoscopy was performed for true screening purposes or for post-symptomatic diagnosis.
Using data from the National Health Interview Survey between 2010 to mid-2018, we assessed response to the question “What was the MAIN reason you had [last] colonoscopy?” stratified by age (45−49 versus 50+ years). Multivariable logistic regression defined adjusted odds ratios of receiving last colonoscopy for screening controlling for relevant demographic characteristics. To estimate the cost burden of colonoscopy, the proportion of respondents reporting paying out of pocket for their last colonoscopy was assessed.
Among 29,074 participants who had undergone a colonoscopy, 44.4 % of those aged 45–50 reported routine procedure as the reason for their most recent colonoscopy, as compared to 82.4 % in the 50+ age group (p < 0.001). Characteristics associated with undergoing colonoscopy as a routine procedure included Black race and male sex for both age cohorts (p < 0.01 for all). Notably, almost half (46.9 %) of participants younger than 50 years paid part of or the full cost of their colonoscopy, as compared to 30.7 % over the age of 50 (p < 0.001).
The majority of adults aged 45−49 self-report that last colonoscopy was not performed for screening, which is unsurprising given guidelines for screening for individuals under 50. As guidelines change, continued surveillance of colonoscopy patterns across age cohorts is needed, and studies should also incorporate reasons for testing.
Due to rising incidence and mortality of colorectal cancer in younger adults, in May of 2018, the American Cancer Society (ACS) lowered the age of colorectal cancer (CRC) screening initiation from 50 to 45 years for individuals at average risk [ ]. Currently, ACS guidelines recommend CRC screening from age 45–75 for individuals in good health with greater than 10 years life expectancy. While the United States Preventive Services Task Force (USPSTF) initially maintained that screening should begin at age 50 [ ], updated draft guidelines published in October 2020 also lowered age of initiation to 45, giving a Category B recommendation for individuals between the ages of 45−49. As such, increased uptake of CRC screening among younger adults in the coming years is likely to occur.
Multiple prior studies have assessed colonoscopy utilization over the past several decades [ ]. However, the majority of prior research on cancer screening focuses on absolute utilization of testing, without specifying reasons why the exam was administered [ ]. From a policy standpoint, distinguishing whether a study was done for true screening purposes to identify formerly unrecognized disease processes or for diagnosis as part of evaluation for physical exam findings or patient-reported symptoms is critical in order to accurately assess both patients’ understanding of screening recommendations and national adherence to guidelines [ ]. Furthermore, most studies do not include data up to 2018, thus do not document most current colonoscopy screening patterns by age until the new guidelines lower screening age were instituted. We therefore used a nationally representative survey to assess self-reported reason for last colonoscopy among adults aged 45−49 years versus 50 years and older from 2010 up until ACS guideline changes in May 2018. Cost burden of last colonoscopy was also ascertained in order to understand potential financial barriers to receipt of colonoscopy.