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There's no way that I'm getting that stuck up my rear end dock. That is just one of the many replies that I get when I say, Hey, you're old enough, do you want to get a colonoscopy? And luckily now there are some alternatives to colonoscopy that we're going to discuss today.
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The American Cancer Society just released updated guidelines this week, and there are real meaningful changes that affect how we counsel patients and what options can be offered to them. So whether you're a clinician, a patient, or just someone who likes staying healthy, this episode is definitely for you. Let's get into it.
First, why does this matter so much right now? Well, colorectal cancer is the third most common cancer and second deadliest in the United States. We're projected to see around 160,000 new diagnoses in 2026 alone, with roughly 55,000 deaths. Those are not small numbers. But here's a very important statistic. Colorectal cancer is now the leading cause of cancer-related deaths in adults under 50.
And this is a very significant shift from what we were seeing even a decade ago. And researchers are pointing to a combination of factors including poor diet, increasing sedentary lifestyle, and emerging data around microplastics in the body. That last one is still being studied. It's a little bit up in the air, but it's on the radar of cancer researchers. And yet, despite all of this, about one in three eligible adults in the US has not been screened as recommended.
And that adds up to approximately 20 million people walking around unscreened. And yes, that was 20 million. That's the backdrop for why the ACS updated these guidelines. The goal isn't to overhaul what's working, the goal is to expand the toolkit, lower the barriers, and reach the people who, for whatever reason, haven't been tested yet.
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So, what's actually changed, right? Let's walk through the new additions. The ACS has added three new tests to its approved screening options, two stool-based at-home tests and one blood-based test. Let's talk about them. The first one is an updated version of a test you've probably heard of. It's called ColoGuard. This is an at-home stool test that's been available for a few years, and many patients are already familiar with this name. The new version analyzes stool samples for specific DNA markers as well as hemoglobin.
Or in layman terms, that means blood. It's more sensitive than the original version, and it's recommended every three years for average risk adults starting at age 45. The second stool-based option is newer. It's called colosense. So previous was colo guard. This is called colo sense. Which what makes this sensible is that instead of looking for DNA, it analyzes RNA markers along with hemoglobin.
Both of these, colosense and the updated cologard, are described by the ACS as having high sensitivity for detecting colorectal cancer itself and moderate sensitivity for advanced precancerous lesions. Now, this is an important distinction that you need to listen to very closely. These tests are better at catching cancer that's already present than catching the polyps that lead to cancer. So this is, you know.
Something that patients should definitely understand up front. They're excellent screening tools, but they're not as comprehensive as a colonoscopy when it comes to precancerous changes. So polyps that are just starting out to grow or changes in the colon that are just starting out, you can see this with on the colonoscopy on the video when you're doing it. But with these easier tests like stool sample uh-based tests and blood-based tests, they don't capture it.
as well. So they don't capture it usually at all. And because they're less comprehensive, both tests are recommended on a three year interval, not a ten year like a colonoscopy. So you're gonna be doing these every three years. That's a trade-off that, you know, is worth hearing.
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When someone chooses a stool test over colonoscopy, they're signing up for that test every three years, not every decade. So some patients will actually prefer that. They don't mind. They're like, yeah, sure, Doc, I'll do that. I don't mind that at all. Others may not realize what they're agreeing to, and it's important to set that expectation up front. The third option, and this is going to generate a lot of patient questions, probably already does, and I know it does for me.
Is the blood test and it's sold under the brand name SHIELD and it was FDA approved back in 2024. The concept is generally appealing, it's just a blood draw, and there's no dietary prep, no bowel cleanse, no procedure, no sedation, no taking a day off work. Just this blood draw that you know comes from your own veins. And patients ask for it. So let's be clear on what the ACS actually says about it. Blood based testing is not as effective.
And stool-based testing. It's not a first-line recommendation. The ACS specifically positioned SHILD as an option, this is the blood test, as an option only for patients who decline or simply cannot complete any of the other screening methods. It's better than nothing, okay? And that framing is intentional. As the guideline authors themselves put it, they said the most effective screening test is the one that the patient completes. And I totally agree. Like if they complete it, that's awesome, dude.
Go for it, right? So if the choice is between SHIELD and nothing, then SHIELD definitely wins. But it should not be replacing a colonoscopy or stool-based testing for patients who can do those. And there's one more point that applies to all three of these. Any positive result will be followed up with a colonoscopy within six months. These tests are screening tools, not diagnostic ones. A positive result is a flag and it says something might be there, right? Something
Could be there, but a colonoscopy is how you find out what it is and address it. This is a critical counseling moment. Patients who opt for an at-home test need to understand before they start that a positive result does not end the process. It starts a new one, and namely that's getting referred for a colonoscopy. So, what stayed the same in the guidelines? Well, colonoscopy remains the cold standard. That's full stop. gastroenterologists will tell you it's still the best single tool.
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We have for detecting colorectal cancer in its earliest, most treatable stages, like I discussed before. It can identify and remove precancerous polyps in the same procedure. And nothing else does that, right? It's a physical process that goes in there and then takes out these polyps. And the blood-based and stool-based tools do not do that. The ACS still recommends that average risk adults begin screening at age 45. That actually changed to 45 in 2021.
When the age was lowered from age 50. And so colonoscopy is recommended every 10 years through age 75 for average risk patients. Now, what is higher risk? What is a higher risk patient? Because I said average, what is higher risk? Those with a personal family history of colorectal cancer or certain polyps, inflammatory bowel disease or IVD, a hereditary syndrome like Lynch syndrome or FAP, or prior abdominal or pelvic radiation, earlier.
And more frequent screening screening screening is still indicated. These new tests don't change that calculation for our high-risk patients. Those individuals need closer surveillance, and colonoscopy remains the appropriate centerpiece of that plan. So people with inflammatory bowel diseases include things like Crohn's disease as well as ulcerative colitis. So when I see them in the office, I
will plan for colonoscopy every three years, two years, or sometimes five years. Okay, so that was high risk patients. Now let's spend a moment on symptoms because this is what patients usually care about. Now and hopefully you come in before these symptoms, but common symptoms of colorectal cancer include changes in bowel habits like constipation or diarrhea, narrowing of your stools becoming pencil like, blood in the stool, and remember sometimes it's blood that you can or maybe can't see.
black or taris tools, abdominal pain or bloating, unexplained anemia, and fatigue. So these are symptoms patients often Google at two in the morning and then they text them to me at 2.01 in the morning. But here's the message, okay? By the time someone is symptomatic, the cancer is often no longer in its early stages. Screening is powerful precisely because it catches disease before symptoms appear. So
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You shouldn't be watching for symptoms. You should go and get the screening done on schedule before you have them. Because early detection changes everything. Data from the National Cancer Institute shows that when colorectal cancer is caught at a localized stage, meaning it hasn't spread, staying right there where it was growing, survival rates exceed 90%. And that number drops significantly when the cancer is detected later.
Because if it's detected later, most likely it has spread to other parts of the body. And that's when the rate that you will live afterwards goes down. So before we close out, let's talk about prevention and a little bit of lifestyle medicine. Because honestly, colorectal cancer isn't just a screening story, it's a lifestyle story, just like all of health. Your weight management matters. Both obes obesity and diabetes are.
Are associated with elevated colorectal cancer risk and helping patients maintain a healthy weight is part of the conversation that I have with them. So I will frequently talk about, you know, they want to lose weight, they come to me like doc, I want to lose weight, and I talk about GLP ones, I talk about strength training, we talk about nutrition and sleep and getting screened for other things like sleep apnea. And this is all part of the conversation. And then I will tell them, hey, if you lose weight.
You can have a significant reduction in your risk for cancer. And like I said, diet matters. A diet low in red and processed meats and high fiber, think about fruits, vegetables, fish, and whole grains. It's associated with lower risk. And that's not new advice, but you know, it's something worth repeating because I have to do this, especially for patients in their 30s who think about this disease or getting screening is decades away.
Exercise also matters. Okay. I want some type of consistent physical activity. Often prescribe a 20-minute resistance training as well as 20 minute walking on alternate days, usually a pushbull legs day. And so this is protective. And gastroenterologists and oncologists will tell you that the clock starts ticking earlier than people think. So I want to build these habits in the 20s and 30s. I want I want to build them, you know, when they're kids, but
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Mostly they come see me in their 20s and 30s. And so this affects the cancer risk at age 50.
So let's bring it all together. Here's the bottom line and the synopsis from the 2026 ACS guidelines. Colonoscopy remains a gold standard. Every 10 years, starting at age 45 for average risk adults, nothing's really changed there. Two new at-home stool tests, updated coligard and colo since are now ACS approved, recommended every three years. They have high sensitivity for cancer and moderate sensitivity for precancerous lesions.
And one new blood test, SHIELD, is available as a last resort for patients who won't or can't do anything else. It's better than no screening, but it's not equivalent to stool or colonoscopy based testing.
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Any positive result from a non-colonoscopy screen needs a follow-up colonoscopy within six months. And most importantly, no matter which test a patient chooses, what matters most is that they actually get screened. There are 20 million eligible Americans that haven't been. And these new options exist to help reach them. Hey, if this was useful, share it with a colleague, a patient, or a family member who's been putting off their screenings. It might be the nudge that gets them.
Over the hill. I'm your host again, this Dr. Tom Rountry, and this has been Clear Health. I'll see you next time.
