Colorectal Cancer Screening in 2025: Disparities Remain Persistent and Significant

Colorectal cancer (CRC) continues to be one of the most significant public health challenges in the United States, with approximately 153,000 new diagnoses and 53,000 deaths expected in 2025, according to data presented by Rachel Issaka, MD, MAS, at the annual American College of Physicians Internal Medicine Meeting, held April 3-5, in New Orleans. Issaka is associate professor, Kathryn Surace-Smith Endowed Chair in Health Equity Research, Director, Population Health Colorectal Cancer Screening Program, Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, WA.

Currently ranking as the second leading cause of cancer deaths in the US, colorectal cancer's impact is projected to worsen among younger populations. By 2030, it's expected to become the number one cause of cancer deaths in adults younger than age 50 years —a shift Issaka called troubling in the epidemiological landscape.

Disparities Remain Significant and Persistent

The highest CRC mortality rates occur at the “intersection of race, place, and class,” Issaka stressed, pointing to the disproportionate distribution of fatal disease across demographic groups. Rural Black Americans living in areas of persistent poverty face substantially higher death rates than their urban counterparts or white Americans in similar settings.

These disparities aren't coincidental, Issaka said. She reiterated for the audience of internal medicine physicians the reality that racism, discrimination, segregation, and other societal injustices serve as fundamental drivers of the inequity, affecting the entire cancer care continuum from risk reduction through treatment and survivorship.

Lives Lost to Screening Deficiencies

Issaka said that most striking to her is the finding that 76% of colorectal cancer deaths can be attributed to screening failures, including:

1. Complete failure to screen
2. Failure to screen at the appropriate interval
3. Failure to follow up properly after screening

Of the estimated 53,000 colorectal cancer deaths projected for 2025, approximately 17,500 (33%) could be prevented through appropriate screening, with an additional 5,300 (10%) preventable through proper follow-up after screening, she reported.

Despite the clear life-saving potential of screening, national data shows that CRC screening rates have largely plateaued, with significant variations by race and ethnicity. While approximately 60% of non-Hispanic White Americans are up-to-date with screening, the rates are notably lower among American Indian/Alaska Native (52%), Hispanic (51%), and Asian (48%) populations.

The Early Detection Advantage

When detected at a localized stage, colorectal cancer has a 90% five-year survival rate. However, only 39% of cases are diagnosed at this early stage, related, in part Issaka said, to inadequate screening participation across the population.

This stark contrast in survival outcomes underscores the critical importance of timely screening. As Issaka quoted renowned gastroenterologist Dr. Sidney Winawer: "The best test is the one that gets done, and done well."

Screening Modalities: Strengths and Limitations

Issaka then provided an in-depth review of current CRC screening methods, comparing their sensitivity, specificity, and practicality in different patient populations.

• Colonoscopy: The gold standard for CRC screening, colonoscopy offers high sensitivity and specificity, allowing for both detection and removal of precancerous polyps. However, its invasiveness, required bowel preparation, and associated costs pose barriers to widespread utilization.
• Fecal immunochemical test (FIT) and fecal occult blood test (FOBT): These stool-based tests are noninvasive and widely accessible. FIT, in particular, has demonstrated superior sensitivity over guaiac-based FOBT for detecting advanced adenomas. However, annual testing and adherence are critical for effectiveness.
• Multitarget stool DNA test (mt-sDNA, eg, Cologuard): This test detects DNA alterations associated with CRC and advanced adenomas. While offering higher sensitivity than FIT alone, its specificity is lower, leading to more false positives and increased follow-up colonoscopies.
• CT colonography (virtual colonoscopy): This imaging-based method is less invasive than traditional colonoscopy but requires bowel preparation. It is a viable option for individuals unwilling or unable to undergo standard colonoscopy.
• Flexible sigmoidoscopy: Less commonly used today, flexible sigmoidoscopy examines the distal colon and rectum. Though less invasive, it fails to detect proximal lesions.

Addressing Screening Disparities

Black Americans experience the highest CRC incidence and mortality rates, yet screening uptake in this group remains lower than in White populations. Additionally, individuals with Medicaid or no insurance often face systemic barriers to screening access. To address these disparities, Issaka advocated for evidence-based interventions, such as:

• Patient Navigation Programs: Providing culturally tailored education and logistical support significantly improves screening adherence.
• Multimodal Outreach: Leveraging electronic health records, text messaging, and community partnerships enhances engagement among historically underserved populations.
• Policy Initiatives: Expanding insurance coverage for non-invasive screening tests and follow-up colonoscopies ensures broader access to preventive care.

Future Directions and Call to Action

Dr. Issaka concluded with an urgent call for healthcare providers to promote CRC screening actively. The integration of non-invasive screening methods, combined with targeted interventions for high-risk populations, holds promise in reducing CRC mortality. Continued research and policy efforts are essential to achieving equitable screening access and improving patient outcomes.

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