Turning the Tide on Colorectal Cancer in Younger Adults

Colorectal cancer used to be framed as an older person’s disease. Not anymore. With screening now recommended starting at 45, uptake among people in their 40s is rising, and more cancers are being found early — when outcomes are far better. The next phase is about reducing friction, presenting real choices, and building distribution that converts intent into completed screening.

What changed, and why it matters

• Screening among ages 45 to 49 rose after eligibility moved to 45. Uptake shifted from roughly one in five to about one in three.
• Early-stage diagnoses climbed in parallel, as is expected when eligibility expands and awareness increases.
• The stage of the cancer at discovery is decisive. Five-year survival is about 90 percent when the disease is localized, and closer to 13 percent once it has spread.

The mechanism is straightforward: shifting the detection window earlier improves the probability that a screen detects earlier, which raises the odds that treatment is curative. We are moving more patients into the high-benefit region of the sensitivity and specificity trade-off rather than relying on late symptomatic detection.

Nudges that work for newly eligible 45–49 year olds

A large randomized program compared outreach strategies and found that the clear winner was mailing an at-home fecal immunochemical test kit by default. Completion was about one in four with the mailed kit compared with mid-teen completion when people had to opt in through a portal. Positive results flowed to follow-up colonoscopy, which is the definitive diagnostic and therapeutic step.

Pros

• Low cost and easy to automate in the EHR.
• Reduces intention-action gaps and procrastination.
• Creates a clean escalation path to colonoscopy after a positive result.

Cons

• One in four completion still leaves headroom.
• Requires logistics, reminders, and tracking or momentum fades.
• FIT does not remove adenomas, so positives must convert to colonoscopy.

Blood-based screening adds a new on-ramp

Colonoscopy remains the prevention workhorse because it finds and removes precancerous lesions. Human factors still deter many people. Stool tests help, yet many never complete them. Blood-based screening creates an additional path during routine labs by analyzing circulating tumor DNA and other analytes in a simple draw.

• An FDA-cleared blood test for colorectal screening now exists and is being adopted. It demonstrates high cancer sensitivity with about 90 percent specificity in a low-prevalence setting.
• Companies like Freenome, an Averin portfolio company, are advancing a multiomics approaches that integrate tumor-derived signals with features like DNA methylation and proteins, using machine learning to optimize the decision threshold across the ROC curve. The objective is high sensitivity at clinically useful specificity in a workflow that feels routine.

Pros

• Frictionless add-on to annual care that can substantially lift participation.
• Credible alternative option for patients.
• Scales through primary care, employer clinics, and retail labs.

Cons

• Lower adenoma sensitivity than colonoscopy, so prevention still depends on timely follow-up.
• Positive results must translate into capacity for diagnostic colonoscopy.
• Real-world benefit depends on closing the loop, not just ordering a test.

Access is about pipes, not just assay performance. Partnerships that pair strong assays with established logistics, health system relationships, and payer connectivity can meaningfully accelerate reach. The operational goal is simple: present three clear choices at age 45, FIT, stool DNA testing, or a blood-based screen, with fast handoffs to colonoscopy when indicated. 

Through lines to the future: beyond colorectal cancer

The same building blocks that are working in colorectal screening point to a broader early detection layer.

• Multi-cancer early detection. Liquid biopsy approaches are progressing toward multi-cancer early detection. Expect targeted deployment first in cancers with high mortality and actionable follow-up, such as pancreatic, ovarian, and liver.
• Risk-adapted pathways. Screening intervals and modalities will tune to individual risk profiles that blend family history, clinical factors, and eventually polygenic risk scores. High-risk patients get earlier or more frequent testing. Lower-risk patients can safely extend intervals.
• Imaging plus AI. AI-assisted detection is lifting yields in colonoscopy and will continue to advance in mammography, low-dose CT for lung cancer, and ultrasound for targeted populations.
• Bias and validity guardrails. Plan for lead-time bias, length bias, and overdiagnosis. Prioritize endpoints like stage shift, treatment intensity avoided, and disease-specific mortality, not only detection counts.

Within five years, many systems will adopt a periodic blood screen paired with modality-specific follow-up as a default prevention layer, much like vaccines. The colorectal playbook is the template. Younger adults are finally getting screened, and more cancers are being caught early. Offer real choice, remove friction, guarantee fast follow-up, and extend the same logistics to a broader set of cancers — this is the playbook to ensure the momentum in colorectal cancer becomes a durable, system-wide prevention platform.