Colorectal Cancer Facts & Figures 2020-2022

CT 75

DE 73

MD 73

NJ 68

RI 75

DC 74

*Blood stool test, sigmoidoscopy, or colonoscopy in the past 1, 5, and 10 years, respectively.

Note: Estimates are age adjusted to the 2000 US standard population and do not distinguish between examinations for screening and diagnosis.

Source: Behavioral Risk Factors Surveillance System, 2018. See Sources of Statistics (page 32) for complete citation and more information.

Colorectal Cancer Screening Test Use* (%), Adults 50 Years and Older by State, 2018

58% to 64%

65% to 69%

70% to 72%

73% to 76%

Colorectal Cancer

Facts & Figures 2020-2022

(page 32)

Contents

Colorectal Cancer Basic Facts 1

Figure 1. Anatomy of the Gastrointestinal System 1

Figure 2. Stages of Colorectal Cancer Growth 2

Colorectal Cancer Occurrence 3

Table 1. Estimated Number of Colorectal Cancer Cases

and Deaths in the US in 2020 by Age 3

Figure 3. Colorectal Cancer Incidence (2012-2016)

and Mortality (2013-2017) Rates by Subsite and Sex, US 4

Figure 4. Age-specific Colorectal Cancer Incidence Rates,

US, 2012-2016 4

Figure 5. Colorectal Cancer Incidence (2012-2016) and

Mortality (2013-2017) Rates by Race/Ethnicity and Sex, US 5

Figure 6. Trends in Colorectal Cancer Incidence (1975-2016)

and Mortality (1930-2017) Rates by Sex, US 6

Figure 7. Trends in Colorectal Cancer Incidence (1995-2016)

and Mortality (1970-2017) Rates by Age and Sex, US 7

Figure 8. Trends in Colorectal Cancer Incidence (1975-2016)

and Mortality (1970-2017) Rates by Race, US 8

Figure 9. Colorectal Cancer Incidence (2012-2016) and

Mortality (2013-2017) Rates by State, US 9

Table 2. Colorectal Cancer Incidence (2012-2016) and

Mortality (2013-2017) Rates by Race/Ethnicity and State, US 10

Figure 10. Colorectal Cancer Five-year Survival (%)

by Age and Race/Ethnicity, 2009-2015 11

Figure 11. Colorectal Cancer Stage Distribution (%) by Age

and Race/Ethnicity, 2012-2016 12

Colorectal Cancer Risk Factors 13

Table 3. Relative Risks for Established Colorectal Cancer

Risk Factors 13

Colorectal Cancer Screening 18

Table 4. Characteristics of Recommended Colorectal Cancer

Screening Tests 20

Table 5. Colorectal Cancer Screening (%), Adults 45 Years

and Older, US, 2018 23

Figure 12. Colorectal Cancer Screening (%), Adults 50 Years

and Older by State, 2018 24

Table 6. Colorectal Cancer Screening (%), Adults 50 Years

and Older by State, 2018 25

Colorectal Cancer Treatment 26

What Is the American Cancer Society Doing

about Colorectal Cancer? 30

Sources of Statistics 32

References 33

Global Headquarters: American Cancer Society Inc.

250 Williams Street, NW, Atlanta, GA 30303-1002

404-320-3333

including the right to reproduce this publication or

portions thereof in any form.

For permission, email the American Cancer Society

Legal department at permissionsrequests@cancer.org.

This publication attempts to summarize current scientific information about colorectal cancer.

Except when specified, it does not represent the official policy of the American Cancer Society.

Suggested citation: American Cancer Society. Colorectal Cancer Facts & Figures 2020-2022.

Atlanta: American Cancer Society; 2020.

Colorectal Cancer Facts & Figures 2020-2022 1

Colorectal Cancer

Basic Facts

What is colorectal cancer?

Cancer is a disease characterized by the unchecked

division of abnormal cells. When this type of growth

occurs in the colon or rectum, it is called colorectal

cancer (CRC). The colon and rectum (colorectum), along

with the anus, make up the large intestine, the final

segment of the gastrointestinal (GI) system. The large

intestine is sometimes called the large bowel, which is

why CRC is sometimes referred to as bowel cancer. The

function of the large intestine is to absorb water and

electrolytes from food matter and eliminate feces. As

depicted in

Figure 1

, the first part of the large intestine is

the colon, a muscular tube about 1.5 meters (5 feet) long

and 5 centimeters (2 inches) in diameter that is divided

into 4 sections:

• The ascending colon begins with the cecum (a pouch

where undigested food is received from the small

intestine) and extends upward on the right side of the

abdomen.

• The transverse colon crosses the body from right to

left, and is referred to collectively with the ascending

colon as the proximal, or right, colon.

• The descending colon descends on the left side.

• The sigmoid colon, named for its “S” shape, is the final

portion of the colon and is referred to collectively

with the descending colon as the distal, or left, colon.

Waste passes from the sigmoid colon into the rectum –

the final 15 centimeters (6 inches) of the large intestine –

and is then expelled through the anus (2-3 centimeters or

1 inch). Despite their anatomic proximity, cancers in the

anus are classified separately from those in the rectum

because they usually originate from different cell types,

and thus have different characteristics.

However, tumors within the colorectum also vary in their

molecular, biological, and clinical features, and in their

association with risk factors.

1, 2

For example, physical

inactivity is associated with increased risk of cancer in

the colon, but not in the rectum. In addition, patients are

more likely to be diagnosed with tumors in the proximal

colon if they are older (versus younger), black (versus

white), or female (versus male).

3, 4

What is a colorectal polyp?

CRC almost always begins as a polyp, which is a

noncancerous growth that develops in the mucosal layer

(inner lining) of the colon or rectum. Polyps are common,

detected in about half (including serrated polyps) of

average-risk individuals 50 years of age or older undergoing

colonoscopy, with higher prevalence in older age groups

and among men compared to women.

However, fewer

than 10% of polyps are estimated to progress to invasive

cancer,

6, 7

a process that usually occurs slowly over 10 to

20 years and is more likely as polyps increase in size.

8-10

Polyps are classified based on their growth pattern as

adenomatous (i.e., adenoma), which is the most common

cancer precursor, or serrated, so-called because of its

saw-toothed appearance under a microscope.

Serrated

Figure 1. Anatomy of the Gastrointestinal System

Esophagus

Stomach

Transverse

colon

Descending

colon

Sigmoid

colon

Ascending

colon

Anus

Liver

Small

intestine

Gallbladder

Rectum

Cecum

Appendix

2 Colorectal Cancer Facts & Figures 2020-2022

polyps are further subdivided based on biological

characteristics into sessile serrated polyps (SSPs),

traditional serrated adenomas (TSAs), and hyperplastic

polyps (HPs). Similar to adenomas, SSPs, TSAs, and large

HPs are associated with an increased risk for CRC. SSPs are

the most difficult to detect during colonoscopy because they

are usually flat, covered with a mucous cap, and colored like

the surrounding tissue. These features likely contribute to

their role as precursors for a large proportion of cancers

diagnosed prior to the next recommended colonoscopy

(interval or post colonoscopy cancers).

What are the stages of

colorectal cancer?

Once a polyp progresses to cancer, it can grow into the

wall of the colon or rectum where it may invade blood or

lymph vessels that carry away cellular waste and fluid

(

Figure 2

). Cancer cells typically spread first into nearby

lymph nodes, which are bean-shaped structures that help

fight infections. They can also be carried via blood vessels

to other organs and tissues, such as the liver or lungs,

be shed directly into the peritoneum (membrane lining

the abdomen).

The spread of cancer cells to parts of the

body distant from where the tumor started is called

metastasis.

The extent to which cancer has spread at the time of

diagnosis is described as its stage.

Staging is essential for determining

treatment choices and assessing

prognosis (prediction of disease

outcome). The two most common cancer

staging systems are the American Joint

Committee on Cancer (AJCC) tumor,

node, and metastasis (TNM) system,

typically used in clinical settings, and

the Surveillance, Epidemiology, and End

Results (SEER) summary staging system,

used for descriptive and statistical

analysis of tumor registry data. In this

document, we will describe CRC stages

using the SEER summary staging

system:

• In situ: Cancers that have not yet begun to invade the

wall of the colon or rectum; these preinvasive lesions

are not included in the cancer statistics provided in

this report

• Local: Cancers that have grown into the wall of the

colon or rectum, but have not extended through the

wall into nearby tissues

• Regional: Cancers that have spread through the wall

of the colon or rectum and have invaded nearby

tissue, or that have spread to nearby lymph nodes

• Distant: Cancers that have spread to other parts of

the body, such as the liver or lung

What are the symptoms of

colorectal cancer?

Early CRC often has no symptoms, which is one of the

reasons screening is so important. As a tumor grows, it

may bleed or block the intestine. The most common

symptoms are:

• Bleeding from the rectum

• Blood in the stool or in the toilet after having a

bowel movement

• Dark or black stools

Figure 2. Stages of Colorectal Cancer Growth

U.S. Govt. has certain rights

Colorectal Cancer Facts & Figures 2020-2022 3

• A change in bowel habits or the shape of the stool

(e.g., more narrow than usual)

• Cramping, pain, or discomfort in the lower abdomen

• An urge to have a bowel movement when the bowel

is empty

• Constipation or diarrhea that lasts for more than a

few days

• Decreased appetite

• Unintentional weight loss

In some cases, blood loss from the cancer leads to anemia

(low number of red blood cells), causing symptoms such

as weakness, excessive fatigue, and sometimes shortness

of breath. Timely evaluation of symptoms consistent with

CRC is essential for all individuals, regardless of age, given

the increasing incidence in young adults (see page 6).

Colorectal Cancer Occurrence

How many new cases and deaths are

estimated to occur in 2020?

In 2020, there will be an estimated 104,610 new cases of

colon cancer and 43,340 cases of rectal cancer diagnosed

in the US (

Table 1

). Although the majority of CRCs are in

adults ages 50 and older, 17,930 (12%) will be diagnosed in

individuals younger than age 50, the equivalent of 49 new

cases per day.

An estimated 53,200 people will die from CRC in 2020,

including 3,640 men and women younger than age 50.

Unfortunately, reliable statistics on deaths from colon

and rectal cancers separately are not available because

almost 40% of deaths from rectal cancer are misclassified

as colon cancer on death certificates.

The high level of

misclassification is partly attributed to the misconception

among some that the terms colon cancer and colorectal

cancer are synonymous because of the widespread use of

“colon cancer” to refer to both colon and rectal cancers in

educational messaging. To help mitigate the issue and be

more explicitly inclusive of rectal cancer patients, several

organizations have publicly ended this practice.

The

ability to study these deaths separately is increasingly

important given the steep rise in rectal cancer incidence

among younger adults.

How many people who have been

diagnosed with colorectal cancer are

alive today?

As of January 1, 2019, there were 776,120 men and 768,650

women alive in the US with a history of CRC.

About

one-third (35%) of these individuals were diagnosed

within the preceding 5 years, and more than half (56%)

were ages 65-84 years. Some of these people were cancer-

free, while others still had evidence of cancer and may

have been undergoing treatment.

What is the risk of developing

colorectal cancer?

Approximately 4.4% of men (1 in 23) and 4.1% of women

(1 in 25) will be diagnosed with CRC in their lifetime.

Lifetime risk is similar in men and women despite higher

incidence rates in men because women have longer life

expectancy. In addition to sex, age and race/ethnicity

also have a large influence on risk.

Table 1. Estimated Number of Colorectal Cancer Cases

and Deaths in the US in 2020 by Age

Cases Deaths*

Age Colorectum Colon Rectum Colorectum

0-49 years 17,93 0 11,5 40 6,390 3,640

50-64 years 50,010 32,290 17,720 13,380

65+ years 80,010 60,780 19,230 36,180

All ages 147,95 0 104,610 43,340 53,200

Estimates are rounded to the nearest 10 and exclude in situ carcinoma.

*Deaths for colon and rectal cancers are combined because a large number of

rectal cancer deaths are misclassified as colon.

4 Colorectal Cancer Facts & Figures 2020-2022

Sex

CRC incidence rates are 30% higher in men than in

women, with a larger disparity for rectal cancer (60%

higher) than for colon cancer (20% higher;

Figure 3

). As

expected, women also have a lower prevalence of both

adenomas overall and of advanced adenomas.

20, 21

However, among individuals 50 and older, women are

more likely than men to develop adenomas in the proximal

colon,

which are less efficiently detected through

screening.

Gender disparities likely reflect differences in

exposures to risk factors (e.g., cigarette smoking) and sex

hormones, as well as complex interactions between these

influences.

Notably, CRC incidence rates in men and

women younger than 45 years are comparable.

Age

Like most types of cancer, the risk of CRC increases with

age. For every subsequent 5-year age group, the incidence

rate approximately doubles until age 50, and thereafter

increases by about 30% (

Figure 4

). The exception is ages

50-54 years versus ages 55-59 years, for which there is only

a 15% difference (60 versus 68 per 100,000, respectively),

partly because the natural age-associated influence on

risk is disrupted by first-time CRC screening in the

younger age group. The screening effect is magnified in

current rates by single year of age (

Figure 4

), which are

actually higher in individuals ages 50-51 years than in

those ages 52-55 years. This phenomenon is absent in

incidence rates during the 1970s, prior to the uptake of

screening.

Source: Main ﬁgure: NAACCR, 2019. Inset: Surveillance, Epidemiology, and End Results (SEER) Program, 2019.

Rate per 100,000 population

Figure 4. Age-specific Colorectal Cancer Incidence Rates, US, 2012-2016

100

150

200

250

300

85+ years

80-84 years

75-79 years

70-74 years

65-69 years

60-64 years

55-59 years

50-54 years

45-49 years

40-44 years

35-39 years

30-34 years

25-29 years

20-24 years

15-19 years

10-14 years

5-9 years

59 years

58 years

57 years

56 years

55 years

54 years

53 years

52 years

51 years

50 years

0.1 0.3

0.9 1.5

3.0

5.7

10.5

19.0

33.1

59.5

68.4

90.2

121.4

153.0

197.5

237.9

258.8

Rates are ag

e adjusted to the 2000 US standard population. *Mortality rates by

anatomic subsite are not available because a large number of rectal cancer

deaths are misclassiﬁed as colon.

Sources: Incidence – North American Association of Central Cancer Registries

(NAACCR), 2019. Mortality – National Center for Health Statistics (NCHS), 2019.

Figure 3. Colorectal Cancer Incidence (2012-2016) and

Mortality (2013-2017) Rates by Subsite and Sex, US

Rate per 100,000 population

38.7

27.6

11.2

13.9

14.1

16.6

34.0

25.3

8.7

11.7

44.4

30.3

Sexes combined

FemaleMale

Incidence Mortality*

ColorectumRectumColonColorectum

Colorectal Cancer Facts & Figures 2020-2022 5

The median age at CRC diagnosis is 66 years in men and

69 years in women, but is younger for rectal cancer (age

62 and 63, respectively) than for colon cancer (age 67 and

71, respectively).

CRC patients overall are increasingly

younger, shifting from a median age of 72 years for

diagnoses in the early 2000s to 66 years today.

This is

because incidence is increasing in younger adults and

declining in older age groups.

Race/ethnicity

Among broadly defined racial and ethnic groups, CRC

incidence and mortality are highest in non-Hispanic

blacks (hereafter, blacks), followed closely by American

Indians and Alaska Natives (AIANs), and lowest in Asians/

Pacific Islanders (APIs;

Figure 5

). During 2012-2016, CRC

incidence rates in blacks were about 20% higher than

those in non-Hispanic whites (NHWs) and 50% higher

than those in APIs. The disparity for mortality is twice

that for incidence; CRC death rates in blacks are almost

40% higher than those in NHWs and double those in APIs.

Reasons for racial/ethnic disparities in CRC are complex,

but largely reflect differences in risk factor prevalence

and health care access, both of which are related to

socioeconomic status.

In 2018, the median family

income was $41,361 among blacks compared to $70,642

among NHWs, with 21% and 8%, respectively, living in

poverty.

People with the lowest socioeconomic status

are 40% more likely to be diagnosed with CRC than those

with the highest socioeconomic status.

Close to half

(44%) of this disparity is attributed to differences in the

prevalence of risk factors associated with CRC (e.g.,

smoking, obesity)

and a similar proportion is due to

differences in CRC screening.

After controlling for

differences in risk factors, black individuals are no more

likely than whites to develop adenomas or CRC, but are

less likely to receive timely follow-up of a positive screening

test and/or high-quality colonoscopy.

31, 32

Higher CRC

mortality among blacks may also reflect a larger

proportion of tumors in the proximal colon.

Importantly, the broad racial and ethnic groups to which

cancer statistics are generally limited mask striking

differences within these heterogeneous populations. For

example, although CRC incidence in API men overall is

25% lower than in NHW men, rates in Japanese men are

23% higher.

Even more alarming is the burden among

Alaska Natives, who have the highest CRC incidence (89

per 100,000) and mortality (40 per 100,000) rates in the

US, double those in blacks (46 and 19, respectively). CRC

AI: American Indian, excluding Alaska; AN: Alaska Native. Rates are age adjusted to the 2000 US standard population. *Statistics based on data from Purchased/Referred Care

Delivery Area (PRCDA) counties. AI/AN incidence rates exclude data from Kansas and Minnesota. Incidence rates for Alaska Native men and women are not statistically

signiﬁcantly different.

Source: Incidence – NAACCR, 2019. Mortality – NCHS, 2019.

Rate per 100,000 population

Figure 5. Colorectal Cancer Incidence (2012-2016) and Mortality (2013-2017) Rates by Race/Ethnicity and Sex, US

Non-Hispanic White Hispanic/Latino Asian/Pacific IslanderNon-Hispanic Black

American Indian/Alaska Native*

45.7

43.3

38.6

34.1

30.0

53.8

48.5

44.0

40.9

35.3

39.9

39.1

33.9

28.7

25.7

19.0

15.8

13.8

11.1

9.5

23.8

19.4

16.3

14.1

11.4

15.6

13.0

11.7

8.7

8.1

WomenMenSexes combinedWomenMenSexes combined

100

WomenMenSexes

combined

89.0

40.7

85 .1

92.9

46.4

36.1

WomenMenSexes

combined

39.6

14.5

44.8

36.1

18.0

11. 8

MortalityIncidence

6 Colorectal Cancer Facts & Figures 2020-2022

has been the most commonly diagnosed cancer in Alaska

Natives since the early 1970s for reasons that are

unknown, but may include a higher prevalence of CRC

risk factors, such as a diet high in animal fat and low in

fruits and vegetables, vitamin D deficiency, smoking,

obesity, and diabetes.

34, 35

In addition, Alaska Natives,

particularly rural residents, have a high prevalence of

Helicobacter pylori (H. pylori),

a bacteria associated with

inflammation and cancer of the stomach that may also be

associated with CRC risk.

37, 38

Despite a disproportionately

high burden of advanced adenomas among Alaska

Natives,

the availability of endoscopic services in much

of Alaska is inadequate.

40, 41

A recent study found that

Alaska had the lowest county-level CRC screening

prevalence in the nation.

In addition, the primary mode

of screening at Indian Health Service facilities is stool

testing, which has a limited capacity for cancer prevention

and requires timely follow-up with colonoscopy for

positive tests. Notably, AIANs are the only racial and

ethnic group for which CRC mortality rates are not

declining (see page 8).

How has colorectal cancer occurrence

changed over time?

Incidence

Despite higher incidence in men than in women, trends

over time are very similar by sex (

Figure 6

). CRC incidence

rates increased from 1975 through the mid-1980s, but

since have generally decreased. The decline prior to 2000

is attributed equally to changing patterns in risk factors

(e.g., reductions in smoking) and the uptake of CRC

screening.

However, the accelerated decline that began

during the late 2000s is thought to predominantly reflect

widespread uptake of CRC screening with colonoscopy,

which increased among adults ≥50 years of age from 20%

in 2000 to 61% in 2018.

There is about a decade of lag

time between the detection and removal of precancerous

polyps through screening and its reflection on CRC

incidence rates.

9, 45

Notably, however, declines in CRC

incidence have decelerated in the most recent 5 data

years (2012-2016), perhaps reflecting a slowing in first-

time screening,

changing risk factors exposures, such

as obesity, or a combination thereof.

Age-specific incidence trends

CRC trends overall reflect the majority of cases that occur

in older age groups, masking trends in young adults. CRC

incidence rates have been increasing since the mid-1980s

in adults ages 20-39 years and since the mid-1990s in adults

ages 40-54 years, with younger age groups experiencing

the steepest increase.

This pattern is called a birth cohort

effect because generations of individuals with higher

incidence carry the elevated risk with them as they age.

Indeed, after decades of decline, incidence rates have also

begun to increase in ages 50-64 years. During the most

recent five data years (2012-2016), incidence rates increased

by 2.2% annually in individuals younger than 50 years

and by 1% annually in those ages 50-64 years, a sharp

contrast to declines of 3.3% per year in adults ages 65

and older (

Figure 7

). Although a similar incidence pattern

Rates are age adjusted to the 2000 US standard population. Incidence rates are

adjusted for delays in reporting and exclude appendix. Due to changes in

International Classiﬁcation of Diseases (ICD) coding, numerator information for

mortality has changed over time.

Source: Incidence – Surveillance, Epidemiology, and End Results (SEER) Program,

2019. Mortality – US Mortality Volumes 1930 to 1959, US; Mortality Data

1960-2017, NCHS, 2019.

Rate per 100,000 population

Figure 6. Trends in Colorectal Cancer Incidence

(1975-2016) and Mortality (1930-2017) Rates by Sex, US

Female mortality

Female incidence

Male incidence

201020001990198019701960195019401930

Male mortality

Year of diagnosis/death

Colorectal Cancer Facts & Figures 2020-2022 7

has been reported in many other high-income countries,

reasons for the increasing trend in younger age groups

are unknown. It may reflect changes in established risk

factors, such as a more sedentary lifestyle and/or

unfavorable dietary patterns, or other exposures whose

association with CRC risk is yet unknown.

Rates are age adjusted to the 2000 US standard population. Incidence rates are adjusted for reporting delays and exclude appendix.

Source: Incidence – NAACCR, 2019. Mortality – NCHS, 2019.

Rate per 100,000 population

Figure 7. Trends in Colorectal Cancer Incidence (1995-2016) and Mortality (1970-2017) Rates by Age and Sex, US

Ages 0-49

Incidence Mortality

Rate per 100,000 population

Ages 50-64

Rate per 100,000 population

Ages 65+

Male

Female

Male

Female

Rate per 100,000 population

Ages 0-49

Rate per 100,000 population

Ages 50-64

Rate per 100,000 population

Ages 65+

Male

Female

Male

20152010200520001995

0.0

0.5

1.0

1.5

2.0

2.5

3.0

2015201020052000199519901985198019751970

100

120

20152010200520001995

2015201020052000199519901985198019751970

100

150

200

250

300

350

400

450

20152010200520001995

100

150

200

250

2015201020052000199519901985198019751970

Male

Female

Male

Female

Year of deathYear of diagnosis

8 Colorectal Cancer Facts & Figures 2020-2022

Racial/ethnic incidence trends

Historical cancer incidence data in the US are available

only for the categories white, black, and other race. CRC

incidence was similar in whites and blacks until the

mid-1980s, when rates began declining in whites while

remaining stable in blacks (

Figure 8

). These trends created

a widening racial gap until the mid-2000s and likely

reflect a combination of earlier access to and more rapid

uptake of CRC screening tests among whites, as well as

changing patterns in the prevalence of CRC risk factors.

Since the mid-2000s, CRC incidence rates decreased by

about 1%-3% per year in all broadly defined racial/ethnic

groups, although the pace appears to be slowing in recent

years.

Notably, the steepest increase in early-onset CRC

is among NHWs and AIANs.

As a result, incidence rates

in NHWs ages 20-49 years are now equivalent to those in

blacks (14.1 per 100,000 during 2015-2016), despite being

40% higher in blacks during 1995-1996.

Mortality

CRC death rates have been decreasing since 1947 in

women, but only since 1980 in men (

Figure 6

). This

inconsistency likely reflects sex differences in incidence

trends because of variable patterns in CRC risk factors,

although population-based incidence data are not

available prior to 1975. Trends over the past three

decades are very similar by sex. Declines in mortality

through 2000 are attributed to improvements in

treatment (12%), changing patterns in CRC risk factors

(35%), and screening (53%).

However, screening likely

played an even larger role in more recent trends given its

steep increase since 2000.

Rapid declines in CRC death

rates of about 3% per year from 2002 to 2012 slowed to 2%

per year from 2012 to 2017.

Age-specific mortality trends

Like incidence, CRC mortality trends vary by age (

Figure

). Among older adults, decades of rapid declines have

slowed, from 1% annually during 2004-2013 to 0.6%

during 2013-2017 in those ages 50-64 years and from

3.3% to 2.6%, respectively, in those ages 65 and older. In

contrast, CRC death rates have increased in individuals

younger than 50 years of age by 1.3% per year since 2004.

Racial/ethnic mortality trends

CRC death rates in whites began a slow decline in the

early 1970s that accelerated over time. In contrast, death

rates in blacks increased from the early 1970s until 1990,

then decreased sluggishly during the 1990s before

matching the decline in whites in the early 2000s (

Figure 8

As a result of these divergent trends, although CRC death

rates in blacks were 10% lower than those in whites in the

early 1970s, they were almost 50% higher in 2005. The

widening racial disparity was largely driven by trends

for distant-stage disease, which declined in whites while

remaining stable in blacks through the mid-2000s.

About

half of the racial disparity in mortality is attributed to a

combination of less screening and lower stage-specific

survival rates among blacks.

Since the early 2000s, CRC

death rates have declined consistently by 1.8% per year

in Hispanics and APIs and by 2.8% per year in blacks;

however, rates were stable in AIANs during this time,

and in whites declines slowed from 2.5% per year during

Rates are age adjusted to the 2000 US standard population. Incidence rates are

adjusted for reporting delays and exclude appendix. White and black race are not

mutually exclusive from Hispanic ethnicity.

Source: Incidence – SEER program, 2019. Mortality – NCHS, 2019.

Rate per 100,000 population

Figure 8. Trends in Colorectal Cancer Incidence

(1975-2016) and Mortality (1970-2017) Rates by Race, US

Incidence, blacks

Mortality, blacks

Mortality, whites

Mortality, Hispanics

Incidence, whites

Incidence, Hispanics

2015201020052000199519901985198019751970

Year of diagnosis/death

Colorectal Cancer Facts & Figures 2020-2022 9

2005-2012 to 1.6% per year during 2012-2017. As a result,

the black-white gap has slowly begun to narrow.

How does colorectal cancer

occurrence vary by state?

The geographic pattern of CRC has changed dramatically

over the past several decades. In contrast to the 1970s

and 1980s, when the burden was highest across the

Northeast and lowest in the South,

today it is highest in

parts of the South, Midwest, and Appalachia and lowest

in the West and Northeast. Current incidence rates range

from 49 (per 100,000) in Kentucky to 30 in Utah, while

death rates range from 18 in Mississippi and West Virginia

to 11 in Connecticut and Utah (

Figure 9

). This shift is

consistent with the racial and socioeconomic crossover in

disease burden that occurred during the latter half of the

20th century because of changes in dietary and smoking

patterns, as well as differences in access to early detection

and high-quality treatment.

For example, CRC mortality

among residents of poor counties was 20% lower than

that among residents of affluent counties in the early

1970s, but is currently 30% to 40% higher.

54, 56

Geographic

patterns are generally similar for blacks and whites,

particularly for mortality, highlighting the importance of

socioeconomic status over race in cancer disparities.

Table 2

shows state-level incidence and death rates by

race/ethnicity. Consistent with overall incidence, rates in

NHWs and blacks are lowest in the West and highest in

the South and Midwest. However, among Hispanics there

is no clear pattern, perhaps reflecting geographic

heterogeneity within this population in terms of place of

birth and duration of residence, both of which influence

CRC risk. Although data for AIANs are too sparse to

provide by state, a recent study found that incidence

rates for those living in Alaska (approximately 95 per

100,000) were more than two-fold higher than those

living in the East and Southwest regions (30 to 40 per

100,000) of the US during 2010-2015.

Factors that may

contribute to this disparity include differences in diet

and the prevalence of obesity and smoking, as well as

access to medical services, including screening. Among

some more isolated groups (e.g., Alaska Natives), genetic

differences may also play a role. (See page 5 and page 6

for more information about CRC in Alaska Natives.)

Figure 9. Colorectal Cancer Incidence (2012-2016) and Mortality (2013-2017) Rates by State, US

Incidence

HI PRPR

Mortality

Nevada and the District of Columbia did not meet NAACCR high-quality incidence data standards for one or more years during 2012-2016. Incidence rates for the District of

Columbia are based on data years 2012-2014. Rates are age adjusted to the 2000 standard population.

Sources: Incidence – NAACCR, 2019. Mortality – NCHS, 2019.

29.7- 35.6

35.7 - 38.9

39.0 - 44.0

44.1 - 49.2

Rate per 100,000

11.0- 12.5

12.6 - 14.1

14.2 - 15.9

16.0 - 18.3

Data unavailable

Rate per 100,000

10 Colorectal Cancer Facts & Figures 2020-2022

Table 2. Colorectal Cancer Incidence (2012-2016) and Mortality (2013-2017) Rates* by Race/Ethnicity and State, US

State

Incidence Mortality

Men Women Men Women

Non-

Hispanic

white

Non-

Hispanic

black Hispanic

Non-

Hispanic

white

Non-

Hispanic

black Hispanic

Non-

Hispanic

white

Non-

Hispanic

black Hispanic

Non-

Hispanic

white

Non-

Hispanic

black Hispanic

Alabama 49.4 58.9 27.6 36.3 44.6 25.5 18.5 26.4 † 12.0 17.7 †

Alaska 37.0 † † 33.1 † † 13.3 † † 11.5 † †

Arizona 37.8 33.5 41.9 29.2 33.1 26.2 15.3 18.2 15.3 10.9 16.4 8.8

Arkansas 50.1 58.2 29.4 36.5 45.8 32.0 19.4 26.0 † 13.0 19.5 †

California 40.4 48.5 38.4 32.4 39.4 27.7 14.9 21.9 13.9 11.7 16.0 8.8

Colorado 35.5 48.8 44.7 29.5 34.6 33.5 13.4 19.5 16.8 10.4 11.5 11.3

Connecticut 40.8 46.1 49.4 31.5 36.1 32.9 13.0 16.7 12.8 9.5 10.9 7.1

Delaware 42.8 51.0 34.9 32.2 38.4 42.8 17.5 17.1 † 10.2 15.7 †

Dist. Of Columbia

‡,§

29.2 61.7 † 27. 8 44.6 † 7.9 26.9 † 7.3 17. 8 †

Florida 41.3 48.9 43.5 31.3 36.7 31.6 15.5 20.6 14.6 10.9 14.0 9.6

Georgia 47.8 57.3 37.3 34.5 41.4 30.9 17.6 25.7 10.4 11.5 15.1 5.6

Hawaii 42.2 44.5 46.5 37.3 † 42.5 12.3 † 19.7 13.0 † †

Idaho 39.4 † 31.4 32.3 † 24.0 15.4 † 11.9 11.4 † †

Illinois 50.3 64.4 37.5 36.8 45.9 28.5 17.5 29.1 12.4 12.4 19.0 6.8

Indiana 48.7 52.6 35.7 38.0 41.4 31.1 18.0 24.4 10.5 12.9 17.0 6.3

Iowa 50.5 57.8 36.2 39.7 37.5 19.1 17. 3 18.0 † 12.7 16.2 †

Kansas 45.2 56.6 44.8 34.9 38.5 24.7 17.8 25.3 16.8 12.2 16.4 8.9

Kentucky 57. 8 59.4 32.8 42.4 45.0 21.5 20.2 24.6 † 13.9 16.7 †

Louisiana 51.6 65.8 28.9 36.9 47. 8 22.3 18.5 28.5 † 13.0 18.2 †

Maine 41.9 † † 33.8 † † 14.7 † † 11. 4 † †

Maryland 40.0 47.8 28.4 33.1 35.6 22.3 15.4 22.5 7.5 11.5 13.9 5.2

Massachusetts 39.6 44.6 33.1 31.6 33.4 23.2 14.1 16.3 8.5 10.5 11.4 7.5

Michigan 40.7 55.3 36.1 32.4 40.8 25.3 15.8 23.6 11.6 11.5 17.0 9.4

Minnesota 42.1 47.9 33.6 33.4 40.0 43.5 14.3 13.2 † 10.7 13.2 12.6

Mississippi 52.9 70.4 † 37.8 48.9 † 20.2 30.5 † 13.9 18.0 †

Missouri 47.6 56.6 29.8 35.1 41.8 23.7 17.3 26.1 † 12.0 16.1 †

Montana 42.1 † 63.0 32.2 † † 15.5 † † 10.6 † †

Nebraska 49.0 70.8 36.9 37.5 38.5 33.9 17.5 27.8 † 12.5 20.7 †

Nevada

‡

42.3 47.1 35.2 33.5 33.3 25.5 19.9 30.4 13.6 14.9 17.0 9.1

New Hampshire 42.2 † † 33.2 † † 14.1 † † 11.8 † †

New Jersey 48.1 54.1 43.8 36.9 41.5 32.9 17.1 24.2 12.4 12.4 14.5 8.1

New Mexico 33.7 32.0 42.5 27. 8 32.3 30.8 14.7 † 18.8 10.5 † 12.1

New York 44.8 50.7 43.6 34.8 36.6 29.1 15.3 18.2 13.6 11.3 13.7 8.2

North Carolina 41.7 51.6 27.8 32.0 36.3 24.2 15.3 23.2 6.4 10.6 14.8 6.0

North Dakota 51.9 † † 36.8 † † 16.5 † † 11.0 † †

Ohio 47.1 48.1 33.0 36.2 37.3 21.1 18.2 23.2 7.4 13.0 15.8 7.3

Oklahoma 46.8 54.6 37.3 35.2 40.6 33.0 20.3 28.4 14.1 13.7 15.6 6.7

Oregon 38.6 40.3 35.8 30.6 31.4 29.0 15.3 21.0 11. 2 11.6 † 6.2

Pennsylvania 48.5 52.7 40.3 36.0 41.3 26.9 17.6 23.4 13.5 12.3 15.4 9.0

Rhode Island 38.5 35.7 35.3 31.4 25.2 23.0 14.9 † † 11.5 † †

South Carolina 42.5 54.5 29.0 32.4 37.3 30.4 16.0 24.8 † 11.1 14.9 †

South Dakota 46.4 † † 36.2 † † 19.5 † † 12.5 † †

Tennessee 45.7 56.9 21.4 35.2 41.4 17.4 17.7 28.3 † 12.5 18.0 †

Texas 44.5 56.4 46.0 32.1 40.9 28.0 17.2 26.6 17.2 11.4 16.3 8.9

Utah 32.9 58.7 38.7 25.6 † 32.2 12.7 † 12.5 9.6 † 9.1

Vermont 37.3 † † 33.2 † † 16.4 † † 13.9 † †

Virginia 39.2 49.4 25.5 31.3 38.2 24.0 15.8 24.4 9.1 10.9 15.2 6.3

Washington 39.2 42.6 36.0 32.5 33.8 26.1 14.7 17.1 9.5 10.9 13.3 6.5

West Virginia 52.0 50.1 † 41.5 43.6 † 20.4 30.6 † 15.8 15.8 †

Wisconsin 41.5 64.0 28.9 31.9 43.7 25.6 15.0 24.7 11.7 11.0 16.9 6.8

Wyoming 36.9 † 41.7 28.6 † 32.6 14.1 † † 10.0 † †

US 44.0 53.8 40.8 33.9 39.9 28.7 16.3 23.8 14.1 11.7 15.6 8.7

*Rates are per 100,000 and age adjusted to the 2000 US standard population. †Statistics not displayed due to fewer than 25 cases or deaths. ‡Incidence data for these

states are not included in US combined incidence rates because data did not meet inclusion standards for all years during 2012-2016 according to the North American

Association of Central Cancer Registries (NAACCR). §Rates are based on cases diagnosed during 2012-2014.

Sources: Incidence – NAACCR, 2019. Mortality – NCHS, 2019.

Colorectal Cancer Facts & Figures 2020-2022 11

Colorectal cancer survival

The relative survival rate for CRC is 64% at 5 years

following diagnosis and 58% at 10 years.

The most

important predictor of CRC survival is stage at diagnosis.

The 5-year survival rate is 90% for the 39% of patients

diagnosed with localized-stage disease, but declines to

71% and 14% for those diagnosed with regional and distant

stages, respectively (

Figure 10

and

Figure 11

). Rectal cancer

is diagnosed at a localized stage slightly more often than

colon cancer, 41% versus 38%, likely due to the earlier

appearance of symptoms and partly explaining the higher

overall 5-year relative survival (67% versus 63%). Factors

associated with advanced-stage CRC diagnosis include

low socioeconomic status, black race, and young age.

60, 61

Factors associated with CRC survival in addition to stage

include age at diagnosis, the presence of other illnesses,

and other tumor and patient characteristics, such as

race/ethnicity and socioeconomic status.

For reasons

that are not explained by tumor differences or other

known factors, women are slightly more likely than men

to survive after a CRC diagnosis.

There is some evidence

that patients with tumors located in the proximal colon

have lower survival rates than those with tumors in the

distal colon,

but this association may be confined to

distant-stage diagnoses.

Age

Although CRC patients younger than age 50 have higher

5-year relative survival rates than their older counterparts

for every stage of diagnosis (

Figure 10

), overall survival

among patients younger than age 50 (68%) is similar to

that in ages 50-64 years (69%) because of a later stage at

diagnosis. Approximately 26% of CRCs are diagnosed

at a distant stage among patients younger than age 50,

compared to 23% in ages 50-64 years and 19% among

those ages 65 and older (

Figure 11

). Despite having the

highest proportion of early-stage diagnoses, however,

individuals ages 65 and older have the lowest overall 5-year

relative survival (61%) because their stage advantage is

outweighed by age-related disadvantages, such as

additional health issues.

*Cause-specific survival rates are the probability of not dying from colorectal cancer within 5 years of diagnosis. Rates are based on cases diagnosed from 2009 to 2015, all

followed through 2016. Rates for American Indians/Alaska Natives are based on small case numbers, particularly for distant-stage disease.

Source: SEER Program, 2019.

Figure 10. Colorectal Cancer Five-year Survival (%) by Age and Race/Ethnicity, 2009-2015

0-49 years

50-64 years 65+ years All ages

Non-Hispanic white

Non-Hispanic black

Asian and Pacific Islander

American Indian/Alaska Native

Hispanic

100

DistantRegionalLocalAll stages

100

DistantRegionalLocalAll stages

Percent

67 67

12 Colorectal Cancer Facts & Figures 2020-2022

Race/ethnicity

Outcomes among racial/ethnic minorities are described in

terms of cause-specific survival because life expectancy

data for minority groups are inadequate to calculate

relative survival. The highest CRC survival rates are for

APIs (68%) and the lowest are for blacks (60%;

Figure 10

one-quarter of whom are diagnosed with distant-stage

disease (

Figure 11

). As described earlier, disparities in CRC

outcomes are largely driven by socioeconomic inequalities

that result in differences in access to early detection and

receipt of timely, high-quality treatment.

61, 66

Access to care

is directly related to stage at diagnosis, which plays the

largest role in racial/ethnic survival disparities.

Notably,

when CRC is diagnosed at localized stage, 5-year survival

is relatively similar (89%-92%) across racial/ethnic groups.

A recent nationwide study found that more than one-

half of the black-white survival disparity is explained by

differences in insurance status and one-quarter is due to

differences in tumor characteristics (e.g., grade, location).

There is also compelling evidence that black patients are

less likely to receive prompt follow-up after an abnormal

CRC screening test

and appropriate surgery, adjuvant

chemotherapy, and radiation treatments.

3, 68-70

Although a

recent study found no evidence of treatment delays in an

equal-access health system,

equal cancer treatment does

not eliminate the racial survival disparity.

72, 73

Thus, equity

in care across the cancer continuum, from prevention

to early detection to clinical-trial participation and

individualized treatment, is necessary to eliminate these

disparities.

Changes over time

The 5-year relative survival rate for CRC has increased

moderately from 50% in the mid-1970s to 64% during

2009-2015.

However, recent advances in the treatment

of metastatic disease, including improved surgical

methods and the development of targeted therapies,

75-77

have rapidly extended survival for these patients. For

example, the 2-year relative survival rate for distant-

stage disease increased from 21% for patients diagnosed

during the mid-1990s to 37% for those diagnosed during

2009-2015, with a larger jump for rectal cancer (22% to 41%)

than for colon cancer (21% to 36%). Although progress is

evident across race and age,

gains are most prominent

among white and non-elderly patients.

*Cause-specific survival rates are the probability of not dying from colorectal cancer within 5 years of diagnosis. Rates are based on cases diagnosed from 2009 to 2015, all

followed through 2016. Rates for American Indians/Alaska Natives are based on small case numbers, particularly for distant-stage disease.

Source: SEER Program, 2019.

Figure 10. Colorectal Cancer Five-year Survival (%) by Age and Race/Ethnicity, 2009-2015

0-49 years

50-64 years 65+ years All ages

Non-Hispanic white

Non-Hispanic black

Asian and Pacific Islander

American Indian/Alaska Native

Hispanic

100

DistantRegionalLocalAll stages

100

DistantRegionalLocalAll stages

Percent

67 67

*Cause-specific survival rates are the probability of not dying from colorectal cancer within 5 years of diagnosis. Rates are based on cases diagnosed from 2009 to 2015, all

followed through 2016. Rates for American Indians/Alaska Natives are based on small case numbers, particularly for distant-stage disease.

Source: SEER Program, 2019.

Figure 10. Colorectal Cancer Five-year Survival (%) by Age and Race/Ethnicity, 2009-2015

0-49 years

50-64 years 65+ years All ages

Non-Hispanic white

Non-Hispanic black

Asian and Pacific Islander

American Indian/Alaska Native

Hispanic

100

DistantRegionalLocalAll stages

100

DistantRegionalLocalAll stages

Percent

67 67

Source: NAACCR, 2019.

Figure 11. Colorectal Cancer Stage Distribution (%) by Age and Race/Ethnicity, 2012-2016

0-49 years 50-64 years 65+ years All ages Non-Hispanic white

Non-Hispanic black

Asian and Pacific Islander

American Indian/Alaska Native

Hispanic

UnstagedDistantRegionalLocal

Percent

37 37 37

35 35

20 20

Colorectal Cancer Facts & Figures 2020-2022 13

Colorectal Cancer Risk Factors

In the United States, more than half (55%) of all CRCs are

attributable to lifestyle factors, including an unhealthy diet,

insufficient physical activity, high alcohol consumption,

and smoking.

These behaviors are traditionally associated

with high-income countries, where CRC rates are highest.

On a global scale, increasing CRC incidence is considered

a marker of economic transition.

Importantly, however,

numerous studies have shown that people with healthy

lifestyle behaviors have a 27% to 52% lower risk of CRC

compared to those without these behaviors.

Nonmodifiable factors that increase risk are related to

heredity and medical history, including a personal or

family history of CRC or adenomas (precancerous polyps)

and a personal history of long-term chronic inflammatory

bowel disease. Most people at increased risk because of a

medical or family history should begin CRC screening

before age 45. (For more information on CRC screening

guidelines, please see page 30.) The following sections

present current knowledge about factors associated with

CRC risk.

Heredity and family history

Up to 30% of CRC patients have a family history of the

disease, making this one of the most important and

actionable risk factors.

83-85

People with a first-degree

relative (parent, sibling, or child) who has been diagnosed

with CRC have 2 to 4 times the risk of developing the

disease compared to people without this family history,

with higher risk for diagnosis before age 50 and/or multiple

affected relatives (

Table 3

However, a history of CRC

among more distant relatives also increases risk,

does a family history (first- or second-degree relatives)

of adenomas.

Much of the CRC clustered in families is

thought to reflect interactions between lifestyle factors

and the cumulative effect of relatively common genetic

variations that increase disease risk, referred to as high

prevalence/low penetrance mutations.

Identification of families with a history of CRC, especially

high-burden families with undiagnosed genetic syndromes

(i.e., low prevalence/high penetrance mutations, described

below), offers substantial opportunity to lessen cancer

incidence and mortality through increased surveillance

with colonoscopy. However, patient family history in

medical records continues to be incomplete. One study

found that less than half of primary care physicians

documented information about family members other

than first-degree relatives, and age at cancer diagnosis

was rarely collected.

Another study found that only

22% of CRC patient medical records had family history

information sufficient to identify individuals who should

be referred for genetic counseling and/or testing.

Table 3. Relative Risks for Established Colorectal

Cancer Risk Factors

Relative risk*

Factors that increase risk:

Heredity and medical history

Family history

CRC

1 or more first-degree relatives 2.2

1 or more first-degree relatives diagnosed

before age 50

3.6

2 or more first-degree relatives 4.0

1 or more second-degree relatives 1.7

Adenoma

1 or more first-degree relatives 2.0

Inflammatory bowel disease

115

1.7

Type 2 diabetes

124

Male 1.4

Female 1.2†

Modifiable factors

Heavy alcohol (daily average >3 drinks)

195

1.3

Obesity (body mass index ≥30 kg/m

)

146

1.3

Colon, male 1.5

Colon, female 1.1

Rectum, male 1.3

Rectum, female 1.0†

1.1

1.2

Red meat (100 g/day)

166

rocessed meat (50 g/day)

166

Smoking

190

Current vs. never 1.5

Former vs. never 1.2

Factors that decrease risk:

Physical activity

138

0.7

Dairy (400 g/day)

166

0.9

*Relative risk compares the risk of disease among people with a particular

“exposure” to the risk among people without that exposure. Relative risk for

dietary factors compares the highest with the lowest consumption. If the

relative risk is more than 1.0, then risk is higher among exposed than

unexposed persons. Relative risks less than 1.0 indicate a protective effect.

†Relative risk was not statistically significant.

14 Colorectal Cancer Facts & Figures 2020-2022

Hereditary syndromes

A recent study found that 5% of CRC patients have an

inherited gene mutation (germline mutation) associated

with a known high-risk hereditary condition, and an

additional 5% have mutations associated with moderately

increased risk.

Lynch syndrome

The most common hereditary risk factor for CRC is Lynch

syndrome, which accounts for about 3% of all CRCs.

People with Lynch syndrome are also at increased risk

for many other cancers, including endometrial, ovarian,

small intestine, stomach, urinary bladder, and female

breast.

These individuals have a mutation in certain

genes that hinders the cell’s ability to correct errors

introduced during DNA replication. These mistakes

result in additional mutations that can ultimately lead to

cancer,

the likelihood of which is dependent on which

gene is affected. Among the 80% of Lynch syndrome

patients with high-risk gene (MLH1 or MSH2) mutations,

19% to 25% will develop CRC by age 50 and 40% will

develop the disease by age 70.

The median age at CRC

diagnosis among Lynch syndrome patients is 61 years of

age,

and 8% of CRCs that occur in adults younger than

age 50 are caused by Lynch syndrome.

Although an estimated 1.2 million Americans (1 in 279)

have Lynch syndrome,

the vast majority are undiagnosed

because identification is dependent on a cancer diagnosis.

However, there is increasing recognition of the need for a

more proactive approach because rigorous colonoscopy

surveillance leads to early-stage diagnosis and high

survival in Lynch syndrome patients.

Numerous

organizations, including the National Comprehensive

Cancer Network and American Society for Clinical

Oncology, recommend testing for Lynch snydrome in

all patients with colorectal or endometrial cancer.

99, 100

Although implementation of universal testing has been

slow in the community hospital setting,

101

most major

public and private insurers cover the screening.

102

Polyposis syndromes

Polyposis syndromes are another type of hereditary

condition associated with increased CRC risk, the most

common of which is familial adenomatous polyposis

(FAP), which accounts for about 1% of all CRCs.

FAP is

characterized by the development of up to thousands of

colorectal polyps in the second and third decade of life. It

is typically caused by a mutation in the adenomatous

polyposis coli (APC) gene, which normally prevents

uncontrolled cell growth and division.

103

These mutations

are usually inherited, but occur spontaneously in 10% to

25% of affected people so there is not always a family

history of the condition.

104

Disease severity ranges from

severe (classic FAP) to mild (attenuated FAP), with the

latter associated with later age at onset and fewer polyps

(<100), but still high lifetime CRC risk.

105

Surgery is the

standard method of cancer prevention for people with

FAP once adenoma development is beyond the control of

colonoscopy. MUTYH-associated polyposis (MAP) is a

more recently recognized syndrome with large variability

in clinical features, but in which patients typically

develop a similar number of polyps as those with

attenuated FAP.

103

Other colorectal polyposis syndromes

include Peutz-Jeghers syndrome, juvenile polyposis

syndrome, and serrated polyposis syndrome.

106

BRCA1 and BRCA2

Approximately 1% of CRC patients have heritable

mutations in the breast cancer susceptibility genes

BRCA1 and/or BRCA2,

which are among the most

well-studied cancer predisposing genes. A gene panel

study of CRC patients younger than age 50 also found a

1% prevalence.

In addition to breast cancer, these

mutations confer increased risk for cancers of the ovary,

prostate, and pancreas.

107

Although their influence on

CRC risk is not well studied, a recent review reported an

association limited to BRCA1 mutation carriers, who

have about a 50% increased risk of the disease compared

to individuals without the mutation.

108

Personal medical history

People with a personal history of CRC are more likely to

develop a subsequent cancer in the colon or rectum,

especially when the initial diagnosis was at a young

age;

109

however, only 2% of patients will develop a second

primary CRC.

110

A history of adenomatous polyps also

increases CRC risk, especially multiple or large polyps.

111

Colorectal Cancer Facts & Figures 2020-2022 15

CRC risk is also increased among individuals with a

history of other cancer types because of the carcinogenic

effects of some treatments. Examples include childhood

cancer survivors, especially those who received pelvic or

abdominal or total-body radiotherapy, or certain drugs

(e.g., cisplatin, procarbazine);

112

men treated with

radiotherapy for prostate cancer;

113

and men treated with

platinum-containing chemotherapy for testicular cancer.

114

Chronic inflammatory bowel disease

Chronic inflammatory bowel disease (IBD) is a lifelong

condition, usually diagnosed in early adulthood, in which

the gastrointestinal tract is inflamed over a long period

of time. People with IBD have almost double the risk of

developing CRC compared to people in the general

population.

115

The most common forms of IBD are

ulcerative colitis and Crohn disease. Cancer risk

increases with the extent, duration, and severity of

disease,

115, 116

but has decreased over time, likely due to

the increased use of medications to control inflammation

and screening surveillance to detect premalignant

lesions.

117

Although the efficacy of anti-inflammatory

drugs for limiting IBD-related cancer occurrence

remains unclear, two recent meta-analyses reported

reduced CRC risk of 33% to 50% among individuals with

ulcerative colitis, but no effect for those with Crohn

disease.

118, 119

CRC patients with IBD are about 15 years

younger than those without IBD and 70% more likely to

die from their cancer after accounting for age and stage

at diagnosis.

120

IBD has been diagnosed in an estimated

3.1 million Americans and is most common among

non-Hispanic whites, women, and those with the least

education.

121

Although surveillance data in the US are

sparse, prevalence appears to have increased in recent

years.

122

Diabetes

People who have type 2 (adult onset) diabetes have a

slightly increased risk of CRC that appears stronger in

men than in women.

123, 124

The association between type 2

diabetes and CRC remains even after accounting for

shared risk factors (physical activity, body mass index,

and waist circumference).

125

Although some studies

suggest that metformin, a drug commonly used to lower

blood glucose levels in diabetic patients, independently

reduces CRC incidence,

126-130

a randomized controlled

trial found no association.

131

CRC patients with diabetes

are no more likely to die from their cancer than those

without diabetes, despite higher rates of cancer

recurrence, as well as mortality from other causes.

132

The prevalence of Americans with a history of diabetes

has more than doubled over the past two decades.

133

Although type 2 diabetes is rare among children and

adolescents (ages 0-19 years), incidence rates increased

by 7% per year between 2002 and 2012, from 9.0 cases per

100,000 in 2002-2003 to 12.5 in 2011-2012.

134

According to

the Centers for Disease Control and Prevention, 30.3

million people (9.4% of the population) were diabetic in

2017, including 7.2 million who were undiagnosed and

one-quarter of whom were 65 years of age and older.

135

H. pylori

Results from earlier studies evaluating the link between

infection with H. pylori, a bacteria strongly associated

with excess stomach cancer risk, and CRC occurrence

were inconsistent.

136

However, this may be because the

association is confined to specific subtypes of the

bacterium. A recent large study found that increased CRC

risk is limited to individuals with a history of infection

with particular H. pylori strains, and that this association

is strongest among black Americans.

137

Modifiable risk factors

Physical inactivity

Physical activity is strongly associated with a reduced risk

of colon cancer, but not rectal cancer. Studies consistently

show that the most physically active people have about a

25% lower risk of developing both proximal and distal

colon tumors than the least active people.

138, 139

Being

physically active from a young age may further lower

risk.

140

Likewise, people who are the most sedentary (e.g.,

spend the most hours watching TV) have a 25% to 50%

increased risk of colon cancer compared to those who are

least sedentary.

141

However, sedentary people who become

active later in life may reduce their risk.

142

Additionally,

people who were more physically active before a CRC

diagnosis are less likely to die from the disease than those

who were less active.

143

Based on these findings, as well as

16 Colorectal Cancer Facts & Figures 2020-2022

the numerous other health benefits of regular physical

activity, the American Cancer Society and the Centers for

Disease Control and Prevention recommend that adults

engage in at least 150 to 300 minutes of moderate-intensity

activity or 75 to 150 minutes of vigorous-intensity activity

each week (or a combination of these), preferably spread

throughout the week, and limit time spent sedentary in

activities like watching television.

Overweight and obesity

Excess body weight increases the risk of CRC, even

among those who are physically active.

144, 145

Compared to

people who are normal weight, obese men have about a

50% higher risk of colon cancer and a 25% higher risk of

rectal cancer, whereas obese women have about a 10%

increased risk of colon cancer and no increased risk of

rectal cancer.

146

Excess risk is also associated with higher

abdominal fat, measured by waist circumference or

waist-to-hip ratio, and fat stored within the abdominal

cavity, independent of body mass index and waist

circumference.

147

Thus, abdominal fat specifically may be

more important than overall body weight in influencing

CRC risk.

148

The timing of exposure may also be a factor,

with studies suggesting a stronger influence for excess

body weight during adolescence and young adulthood

among women, but later in life for men.

149

Higher body

weight, even within the normal range, appears to increase

risk of early-onset CRC (before age 50), at least among

women.

150

In addition, high body mass index measured

prior to diagnosis reduces the likelihood of CRC

survival.

147, 151

Excess body weight can have a negative

impact on the proper functioning of many biochemical

processes in the body (metabolic health), and studies

indicate that poor metabolic health may be related to

CRC incidence and survival independent of obesity.

152-154

Diet

Differences in CRC incidence globally, as well as the

relatively rapid changes in risk among immigrant

populations in the United States, have long suggested

that diet is linked to CRC occurrence.

155

Dietary patterns

likely influence risk both indirectly, through excess

calories and obesity, and directly through specific dietary

elements. For example, diet has a large influence on the

composition of the gut microbiome, which is the trillions

of microorganisms, including the 1,000+ different strains

of bacteria, that inhabit the large intestine. High levels of

specific bacteria in the microbiome are associated with

CRC risk.

156, 157

The microbiome is a very active area of

research because it is thought to play a dual role in both

preventing and promoting CRC and many other diseases

through its influence on immune response and

inflammation.

158-162

Diets with greater amounts of certain

foods, such as refined carbohydrates, processed sugar, and

red meat, have a higher potential to increase inflammation

and are associated with increased CRC risk.

163

However, the direct role of specific food items in cancer

occurrence is extremely challenging to study for many

reasons, including 1) difficulty defining and measuring

intake, such as challenges in the accuracy of self-reported

food questionnaires; 2) differences in the sources of

dietary constituents (e.g., cereal grains, fruits, and

vegetables all contribute to fiber intake); 3) the strong

link between dietary patterns and other health behaviors;

and 4) a constantly changing food supply. The following

is a summary of current scientific evidence for dietary

elements linked to CRC:

Dairy/Calcium: Most studies find that calcium

consumption from dairy foods and/or supplements is

associated with a decreased risk of developing adenomas

and CRC,

164-166

although the mechanism remains unclear.

Adequate calcium intake (approximately 700-1,000 mg/

day) seems to confer protection, with limited additional

benefit for higher consumption.

164

The relationship

appears to require years of follow-up to observe;

167

confined to cancers in the distal colon/rectum and

particular molecular subtypes;

168, 169

and perhaps be

moderated by other dietary factors.

164, 170

Whole grains/Fiber: Although it is highly plausible that

dietary fiber decreases risk of CRC for many reasons,

including less exposure to carcinogens because of higher

stool volume and faster transit time, study results,

including those from randomized controlled trials,

remain inconclusive and protective associations are

weak.

164

The evidence for whole grains specifically is

stronger than for overall fiber; two recent meta-analyses

found that CRC risk was decreased by about 5% for every

30 grams/day of whole-grain intake.

166, 171

Importantly, the

Colorectal Cancer Facts & Figures 2020-2022 17

overall health benefit of a diet high in whole grains is

clear,

172

and the American Cancer Society and the World

Cancer Research Fund both advocate a diet high in plant

foods, including whole grains, fruits, and vegetables for

the prevention of cancer and other diseases.

173, 174

Folate: Folate intake, consumed through diet or

supplements, appears to have a complex relationship

with CRC risk, potentially promoting growth of

preexisting tumors, while inhibiting formation of new

tumors in healthy tissue.

164

There has been speculation

that increased folate levels among Americans as a result

of mandatory fortification of enriched flour and cereals

in 1998 were responsible for the unexplained uptick in

CRC incidence rates in the late 1990s (

Figure 6

175

However, this hypothesis is not supported by an analysis

of data from randomized controlled trials that found no

association between five years of folic acid supplementation

and CRC risk.

176

Additional prospective studies conducted

post-fortification found that the highest level of folate

intake was associated with reduced risk of CRC.

177

Fruits and vegetables: Results from numerous studies

specifically evaluating the association between fruit and

vegetable intake and CRC risk are inconsistent.

164

Two

recent meta-analyses found no relationship for fruit and

a possible slightly reduced risk for the highest versus

lowest vegetable consumption.

166, 171

Any protective effect

appears to be for moderate compared to low consumption,

with high consumption providing little additional

benefit.

178, 179

Red and processed meat: Consumption of red and/or

processed meat increases the risk of CRC, with a stronger

association for colon cancer than rectal cancer and for

processed meat than red meat.

166, 180

A recent synthesis of

evidence for the World Cancer Research Fund found that

the risk of CRC is increased by 18% for every 50 grams/day

of processed meat (approximately 2 slices of lunchmeat)

and by 12% for every 100 grams/day of red meat

(marginally significant).

166

In 2015, the International

Agency for Research on Cancer classified processed meat

as “carcinogenic to humans” and red meat as “probably

carcinogenic to humans,” largely based on the evidence

related to CRC risk.

181

The reasons for this association

remain unclear, but may be related to the constituents of

meat and/or to carcinogens (cancer-causing substances)

that form during high-temperature cooking, curing, and/

or smoking.

182

Although there is concern about rising

consumption of processed foods overall, intake of

processed meat appears to have remained stable over

the past two decades.

183

Vitamin D: Higher blood levels of vitamin D may be

associated with lower risk of CRC, although research

findings remain inconsistent.

164

Clinical trials have not

found an association between daily supplementation

with vitamin D and risk of adenomas

167

or CRC.

184

However, a recent study of pooled data from 17 cohort

studies indicated that higher blood levels of vitamin D

(25[OH]D up to 100 nmol/L) were associated with

reduced CRC risk among women, and deficiency was

associated with a 37% increased risk.

185

Forthcoming

data from additional clinical trials evaluating the effect

of vitamin D supplementation on cancer prevention may

help clarify this association,

186, 187

although study design

modifications may be necessary to reconcile the current

controversy.

188

Smoking

In November 2009, the International Agency for Research

on Cancer reported that there is sufficient evidence to

conclude that tobacco smoking causes CRC.

189

In the US,

approximately 12% of CRCs are attributed to cigarette

current or former smoking, with CRC risk in current

smokers about 50% higher than that in never smokers.

80, 190

Most studies find differences in the association by

anatomic and molecular subtypes of CRC.

2, 191, 192

Smoking

is also associated with lower CRC-specific survival,

particularly for current smokers.

193, 194

Alcohol

An estimated 13% of CRCs in the US are attributed to

alcohol consumption.

Although there is strong evidence

that heavy consumption increases risk, the magnitude of

excess risk and the association with smaller quantities is

less certain. A recent meta-analysis reported that light-

to-moderate alcohol consumption (up to two drinks per

day) was associated with a slightly lower (8%) risk than

no consumption/occasional consumption, whereas very

heavy drinking (more than 3 drinks per day) was

18 Colorectal Cancer Facts & Figures 2020-2022

associated with a 25% higher risk.

195

However, other studies

find excess risk with just one drink per day, rising to 44%

for the heaviest drinking.

166, 196

The association appears

stronger in men, especially for heavy consumption,

perhaps because women are less likely to drink heavily

and/or because of hormone-related differences in alcohol

metabolism.

Medications

Nonsteroidal anti-inflammatory drugs

There is extensive evidence that long-term regular use of

aspirin and other nonsteroidal anti-inflammatory drugs

(NSAIDs) lowers risk of CRC.

197-199

The reduction in risk

appears to be stronger among individuals younger than

age 70 and without excess body weight.

200

Aspirin users

who do develop CRC appear to have less aggressive

tumors and better survival compared to non-aspirin

users,

201, 202

although the survival benefit may be limited

to certain tumor subtypes.

203, 204

The American Cancer

Society has not conducted a formal evidence review, but

currently does not recommend the use of NSAIDs for

cancer prevention in the general population because of

the potential side effects, namely serious gastrointestinal

bleeding. However, the US Preventive Services Task Force

currently recommends daily low-dose aspirin for the

prevention of cardiovascular disease and CRC for certain

individuals in their 50s who are at increased risk for

cardiovascular disease; the evidence for individuals in

their 60s is less convincing.

205

Decisions about aspirin use

should be made after discussion with a health care

provider. Visit

uspreventiveservicestaskforce.org

for more

information about their recommendation.

Hormones

The evidence regarding the association between steroid

hormones, both endogenous (naturally occurring within the

body) and exogenous (e.g., hormone replacement therapy

and oral contraceptives), and CRC is inconsistent.

206

Some

studies have found that higher natural levels of estrogen

among postmenopausal women are associated with

reduced CRC risk,

207

while others have found no

association.

208

Reduced risk associated with hormone

replacement therapy appears to be confined to use of

combined estrogen and progesterone formulations.

209, 210

Recent studies do not support an association between

oral contraceptive use and CRC risk.

2, 211, 212

Antibiotics

Emerging evidence suggests that oral antibiotic use may

be associated with increased risk of CRC.

213, 214

Antibiotics

might influence risk by disrupting the critical balance of

the gut microbiome. For more information on the

microbiome, see Diet on (page 16).

Other drugs

Oral bisphosphonates, which are used to treat and

prevent osteoporosis, may reduce CRC risk.

215, 216

Colorectal Cancer Screening

The typically slow course of growth from precancerous

polyp to invasive cancer to advanced-stage disease

provides a unique opportunity for the prevention and

early detection of CRC.

Screening can prevent cancer

through the detection and removal of precancerous

growths and detect the disease at an early stage, when

treatment is usually more successful. As a result,

screening reduces CRC mortality both by decreasing

incidence and increasing survival.

The 2018 American Cancer Society CRC screening

guideline recommends that adults ages 45 years and

older undergo regular screening with a high-sensitivity

stool-based test or visual examination (described below),

depending on patient preference and test availability.

217

As part of the screening process, all positive results on

non-colonoscopy screening tests should be followed up

with a timely colonoscopy because delays in follow-up of

abnormal results increase the risk of advanced CRC and

CRC death.

218, 219

The age to initiate CRC screening was

Colorectal Cancer Facts & Figures 2020-2022 19

lowered from 50 to 45 years because incidence rates are

increasing in younger populations, and modeling studies

demonstrated that the balance of benefit to harm was

more favorable for beginning screening at age 45 than

at 50.

220, 221

Although health insurance coverage for

screening those at average risk before age 50 remains

variable, the American Cancer Society is working

aggressively to educate insurers, lawmakers, and other

stakeholders about the evidence in support of screening

those ages 45-49 years and the importance of expanding

coverage for this group. Screening before age 45 is

recommended for those at an increased risk of CRC

because of family history or certain medical conditions

(see page 13), with age to initiate and rescreening intervals

dependent on individual circumstances. Everyone should

have a conversation with their health care provider about

CRC screening that includes information about cancer

family history well before age 45.

221

Visit

cancer.org/cancer/

colon-rectal-cancer/early-detection/acs-recommendations

for

more information, including specific guidelines for

screening individuals at increased or high risk.

Recommended options for colorectal

cancer screening

There are several recommended methods for CRC

screening, including both visual examinations, which are

performed at a health care facility, and high-sensitivity

stool-based tests, which are collected at home (

Table 4

). All

tests have a comparable ability to improve life expectancy

when performed at the appropriate time intervals and

with the recommended follow-up.

222

Patients should be

given information about the benefits and limitations of

each screening test, and choose one based on their health,

medical history, and preferences with advice from a health

care professional as needed. A growing body of evidence

demonstrates that offering patients different test

options substantially increases adherence to screening

recommendations.

223

As a result, and because one-third

of eligible adults are not up to date with CRC screening,

including half of those ages 50-54 years, the American

Cancer Society and the US Preventive Services Task Force

guidelines do not emphasize any one test and stress that

all recommended tests can help save lives.

217, 224

Visual examinations

Visual tests allow doctors to see the lining of the colon and

rectum through an endoscope or on radiological images.

Colonoscopy

Colonoscopy is the most commonly used CRC screening

test in the US. This procedure, which is usually performed

by a gastroenterologist (a doctor who specializes in the

digestive system) or surgeon, allows for direct visual

examination of the entire colon and rectum. It can be used

as a singular screening test, or may be performed as a

follow-up to abnormal results from stool and other visual

tests to complete the screening process. Colonoscopy has

the longest rescreening interval of all test options, 10

years for average-risk individuals with normal results.

Before undergoing a colonoscopy, patients are instructed

to take special laxative agents to cleanse the colorectum

completely so the intestinal lining can be thoroughly

examined. During the exam, the colon is inflated with

either air or carbon dioxide. Then a long, slender

instrument called a colonoscope is inserted into the anus

and moved slowly through the rectum to the cecum

(beginning of the colon). The colonoscope has a light and

small video camera on the end to allow for the detection

and removal of most polyps with a wire loop or electric

current. Sedation is usually provided during examinations

in the US, although it is used less frequently in some

European countries (e.g., Norway and Poland).

225

While data are not yet available from randomized

controlled trials evaluating the effectiveness of

colonoscopy,

226

results from several trials of flexible

sigmoidoscopy, a similar test discussed in the next

section, provide indirect support for the benefits of

colonoscopy. In addition, observational studies suggest

that colonoscopy can help reduce CRC incidence by about

40% and mortality by about 60%.

227-229

Like all screening tests, colonoscopy has limitations and

potential harms. For example, it can lead to unnecessary

procedures, such as the removal of small polyps that

would not have progressed to cancer.

230

A recent study

found that although >90% of polyps can be safely

20 Colorectal Cancer Facts & Figures 2020-2022

removed during colonoscopy, elective surgery to remove

nonmalignant polyps, which has a higher risk of harms,

increased by more than 50% from 2000 to 2014.

231

Other

limitations of colonoscopy include a higher risk of

complications compared to other screening tests, such

as bowel tears and bleeding, especially when a polyp is

removed or patients are older.

230, 231

Although these side

effects are rare, serious bleeding occurs in 1 to 2 of every

1,000 colonoscopies.

225, 232, 233

In addition, colonoscopy

sometimes misses adenomas, especially those that are

located in the proximal colon; those that occur in high-risk

patients; and those that are flat (sessile adenomas), from

which 20% to 30% of CRCs are thought to originate.

226, 234

The quality of colonoscopy, which is variable in the US, is

also associated with missed lesions, which sometimes

progress to CRC before the next scheduled exam (i.e.,

Table 4. Characteristics of Recommended Colorectal Cancer Screening Tests

Benefits

Performance

& Complexity* Limitations

Test Time

Interval

Visual Examinations

Colonoscopy • Examines entire colon

• Can biopsy and remove

polyps

• Can diagnose other

diseases

• Required for abnormal results

from all other tests

Performance:

Highest

Complexity:

Highest

• Full bowel cleansing

• Can be expensive

• Sedation usually needed, necessitating a

chaperone to return home

• Patient may miss a day of work.

• Highest risk of bowel tears or infections

compared with other tests

10 years

†

Computed

tomographic

colonography

(CTC)

• Examines entire colon

• Fairly quick

• Few complications

• No sedation needed

• Noninvasive

Performance:

High (for large polyps)

Complexity:

Intermediate

• Full bowel cleansing

• Cannot remove polyps or perform biopsies

• Exposure to low-dose radiation

• Colonoscopy necessary if positive

• Not covered by all insurance plans

5 years

Flexible

sigmoidoscopy

• Fairly quick

• Few complications

• Minimal bowel preparation

• Does not require sedation or

a specialist

Performance:

High for rectum & lower

one-third of the colon

Complexity:

Intermediate

• Partial bowel cleansing

• Views only one-third of colon

• Cannot remove large polyps

• Small risk of infection or bowel tear

• Slightly more effective when combined with

annual fecal occult blood testing

• Colonoscopy necessary if positive

• Limited availability

5 years

Stool Tests (Low-sensitivity stool tests, such as single-sample FOBT done in the doctor’s office or toilet bowl tests, are not recommended.)

Fecal immuno-

chemical test

(FIT)

• No bowel cleansing or

sedation

• Performed at home

• Low cost

• Noninvasive

Performance:

Intermediate for cancer

Complexity:

Low

• Requires multiple stool samples

• Will miss most polyps

• May produce false-positive test results

• Slightly more effective when combined with a

flexible sigmoidoscopy every five years

• Colonoscopy necessary if positive

Annual

High-sensitivity

guaiac-based

fecal occult

blood test

(gFOBT)

• No bowel cleansing or

sedation

• Performed at home

• Low cost

• Noninvasive

Performance:

Intermediate for cancer

Complexity:

Low

• Requires multiple stool samples

• Will miss most polyps

• May produce false-positive test results

• Pre-test dietary limitations

• Slightly more effective when combined with a

flexible sigmoidoscopy every five years

• Colonoscopy necessary if positive

Annual

Multitargeted

stool DNA test

(Cologuard

)

• No bowel cleansing or

sedation

• Performed at home

• Requires only a single stool

sample

• Noninvasive

Performance:

Intermediate for cancer

Complexity:

Low

• Will miss most polyps

• More false-positive results than other tests

• Higher cost than gFOBT and FIT

• Colonoscopy necessary if positive

3 years, per

manufacturer’s

recommendation

*Complexity involves patient preparation, inconvenience, facilities and equipment needed, and patient discomfort. †For average-risk individuals, e.g., does not apply to

those who have a history of adenoma.

Colorectal Cancer Facts & Figures 2020-2022 21

interval cancer).

235, 236

Low-quality colonoscopy (measured

as low adenoma detection rate) is associated with a

higher likelihood of interval CRC and CRC death.

236

Flexible sigmoidoscopy

Sigmoidoscopy was a common screening test before

2000, but current availability is limited because it has

mostly been replaced by colonoscopy (see page 23 for

current prevalence of sigmoidoscopy and other screening

tests). These tests are very similar except colonoscopy

can examine the entire colon whereas sigmoidoscopy can

only visualize the rectum and distal one-third of the

colon, and must be repeated more often (

Table 4

). Simple

bowel cleansing, usually with enemas, is sufficient to

prepare the colon, and the procedure is often performed

without sedation in a general health care practitioner’s

office. If there is a polyp or tumor present, the patient

should be referred for a colonoscopy so that the entire

colon can be examined.

Recent analysis of data from randomized controlled

trials with up to 17 years of follow-up shows that

sigmoidoscopy is associated with about a 20%-25%

reduction in CRC incidence and a 25%-30% reduction in

CRC mortality, with greater reductions in men than

women.

237-239

Computed tomographic colonography (CTC)

Also referred to as virtual colonoscopy, CTC is an

imaging procedure that provides 2- or 3-dimensional

views of the entire colon and rectum with the use of a

special x-ray machine linked to a computer.

230

Although a

full bowel cleansing is necessary for a successful

examination, sedation is not required. A small, flexible

tube is inserted into the rectum in order to allow carbon

dioxide, or sometimes air, to inflate the colon; then the

patient passes through the CT scanner, which creates

multiple images of the interior of the colon. CTC is less

invasive than colonoscopy or sigmoidoscopy and

typically takes approximately 10 to 15 minutes to

complete.

240

Patients with adenomas larger than 5

millimeters or other abnormal results are referred for

colonoscopy, optimally on the same day in order to

alleviate the necessity of a second bowel preparation.

Studies have shown that the performance of CTC is similar

to colonoscopy for the detection of invasive cancer and

advanced adenomas, but has lower sensitivity for smaller

adenomas.

241

Potential harms include cumulative

radiation exposure from regular examinations, and

unnecessary tests and/or treatment due to incidental

benign findings outside the colorectum. There is less

evidence on the benefits and harms of this test compared

to others because it is relatively new and remains

uncommon.

224

This may be because it is not covered by

Medicare and commercial insurance coverage is variable;

in 2019, 37 states mandated that commercial plans cover

this test.

242

Stool tests

Most cancerous tumors and some large adenomas bleed

intermittently into the intestine. This blood, which may

not be visible, can be detected in stool with special tests.

Modeling studies suggest that annual screening with

high-sensitivity stool tests and timely follow-up of

abnormal results will result in a reduction in mortality

similar to that achieved by colonoscopy over a lifetime of

screening.

243

Except for the multitargeted stool DNA test,

which is recommended every 3 years, stool tests should

be repeated annually. However, adherence to yearly

testing and timely follow-up with a colonoscopy after a

positive test remains a challenge, especially in low-

resource settings where stool tests are more common.

244-247

Guaiac-based fecal occult blood test (gFOBT)

These tests use a chemical reaction to detect blood in

the stool. Bleeding from cancers or adenomas may be

sporadic or undetectable, so accurate results require

annual testing of samples from 3 consecutive bowel

movements. Patients are typically instructed to avoid

nonsteroidal anti-inflammatory drugs and red meat for

3 days prior to the test because they can lead to a positive

test result when no cancer is present (false positive);

gFOBT detects blood from any source, including meat in

the diet. Vitamin C and large amounts of citrus juices

should also be avoided because they can lead to a negative

test result when cancer is present (false negative). Only

high-sensitivity gFOBT are recommended for CRC

screening.

22 Colorectal Cancer Facts & Figures 2020-2022

Data from a large clinical trial indicated that the regular

use of FOBT reduced the risk of CRC death by 32% after

30 years of follow-up.

248

FOBT has also been shown to

decrease CRC incidence by 20% by detecting large

precancerous adenomas.

249

Fecal immunochemical test (FIT)

The FIT (also sometimes referred to as the

immunochemical FOBT, or iFOBT) uses antibodies

against hemoglobin to specifically detect human blood

in the stool and is about twice as likely as most gFOBT

products to detect both advanced adenomas and

cancer.

250, 251

Many individuals prefer FIT over gFOBT

because of its convenience, lack of dietary restrictions,

and collection of fewer stool samples.

252

Multitargeted stool DNA (Cologuard®)

This test is referred to as “multitargeted” because it not

only detects blood in the stool, but also multiple genetic

mutations in the DNA of cells that are shed into the stool

by large adenomas and CRC. Cologuard® has been shown

to detect cancer and precancerous lesions more often

than FIT, but also results in more false-positive tests,

which can lead to unnecessary colonoscopies.

253

However,

because it is a relatively new test, data are still accumulating

on performance characteristics in community settings.

Although it is recognized as an acceptable screening

option by the American Cancer Society and the US

Preventive Services Task Force

224

and is covered by

Medicare, some private insurance companies may not

cover this test. Patient navigation services, which include

phone calls and reminder letters in multiple languages to

support test completion, are embedded in the cost of the

test, although the services do not extend to colonoscopy

follow-up of abnormal results.

254

Non-recommended tests for colorectal

cancer screening

There are several tests for CRC screening that are not

recommended by the American Cancer Society or other

organizations because of poorer performance. These

include in-office stool tests, in which a single-stool

sample is collected during a digital rectal exam and

placed on an FOBT card, and “toilet bowl tests,” which

are over-the-counter guaiac-based tests that are often

promoted as a type of FOBT. Despite recommendations

against in-office FOBT, some primary care physicians

continue to offer the test.

255

Toilet bowl tests have not

been evaluated in the types of rigorous clinical studies

done on the guaiac-based FOBT and FIT.

Double-contrast barium enema, also called barium

enema with air contrast, is a test that takes an x-ray of

the colon after barium sulfate is introduced. This test is

no longer recommended because it has lower sensitivity

for detecting CRC than other tests.

There are also emerging technologies that are not

currently recommended for CRC screening because there

was insufficient data on their performance compared to

other recommended options at the time the guidelines

were issued. These include blood-based tests that

measure circulating genetic abnormalities associated

with colorectal adenomas and cancer, and capsule

endoscopy, in which the patient undergoes bowel

cleansing and swallows a pill-sized device containing

tiny encapsulated cameras that transmit images of the

colon and rectum to a recording device.

Use of colorectal cancer screening

According to the National Health Interview Survey

(NHIS), CRC screening in accordance with guidelines

increased rapidly among adults ages 50 and older from

2000 (38%) to 2010 (59%), but more slowly in the past

decade, reaching 66% in 2018 (

Table 5

The most recent

NHIS data collected in 2018 contain a mix of respondents

surveyed before and after the release of the American

Cancer Society CRC screening guideline in mid-2018.

Approximately 56% of those ≥45 years of age and 21% of

those ages 45-49 years reported being up to date with

CRC screening in 2018.

Among adults ages 50 and older in 2018:

• 61% reported having a colonoscopy in the past 10

years, and 3% and 1% reported having a sigmoidoscopy

or CT colonography, respectively, in the past 5 years.

• Approximately 11% reported a recent stool test; 9%

reported an FIT or FOBT in the past year and 3%

reported stool DNA testing in the past 3 years.

Colorectal Cancer Facts & Figures 2020-2022 23

• Screening was lowest among ages 50-54 years (48%);

Asian Americans (55%); individuals with less than a

high school education (52%); the uninsured (30%);

and recent (<10 years) immigrants (26%).

The prevalence of CRC screening also varies substantially

among US states and territories (see cover). According to

data from the 2018 Behavioral Risk Factor Surveillance

System (BRFSS):

256

Table 5. Colorectal Cancer Screening (%), Adults 45 Years and Older, US, 2018

Stool test* Colonoscopy† Up to date‡

≥50 years ≥50 years ≥50 years 50-75 years

Overall 11 61 66 67

Gender

Males 12 62 67 67

Females 10 60 64 66

Age (years)

50-64 10 56 61 62

50-54 9 42 48 –

55-64 10 63 68 –

65+ 12 66 71 77

75+ 10 60 63 –

Race/ethnicity

White 10 63 68 69

Black 12 60 65 66

Hispanic 15 52 59 59

American Indian/Alaska Native 12 53 59 56

Asian 15 47 55 58

Sexual orientation

Gay/Lesbian 18 68 76 76

Straight 11 61 66 67

Bisexual 25 49 58 §

Education

Less than high school 11 46 52 53

High school diploma 10 57 62 63

Some college 11 62 68 68

College graduate 11 68 73 73

Immigration status

Born in US 10 63 68 69

Born in US territory § 76 80 84

In US fewer than 10 years § 20 26 30

In US 10+ years 14 49 56 58

Income level

<100% FPL 12 49 55 57

100 to <200% FPL 12 48 55 57

≥200% FPL 11 65 70 70

Insurance status

Uninsured 5 26 30 30

Private 9 60 65 65

Medicare or Medicare & Medicaid 14 61 67 73

Private & Medicare 11 71 74 80

Medicaid or Other state plan 14 44 53 54

FPL: federal poverty level. *Fecal occult blood test (FOBT) OR fecal immunochemical test (FIT) in the past 1 year OR stool DNA (sDNA) test in the past 3 years. †In the

past 10 years. ‡For ages ≥45 and ≥50 years: FOBT/FIT, sigmoidoscopy, colonoscopy, computed tomographic colonography (CTC), orsDNA test in the past 1, 5, 10, 5 and 3

years, respectively. For ages 50-75 years: FOBT/FIT, sigmoidoscopy, colonoscopy, CTC, orsDNA test in the past 1, 5, 10, 5 and 3 years, respectively, OR sigmoidoscopy in

past 10 years with FOBT/FIT in past 1 year. §Estimate not shown due to instability. Note: Estimates do not distinguish between examinations for screening and diagnosis.

All estimates except for age and insurance status are age adjusted to the 2000 US standard population.

Source: National Health Interview Survey, 2018.

24 Colorectal Cancer Facts & Figures 2020-2022

• Screening utilization ranged from 58% in Puerto Rico

and 60% in Wyoming to 76% in Massachusetts (

Figure

and

Table 6

• In all states, screening prevalence is substantially

lower in people ages 50-64 years than in those age 65

and older, with the largest absolute difference in

Puerto Rico (22%) and Florida, Mississippi, and

Oklahoma (all 19%).

Strategies to overcome screening barriers

Screening utilization for CRC remains lower than that

for breast and cervical cancers despite the large body

of evidence supporting its effectiveness for reducing

cancer incidence and mortality.

257

Use of CRC screening

is influenced by numerous individual, provider, health

system, and community factors, as well as public policy.

Barriers to screening include no usual source of care,

inadequate insurance coverage, lack of provider

recommendation, logistical factors (e.g., transportation,

scheduling, and language), fear, and lack of knowledge.

258-263

These barriers are more prevalent among people with

fewer financial resources, lower educational attainment,

and among racial/ethnic minorities, resulting in

disparities in screening prevalence and outcomes.

264

Interventions to help overcome these barriers include

increasing individual patient awareness (e.g., education and

reminders), ease of access (e.g., providing transportation,

reducing out-of-pocket expenses, mailed FIT kits, patient

navigators), provider delivery (e.g., provider reminders,

assessment, and feedback), and community demand

(e.g., media campaigns).

265

Multi-component interventions

are recommended because they are more effective at

increasing CRC screening utilization than a single

approach.

265, 266

Additionally, adherence to CRC screening

guidelines increases when patients are offered a variety

of tests.

222, 223, 267, 268

Importantly, however, the effectiveness

of screening is compromised without timely follow-up of

abnormal results. Follow-up of colonoscopy among adults

with a positive stool test may be increased through the

use of patient navigators and provider-level interventions,

such as physician reminders and performance data,

although evidence for effective strategies remains sparse.

269

Figure 12. Colorectal Cancer Screening* (%), Adults

50 Years and Older by State, 2018

Wyoming

Nevada

Texas

Alaska

New Mexico

Oklahoma

Mississippi

Montana

Arkansas

Illinois

Idaho

North Dakota

Arizona

New Jersey

Kansas

Indiana

West Virginia

Nebraska

Ohio

South Dakota

Colorado

Missouri

Utah

Tennessee

Georgia

Virginia

Pennsylvania

Alabama

Kentucky

New York

Louisiana

Florida

Iowa

Vermont

North Carolina

South Carolina

Washington

Oregon

Maryland

Hawaii

Delaware

Minnesota

California

District of Columbia

Michigan

Wisconsin

Connecticut

New Hampshire

Rhode Island

Maine

Massachusetts

Percent

*Blood stool test, sigmoidoscopy, or colonoscopy in the past 1, 5, and 10

years, respectively. Note: Estimates are age adjusted to the 2000 US standard

population and do not distinguish between examinations for screening and

diagnosis.

Source: Behavioral Risk Factors Surveillance System, 2018. See Sources of

Statistics (p. 32) for complete citation and more information.

50 60 70 80 90 100

Colorectal Cancer Facts & Figures 2020-2022 25

Table 6. Colorectal Cancer Screening* (%), Adults 50 Years and Older by State, 2018

All races

Non-Hispanic

white

Non-Hispanic

black

≥50 years 50 to 64 years ≥65 years 50 to 75 years ≥50 years ≥50 years

United States (median)

70 63 75 69 71 71

Range

60-76 50-72 66-82 58-77 61-80 63-84

Alabama

70 63 76 70 71 67

Alaska

62 52 70 60 62 †

Arizona

67 59 76 66 69 75

Arkansas

67 58 74 66 67 69

California

73 64 82 72 80 77

Colorado

69 62 74 69 71 76

Connecticut

75 71 78 75 76 76

Delaware

73 67 78 72 75 71

District of Columbia

74 69 78 74 77 73

Florida

71 61 80 69 74 67

Georgia

70 61 78 68 71 71

Hawaii

73 69 75 75 78 †

Idaho

67 59 72 66 68 †

Illinois

67 61 70 67 67 74

Indiana

68 61 73 68 69 67

Iowa

71 66 74 71 71 84

Kansas

68 60 74 67 69 66

Kentucky

70 63 76 69 70 70

Louisiana

70 64 76 69 71 70

Maine

75 69 79 75 76 †

Maryland

73 67 78 73 73 77

Massachusetts

76 72 78 77 77 82

Michigan

74 69 77 74 75 71

Minnesota

73 68 77 73 75 66

Mississippi

64 54 73 62 64 65

Missouri

69 62 75 69 69 71

Montana

65 56 71 64 65 †

Nebraska

68 62 72 68 70 67

Nevada

62 52 69 60 67 67

New Hampshire

75 70 78 75 75 †

New Jersey

68 59 75 67 69 76

New Mexico

63 55 66 64 66 †

New York

70 65 75 70 72 70

North Carolina

71 64 77 71 73 69

North Dakota

67 61 72 67 68 †

Ohio

68 61 75 67 69 68

Oklahoma

64 54 73 62 65 68

Oregon

72 66 77 72 72 †

Pennsylvania

70 66 72 72 71 68

Rhode Island

75 70 79 76 77 75

South Carolina

72 62 80 70 72 71

South Dakota

69 63 74 69 70 †

Tennessee

70 60 77 69 71 63

Texas

62 53 71 60 68 68

Utah

69 63 73 70 72 †

Vermont

71 65 72 71 71 †

Virginia

70 63 75 70 70 72

Washington

72 65 77 72 73 71

West Virginia

68 61 74 67 69 66

Wisconsin

74 69 77 75 75 82

Wyoming

60 50 67 58 61 †

Puerto Rico 58 48 70 55 † †

*Blood stool test, sigmoidoscopy, or colonoscopy in the past 1, 5, and 10 years, respectively. †Estimate not presented due to instability. Note: Estimates are age adjusted

to the 2000 US standard population and do not distinguish between examinations for screening and diagnosis. Puerto Rico not included in ranges or medians.

Source: Behavioral Risk Factor Surveillance System, 2018.

26 Colorectal Cancer Facts & Figures 2020-2022

The National Colorectal Cancer Roundtable (NCCRT), a

coalition of public, private, and voluntary organizations

and individuals established in 1997 by the American

Cancer Society and the CDC to promote CRC screening,

has produced evidence-based toolkits for policy makers,

communities, health systems, and health care providers

to help improve CRC screening uptake.

270, 271

Other efforts

include the CDC’s Colorectal Cancer Control Program

(CRCCP), which uses multicomponent interventions to

increase CRC screening among low-income, underinsured,

or uninsured individuals and certain racial and ethnic

groups, in particular. During its first year (2015-2016),

CRC screening prevalence increased by 4.4% in clinics

receiving CRCCP funds, resulting in an additional 24,100

people screened.

272

Integrated health systems have

improved CRC screening participation and reduced

CRC incidence and mortality by implementing patient

reminders and mailed FIT kits.

273

Mailed outreach FIT

programs may also be effective in community health

center settings, which historically have low CRC screening

rates and limited resources.

274

On a broader scale, provisions of the Patient Protection

and Affordable Care Act (ACA) removed some barriers to

screening. For example, CRC screening increased faster

in states that adopted the ACA provision to expand

Medicaid eligibility compared to those that did not.

275

The ACA also reduced or eliminated out-of-pocket

screening costs for those who are insured, although

loopholes remain.

276

All recommended screening options,

including colonoscopy, are covered without cost sharing

for people with Medicare insurance and most commercial

insurance plans. However, the required follow-up

colonoscopy for a positive stool test is often coded as a

diagnostic procedure, resulting in out-of-pocket costs for

patients. In addition, Medicare still imposes cost sharing

on beneficiaries who have a polyp removed during a

screening colonoscopy, undermining efforts to improve

CRC screening, particularly among low-income patients

who are at highest risk for CRC.

277

Visit

cancer.org/colonmd

for more information on programs

and resources aimed at increasing CRC screening.

Colorectal Cancer Treatment

Treatment for CRC has advanced rapidly over the past

several decades, particularly for advanced disease.

76, 278

However, it has also become increasingly clear that

outcomes vary widely based on tumor-specific molecular

features, tumor location, and patient characteristics.

279-281

Treatment decisions are made by patients with their

physicians after considering the best options available

for their tumor characteristics along with the risks and

benefits associated with each.

Colon cancer

Most people with colon cancer will have some type of

surgery to remove the tumor. Adjuvant chemotherapy

(given after surgery) may also be used. Radiation is used

less often to treat colon cancer.

Carcinoma in situ

Carcinoma in situ is malignant cancer that has not

spread beyond the layer of cells in which it began.

Surgery to remove the growth of abnormal cells may be

accomplished by polyp removal through a colonoscope

(polypectomy) or more invasive surgery. Resection of a

segment of the colon may be necessary if the tumor is too

large to be removed by local excision or if cancer cells are

found after the polyp is removed.

Localized stage

Localized stage refers to invasive cancer that has

penetrated into (but not completely through) the wall

of the colon. Surgical resection to remove the cancer,

together with a length of normal colon on either side of

the tumor and nearby lymph nodes, is the standard

treatment.

Colorectal Cancer Facts & Figures 2020-2022 27

Regional stage

Regional stage describes cancers that have grown

through the wall of the colon and/or spread to nearby

lymph nodes. If the cancer has not spread to nearby

lymph nodes, surgical resection to remove the tumor and

nearby colon and surrounding lymph nodes may be the

only treatment needed. If the cancer is likely to come back

because it has spread to other tissues or has high-risk

characteristics, chemotherapy may also be recommended.

If the cancer has spread to nearby lymph nodes, surgical

resection is usually followed by chemotherapy. Adjuvant

chemotherapy based on the drug fluorouracil (5-FU) is

typically used in patients with stage III or high-risk stage

II disease who are in otherwise good health.

282

Oxaliplatin

is often part of adjuvant chemotherapy as well.

283

However, some patients may not tolerate this regimen

given its toxicity, and there is growing appreciation for

the need to confine its use to patients who are most likely

to benefit.

76, 284, 285

Adjuvant chemotherapy for colon cancer

is as effective in patients ages 70 and older (almost half of

all patients) who are otherwise as healthy as in younger

patients, although certain drugs (e.g., oxaliplatin) may be

avoided to limit toxicity. However, studies indicate that

individuals 75 years of age and older are far less likely

than younger patients to receive this treatment.

76, 286

Distant stage

At this stage, the cancer has spread to distant organs and

tissues, such as the liver, lungs, peritoneum (lining of the

abdomen), or ovaries. When surgery is performed, the

goal is usually to relieve or prevent blockage of the colon

and to prevent other local complications. If there are only

a few metastases to the liver or lungs, surgery to remove

these, as well as the colon tumor, may improve survival.

Chemotherapy and targeted therapies may be given alone

or in combination to relieve symptoms and prolong

survival. A number of targeted therapies have been

approved in recent years by the US Food and Drug

Administration to treat metastatic CRC. Some of these

drugs inhibit new blood vessel growth to the tumor by

targeting a protein called vascular endothelial growth

factor (VEGF). Others interfere with cancer cell growth

by targeting the epidermal growth factor receptor

(EGFR) or other proteins. Genetic testing of tumors is

important because those with certain mutations (e.g.,

KRAS, NRAS, or BRAF) largely do not respond to these

drugs.

287

Immunotherapy drugs are also now approved to

treat a small portion of CRCs.

Rectal cancer

Surgery is usually the main treatment for rectal cancer,

often accompanied by chemotherapy and radiation

before and/or after surgery to reduce the risk of spread

and recurrence. The chemotherapy drugs used in the

treatment of rectal cancer are largely the same as those

used for colon cancer.

Carcinoma in situ

Treatment options include polypectomy (polyp removal),

local excision, or full-thickness rectal resection. This

resection may be carried out through the anus. No further

treatment is needed.

Localized stage

At this stage, the cancer has grown through the first layer

of the rectum into deeper layers, but has not spread

outside the rectal wall. Some small localized rectal

cancers may be treated by removal through the anus,

without an abdominal incision. For other tumors,

depending on the location, surgery may involve removal

of the cancer and some surrounding normal tissue

through one or more small abdominal incisions. For

cancers close to the anus, surgery may require removal

of the anus and the sphincter muscle, so a permanent

colostomy is needed (see next section for information

about colostomy). In most cases, no further treatment is

needed unless the tumor has high-risk features. Patients

who are not candidates for surgery may be treated with

radiation therapy.

Regional stage

At this stage, the cancer has grown through the wall of

the rectum, and may have spread into nearby tissues

and/or lymph nodes. Patients with regional-stage disease

28 Colorectal Cancer Facts & Figures 2020-2022

are increasingly treated with chemotherapy and radiation

(chemoradiation) before surgery. Some patients also

receive chemotherapy after surgery, although the potential

benefits are debated.

288-290

Distant stage

At this stage, the cancer has spread to distant organs and

tissues, such as the liver or lung. In rare cases, the cancer

can be successfully treated by removing all of the tumors

with surgery, along with other treatments. Otherwise,

palliative treatments (surgery, chemotherapy, and/or

radiation therapy) are used to relieve, delay, or prevent

symptoms and prolong life. Similar to colon cancer, a

number of targeted therapies have been approved to treat

select metastatic rectal cancers, including VEGF and

EGFR inhibitors.

Colostomy

When a section of the colon or rectum is removed during

surgery, the healthy parts can usually be reconnected,

allowing the patient to eliminate waste normally. When

reconnection is not immediately possible, the surgeon

connects the colon to an opening (stoma) that is made

in the skin of the abdomen, allowing waste to leave the

body. The surgical procedure to create an opening in the

body for the elimination of waste is called an ostomy.

When the stoma is connected to the colon it is called a

colostomy; when the stoma is connected to the small

intestine it is called an ileostomy. Usually a flat bag, held

in place by a special adhesive, fits over the stoma to

collect waste.

Most patients with CRC who require a colostomy need it

only temporarily, until the colon or rectum heals from

surgery. After healing takes place, usually in 6 to 8 weeks,

the surgeon reconnects the ends of the colon and closes

the stoma. A permanent colostomy is necessary more

often for rectal than for colon cancer patients.

A person with an ostomy learns to care for it with help

from doctors, nurses, and enterostomal therapists

(health professionals trained to care for people with

stomas). If surgery is expected to result in an ostomy, an

enterostomal therapist will often visit the patient before

surgery to explain what to expect and how to care for the

ostomy. They also provide information about lifestyle

issues, including emotional, physical, and sexual

concerns, as well as resources and support groups.

Side effects of colorectal cancer

treatment

Although many side effects that occur during cancer

treatment are temporary, some persist after treatment

has ended (long-term effects) and others do not arise

until several years later (late effects). Side effects should

be discussed with a clinician because treatment options

are often available. For example, antiemetic drugs can

prevent or lessen nausea and vomiting following

chemotherapy. To manage the long-term and late

effects of treatment, the American Cancer Society has

established guidelines to aid primary care clinicians in

delivering risk-based care to CRC survivors (see sidebar).

291

Short- and long-term effects of specific modes of CRC

treatment are briefly described in the following sections.

For more information on late and long-term effects of

cancer and its treatment, visit

cancer.org/treatment/

treatments-and-side-effects.html

Surgery

The time needed to heal after surgery is different for each

person. Patients often have some pain for the first few

days that can usually be controlled with medication. It

can take a few days to be able to eat normally again.

About 25% of patients experience a delay in bowel

function (postoperative ileus) because of bowel stress

caused by surgical manipulation, which may require an

extended hospital stay.

292

Patients are monitored for signs

of bleeding, infection, or other problems that require

immediate treatment.

Other side effects from surgery for CRC may include

fatigue, possibly for an extended period of time; frequent

or urgent bowel movements, diarrhea, constipation,

gas, and/or bloating, particularly among rectal cancer

patients; a temporary or permanent colostomy; and

urogenital/sexual dysfunction (e.g., erectile dysfunction

in men).

Colorectal Cancer Facts & Figures 2020-2022 29

Radiation therapy

Side effects of radiation therapy can include skin

irritation, nausea, diarrhea, rectal irritation and/or

painful inflammation, rectal bleeding, bladder

dysfunction (irritation, pain, and/or frequent urination),

fatigue, or sexual problems. Many of these side effects go

away after treatments are completed, but some, like

sexual problems and some degree of rectal and/or

bladder irritation, may be permanent. Late effects

include increased risk of bowel obstruction and fractures

in the bone at the base of the spine (the sacrum). In

addition, radiation to the pelvic area in women may

damage the ovaries, causing infertility. Fertility

counseling prior to treatment is recommended for

women for whom this is a concern (see Sexual function

and fertility, below). Radiation also increases the risk of

developing second cancers in exposed areas.

Chemotherapy

The chemotherapy drugs most often used in the

treatment of CRC are 5-fluorouracil (5-FU), capecitabine,

oxaliplatin, and irinotecan. Side effects depend on the

type and dosage of drugs, the length of treatment, and

individual patient characteristics. Some side effects are

temporary (e.g., hair loss), while others may persist after

treatment (e.g., numbness in the hands or feet). Some

patients may experience low blood cell counts because

chemotherapy can harm the blood-producing cells of the

bone marrow. This can increase the chance of infection

(due to a shortage of white blood cells), bleeding or

bruising after minor cuts or injuries (due to a shortage of

blood platelets), and fatigue or shortness of breath.

Targeted therapy

Targeted therapy is a newer class of drugs resulting from

an increased understanding of the molecular features of

cancer development. Targeted drugs for CRC (e.g., EGFR

and VEGF inhibitors) often have different but notable

side effects compared to conventional chemotherapy

drugs, such as dry skin or skin rash.

Sexual function and fertility

Many treatments for CRC directly or indirectly impact

sexual function and fertility in both male and female

patients.

293, 294

This is a particularly relevant issue for the

increasing number of affected young adults in their

reproductive years. The American Society for Clinical

Oncology clinical practice guidelines recommend that

fertility preservation be discussed with all new patients

at the time of diagnosis because efforts such as sperm

banking, embryo/oocyte cryopreservation (the freezing of

fertilized or unfertilized eggs), and ovarian transposition

(a surgical repositioning of the ovaries away from the

field of radiation) should be started far in advance of

treatment.

295

For more information, visit

cancer.org/

treatment/treatments-and-side-effects/physical-side-effects/

fertility-and-sexual-side-effects.html

American Cancer Society Colorectal

Cancer Posttreatment Survivorship

Care Guidelines

CRC patients have specific needs and concerns once

treatment ends. In 2015, a multidisciplinary expert

workgroup published evidence- and consensus-

based posttreatment care guidelines for clinicians to

aid in providing comprehensive, long-term care for

colorectal cancer survivors. These guidelines include

information on surveillance for cancer recurrence,

screening for new cancers, management of chronic

and late effects, and referrals for rehabilitation,

psychosocial and palliative care, or other specialty care.

Visit

cancer.org/health-care-professionals/american-

cancer-society-survivorship-guidelines/colorectal-

cancer-survivorship-care-guidelines.html

for full text of

the guidelines, as well as resources for clinicians.

30 Colorectal Cancer Facts & Figures 2020-2022

What Is the American Cancer Society Doing

about Colorectal Cancer?

Research

Colorectal cancer is an active area of scientific research;

studies span the cancer continuum from prevention and

early detection to treatment and beyond. As of August 1,

2019, the American Cancer Society was funding 78 grants

totaling more than $25 million in colorectal cancer

research. Examples of projects in which researchers in

the American Cancer Society Extramural Research

program are engaged include:

• Evaluating why certain colorectal cancers evade or

resist treatment

• Exploring new ways to prevent colorectal cancer by

manipulating gut microbiota

• Investigating whether increased consumption of

cooked dry beans, which have anti-inflammatory

and anti-cancer properties, could lower the risk of

colorectal cancer recurrence in survivors with obesity

• Understanding barriers to colonoscopy screening in

North and South Carolina

Examples of CRC research projects conducted within the

American Cancer Society Intramural Research program

include:

• Monitoring disparities in CRC screening, including

identifying medically underserved populations and

evaluating initiatives to reduce screening disparities

• Exploring the mechanisms underlying CRC

development, such as gene-environment interactions

• Analyzing disparities and emerging trends in

population-based CRC incidence and mortality rates

• Investigating factors associated with survival

following a CRC diagnosis

• Identifying the needs of CRC survivors as they

transition from active treatment and back into the

community care setting

• Developing population-based systems for monitoring

cancer patient-reported quality of life and treatment-

related side effects

Colorectal cancer screening

guidelines

Since 1980, the American Cancer Society has issued

evidence-based recommendations for CRC screening in

average-risk adults that are generally updated every 5

years. These recommendations are developed by an

independent Guideline Development Group of experts in

cancer epidemiology, primary care, and health services

research with the support of American Cancer Society

staff in the Center for Cancer Screening, the Intramural

Research program, and an ad hoc group of clinicians

with expertise in CRC. As part of the ongoing guideline

development process, American Cancer Society staff

monitor the medical and scientific literature for new

evidence that may support a change in the current

recommendations, as well as new information about

CRC screening that should be conveyed to clinicians

and target populations. The most recent update of the

American Cancer Society guideline for CRC screening

was published in 2018.

217

Strategies to reach the 80% in Every

Community nationwide goal

In 2014, the NCCRT launched the 80% by 2018 campaign

to raise CRC screening rates across the nation. Although

the nation as a whole did not achieve the 80% goal, it

was reached and even surpassed in some hospital and

community clinic settings, as well as in some health plans.

80% in Every Community is the new NCCRT campaign to

continue efforts to substantially reduce CRC as a major

public health problem by increasing colorectal screening

rates to 80% or higher in communities across the nation.

The NCCRT, established in 1997 by the American Cancer

Society and the Centers for Disease Control and

Colorectal Cancer Facts & Figures 2020-2022 31

Prevention, is a coalition of more than 100 member

organizations and individual experts dedicated to

reducing CRC incidence and mortality in the US through

coordinated leadership, strategic planning, and advocacy.

Over the past five years, more than 1,750 organizations

have committed to the shared goal of raising CRC

screening utilization. This initiative emphasizes evidence-

based screening activities that respond to individualized

needs, barriers, and motivations within a community.

Talking points, FAQs, press materials, downloadable

graphics, and more are available at

nccrt.org/80-in-every-

community

. The American Cancer Society is committed to

the 80% in Every Community goal as one of our major

initiatives and is implementing several key strategies in

support of this nationwide program, including playing a

major role as convener and leader of the effort.

Notably, our approximately 300-strong force of health

systems staff is playing a crucial role by engaging and

supporting key strategic partners – such as hospitals and

health systems, community health centers, state health

departments, corporate partners, payers, and state

and local coalitions – to encourage and support their

commitment to increasing the number of individuals

who are screened for colorectal cancer. Our staff work

with these partners to assist them in implementing

proven strategies that are known to increase CRC

screening rates, such as implementing provider and

patient reminders, helping providers assess and track

their screening rates, implementing quality screening

navigation, and using the power of the provider

recommendation. The American Cancer Society

Community Health Advocates implementing Nationwide

Grants for Empowerment and Equity (CHANGE)

program provides one avenue for health systems staff to

collaborate at the community level. CHANGE provides

both financial and technical assistance to federally

qualified health centers (FQHCs) and other community

partners to build capacity and implement interventions

to increase cancer screening rates among low income,

low education, and racially diverse populations. Since

2011, the American Cancer Society has awarded 252

grants to community-based partners to implement

evidence-based CRC interventions, reaching over one

million men and women with cancer prevention and

early detection education and outreach and providing

more than 332,000 CRC screening exams. CHANGE

grant-funded FQHCs have been found to increase

screening rates faster than nonfunded FQHCs.

Additionally, the American Cancer Society works to

unify and magnify effective communication to the public

about the value of CRC screening through multiple

channels. These activities include the development and

implementation of targeted traditional and social media

strategies to motivate unscreened consumers to get

screened. Finally, we lead by example, encouraging our own

staff and volunteers to be up to date with recommended

cancer screening tests. Through these actions, the

American Cancer Society is working to leverage the

energy of multiple and diverse partners to make history

and achieve this remarkable public health goal.

Advocacy

Our nonprofit, nonpartisan advocacy affiliate, the

American Cancer Society Cancer Action Network

(ACS CAN), is involved in advocacy efforts at both the

federal and state levels that increase access to quality

CRC screening, treatment, and care for all adults. In

partnership with the American Cancer Society, the

Centers for Disease Control and Prevention (CDC), and

the National Colorectal Cancer Roundtable, as well as

over 1,750 other organizations, ACS CAN hopes to reach

the goal of achieving 80% or higher CRC screening rates

in every community. Following are some of the efforts the

American Cancer Society and ACS CAN are involved in to

help reach that goal:

• Implementing the provisions in the Patient Protection

and Affordable Care Act, more commonly referred to

as the Affordable Care Act or ACA. The reforms in

the ACA, which was signed into law in March 2010,

represent a profound structural change in how

insurance operates and how consumers and patients

use the health insurance system. ACS CAN and the

American Cancer Society have a significant impact

at the federal and state levels through our advocacy

work, which urges policy makers to implement the

law to ensure that all Americans have access to

32 Colorectal Cancer Facts & Figures 2020-2022

evidence-based prevention, early detection, and

treatment services critical to CRC patients. In

particular, ACS CAN has advocated for expansion of

Medicaid in all 50 states for those individuals up to

138% of the federal poverty level, as it was originally

intended by the ACA. This would ensure that low-

income, uninsured, and underinsured Americans

will have access to the same CRC services as those

in private and other public insurances.

• Advocating for clarification on ACA-required coverage

of CRC screening modalities as recommended by

the United States Preventive Services Task Force

(USPSTF). This includes clarifying that there should be

no cost sharing requirements for a colonoscopy that is

ordered to complete the screening process following

a positive CRC stool-based screening test (follow-up

colonoscopy), cost sharing for short interval screening

following the removal of adenomatous polyps during a

screening colonoscopy, and other ambiguous coverage

issues related to CRC screening.

• Supporting the work and maintaining funding for the

CDC’s Colorectal Cancer Control Program (CRCCP),

which currently provides funding to 30 grantees

across the US. The CRCCP’s goal is to increase

CRC screening rates in targeted populations by

implementing evidence-based, system-level

interventions through partnerships with health

systems. The program provides grants for both

population-based education and awareness campaigns

and efforts to improve access to vital CRC screening

tests and follow-up services for at-risk low-income,

uninsured, and underinsured individuals between

the ages of 50 and 75.

• Advocating for passage of the Removing Barriers to

Colorectal Cancer Screening Act of 2019, which will

ease the financial burden of people living on a fixed

income by allowing Medicare beneficiaries to receive

screenings without coinsurance, even when a polyp is

removed. This legislation would help increase

screening rates and reduce the incidence of CRC.

• Advocating for state legislation to ensure insurance

coverage in each state aligns with the American

Cancer Society’s evidence-based CRC guideline,

which recommends average-risk adults begin

screening at age 45

• Engaging governors, mayors, and state legislators to

inform them about the 80% in Every Community

initiative, urging them to help make CRC screening

a priority. Specifically, ACS CAN is urging state and

city governments to work across all sectors to increase

screening rates by eliminating cost and access barriers

to screening and by investing in or creating a state

CRC screening and control program.

Sources of Statistics

New cancer cases. The estimated number of CRC cases

in the US in 2020 was projected using a spatiotemporal

model based on incidence data from 50 states and the

District of Columbia for the years 2002 to 2016 that met

the North American Association of Central Cancer

Registries’ (NAACCR’s) high-quality data standards for

incidence. For more information on this method, please

see Zhu et al.

296

Incidence rates. Incidence rates are defined as the number

of people newly diagnosed with cancer during a given time

period per 100,000 population at risk. CRC incidence rates

for the US were calculated using case data from the

Surveillance, Epidemiology, and End Results (SEER)

Program of the National Cancer Institute, the National

Program of Cancer Registries of the Centers for Disease

Control and Prevention, and NAACCR, and population

data collected by the US Census Bureau. Incidence rates

for Alaska Natives are based on cases reported by the

Alaska Native Tumor Registry (ANTR) of the SEER

Program; rates for American Indians excluding Alaska

Natives are based on NAACCR Purchased/Referred Care

Delivery Area (PRCDA) county regions excluding the

ANTR. Incidence rates were age adjusted to the 2000 US

standard population and adjusted for delays in reporting

when possible. Trends exclude appendix.

Colorectal Cancer Facts & Figures 2020-2022 33

Estimated cancer deaths. The estimated number of CRC

deaths in the US in 2020 was calculated by fitting the

actual number of CRC deaths from 2003 through 2017 to

a statistical model that forecasts the number of deaths

three years ahead. The actual number of deaths was

obtained from the National Center for Health Statistics

(NCHS) at the Centers for Disease Control and Prevention.

For more information on this method, please see Chen

et al.

297

Mortality rates. Mortality rates, or death rates, are

defined as the number of people who die from cancer

during a given time period per 100,000 population.

Mortality rates are based on counts of cancer deaths

compiled by NCHS and population data from the US

Census Bureau. Death rates for Alaska Natives are based

on deaths occurring in the Alaska Community Health

Service Delivery Area region. Due to data limitations,

there may be a small degree of cross-contamination

between rates for American Indians and Alaska Natives

where they are presented separately. Death rates are age

adjusted to the 2000 US standard population.

Survival. Relative and cause-specific (herein referred to

as cancer-specific) survival rates were calculated using

data from the SEER registries. Relative survival rates

account for normal life expectancy by comparing overall

survival among a group of cancer patients to that of

people not diagnosed with cancer who are of the same

age, race, and sex. Cancer-specific survival is the

probability of not dying from a specific cancer (e.g.,

colorectal) within a specified time period following a

diagnosis. Cancer-specific survival was used for rates by

race and ethnicity because reliable estimates of normal

life expectancy historically have not been available by

Hispanic ethnicity or for Asians/Pacific Islanders and

American Indians/Alaska Natives.

Screening. The national prevalence of CRC screening

was estimated from the National Health Interview Survey

(NHIS) 2018 data file, obtained from NCHS, released in

2019 (

cdc.gov/nchs/nhis.htm

). The NHIS is conducted by the

US Census Bureau and is designed to provide national

prevalence estimates on health characteristics such as

cancer screening behaviors. Data are collected through

in-person interviews.

CRC screening prevalence by state was estimated from

the 2018 Behavioral Risk Factor Surveillance System

(BRFSS) public use data files, obtained from the National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and Prevention.

The BRFSS is a telephone survey designed to provide

state prevalence estimates of health behaviors and was

conducted by state health departments.

Important note about estimated cases and deaths.

The projected number of new cancer cases and deaths

for the current year are model based. For this reason,

we discourage the use of our estimates to track cancer

trends. Age-standardized incidence and mortality rates

are used to track cancer incidence and mortality trends.

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Acknowledgments

Rick Alteri; Joseph Anderson; Cammie Barnes; Durado Brooks; Lynn Butterly; Michelle DelFavero;

Carol DeSantis; Ted Gansler; Eric Jacobs; Mamta Kalidas; Marji McCullough; Michael O’Brien;

Alpa Patel; Scott Simpson; Robert Smith; Lindsey Torre; Dana Wagner; and Ann Zauber.

Colorectal Cancer Facts & Figures is a triennial publication of the American Cancer Society, Atlanta, Georgia.

For more information, contact:

Rebecca Siegel, MPH

Kimberly Miller, MPH

Ahmedin Jemal, DVM, PhD

No. 861720

The American Cancer Society’s mission

is to save lives, celebrate lives,

and lead the fight for a world without cancer.