Low Colorectal Cancer Screening Among Adults Aged 45-49 Years in the US, 2023

ABSTRACT

Objectives: Colorectal cancer (CRC) screening has been recommended for US adults aged 45 to 49 years. This study examined the rate and predictors of CRC screening in 2023 among adults aged 45 to 49 years vs adults aged 50 to 54 years.

Study Design: Retrospective observational study.

Methods: All adults aged 45 to 54 years in the 2023 National Health Interview Survey were included. The rate of CRC screening was calculated for the age groups 45 to 49 years and 50 to 54 years. Multivariate logistic regression was used to examine the age group difference in CRC screening, controlling for sex, race/ethnicity, immigrant status (vs born in the US), college education, insurance (vs uninsured), and wellness visit within 1 year.

Results: The rate of CRC screening was significantly lower among adults aged 45 to 49 years than among adults aged 50 to 54 years (36.1% vs 55.6%; P < .001). The age group difference in CRC screening persisted in multivariate logistic regression (aged 45-49 vs 50-54 years: OR, 0.44; 95% CI, 0.39-0.51). Other predictors of CRC screening included US born, college education, insurance, and wellness visit within 1 year. Sensitivity analysis on colonoscopy use confirmed these findings (aged 45-49 vs 50-54 years: OR, 0.48; 95% CI, 0.42-0.55).

Conclusions: Less than half of US adults aged 45 to 49 years were up to date on CRC screening in 2023. Age group–specific interventions may improve CRC screening in the US.

Am J Manag Care. 2026;32(3):e97-e99. https://doi.org/10.37765/ajmc.2026.89902

Takeaway Points

• Less than half of US adults aged 45 to 49 years were up to date on colorectal cancer (CRC) screening in 2023, a significantly lower rate than for adults aged 50 to 54 years.
• Other predictors of CRC screening included US born, college education, insurance, and a wellness visit within 1 year.
• Use of colonoscopy was similarly low among adults aged 45 to 49 years.
• Age group–specific interventions may improve CRC screening in the US.

Colorectal cancer (CRC) screening was recommended for adults aged 45 to 49 years in the US by the American Cancer Society (ACS) in May 2018, followed by the US Preventive Services Task Force (USPSTF) in May 2021.^1,2 Data from previous studies showed low rates of CRC screening in the US, especially for adults aged 45 to 49 years.^3-6 A recent study showed that CRC screening uptake increased among privately insured adults aged 45 to 49 years after May 2021.⁷ Demographic and socioeconomic factors influence the use of CRC screening, including age, sex, race/ethnicity, education, insurance coverage, and primary care access.^8-11 This population-based study using the most recent (2023) National Health Interview Survey (NHIS) examined the rate and predictors of CRC screening among adults aged 45 to 49 years in the US compared with adults aged 50 to 54 years.

DATA AND METHODS

The NHIS is the principal source of information on the health of the civilian noninstitutionalized population in the US.¹² In the 2023 NHIS, CRC screening was defined as use of colonoscopy within 10 years, sigmoidoscopy within 5 years, CT (virtual) colonography within 5 years, Cologuard within 3 years, or fecal occult blood test within 1 year.¹³ Sensitivity analysis examined the use of colonoscopy within 10 years, as colonoscopy is the predominant CRC screening test in the US.

The demographic and socioeconomic variables of interest included age, sex, race/ethnicity, immigrant status (vs born in the US), college education, insurance (vs uninsured), and wellness visit within 1 year. The χ² test was used in testing statistical differences of categorical variables. In addition, we used multivariate logistic regression analysis to control for demographic and socioeconomic factors and examine age group differences (45-49 vs 50-54 years) in CRC screening and colonoscopy use.

RESULTS

The 2023 NHIS included 1900 adults aged 45 to 49 years and 2080 adults aged 50 to 54 years (eAppendix [available at ajmc.com]). Among adults aged 45 to 49 years compared with adults aged 50 to 54 years, there were fewer non-Hispanic White individuals (59.4% vs 64.5%; P < .001), more Hispanic individuals (19.8% vs 16.0%; P < .01), more Asian individuals (7.5% vs 5.6%; P < .05), more immigrants (29.7% vs 26.1%; P < .05), and fewer individuals with wellness visits within 1 year (76.7% vs 80.9%; P < .01).

The rate of CRC screening was significantly lower among adults aged 45 to 49 years than adults aged 50 to 54 years (36.1 vs 55.6%; P < .001) (Figure). The rate of colonoscopy use within 10 years was similarly lower among adults aged 45 to 49 years compared with adults aged 50 to 54 years (27.2% vs 44.2%; P < .001).

In the multivariate logistic regression, there was a significant difference in CRC screening for adults aged 40 to 49 years vs adults aged 50 to 54 years (OR, 0.44; 95% CI, 0.39-0.51) (Table). The other significant predictors of CRC screening included immigrant status (OR, 0.60; 95% CI, 0.50-0.73), college education (OR, 1.84; 95% CI, 1.60-2.13), insurance (OR, 3.73; 95% CI, 2.69-5.18), and wellness visit within 1 year (OR, 3.93; 95% CI, 3.24-4.77). Sensitivity analysis on colonoscopy use confirmed the robustness of these findings (aged 45-49 vs 50-54 years: OR, 0.48; 95% CI, 0.42-0.55), with the additional finding of less colonoscopy use in Asian individuals (OR, 0.70; 95% CI, 0.50-0.98).

DISCUSSION

In this population-based study of US adults aged 45 to 49 years in 2023, less than half were up to date on CRC screening, although this rate is higher than in prior years before the ACS and USPSTF recommendations.^3,4,7 In addition, the rate of CRC screening was significantly lower among adults aged 45 to 49 years than adults aged 50 to 54 years. Therefore, CRC prevention strategies targeting adults aged 45 to 49 years, in addition to traditionally disadvantaged groups, may reduce the burden of CRC.

Limitations

Despite the use of the most recent (2023) NHIS that specifically inquired about CRC screening and the use of multivariate logistic regression to control for demographic and socioeconomic confounders, this study has notable limitations. The lack of detailed health information did not allow the exclusion of adults with significant comorbidities who are not candidates for CRC prevention, leading to potential underestimation of CRC screening. In addition, because recall for colonoscopy can be 10 years, older patients are more likely to be up to date with screening from prior exposure. Finally, this study could not answer the important question of why individuals did not undergo CRC screening, including but not limited to lack of knowledge that 45 years is the recommended age to start CRC screening, lack of medical provider recommendation, individual procrastination, concerns about costs, and language or transportation barriers.

CONCLUSIONS

CRC screening remained low among US adults aged 45 to 49 years in 2023, especially compared with adults aged 50 to 54 years. Age group–specific interventions may improve CRC screening in the US.

Author Affiliations: Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ; Cooper Digestive Health Institute, Mt Laurel, NJ.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; statistical analysis; provision of patients or study materials; obtaining funding; administrative, technical, or logistic support; and supervision.

Address Correspondence to: Yize Richard Wang, MD, PhD, Cooper Digestive Health Institute, 501 Fellowship Rd, Ste 101, Mt Laurel, NJ 08054. Email: wang-yize@cooperhealth.edu.

REFERENCES

1. Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250-281. doi:10.3322/caac.21457

2. Lin JS, Perdue LA, Henrikson NB, Bean SI, Blasi PR. Screening for Colorectal Cancer: An Evidence Update for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality; 2021.

3. Liu PH, Singal AG, Murphy CC. No increase in colorectal cancer screening in 2019 after American Cancer Society recommends starting screening at age 45. Clin Gastroenterol Hepatol. 2023;21(7):1947-1949.e2. doi:10.1016/j.cgh.2022.05.030

4. Star J, Siegel RL, Minihan AK, Smith RA, Jemal A, Bandi P. Colorectal cancer screening test exposure patterns in US adults 45 to 49 years of age, 2019-2021. J Natl Cancer Inst. 2024;116(4):613-617. doi:10.1093/jnci/djae003

5. Ebner DW, Finney Rutten LJ, Miller-Wilson LA, et al. Trends in colorectal cancer screening from the National Health Interview Survey: analysis of the impact of different modalities on overall screening rates. Cancer Prev Res (Phila). 2024;17(6):275-280. doi:10.1158/1940-6207.CAPR-23-0443

6. Cheney C, Parish A, Niedzwiecki D, et al. Colorectal cancer screening uptake and adherence by modality at a large tertiary care center in the United States: a retrospective analysis. Curr Med Res Opin. 2024;40(3):431-439. doi:10.1080/03007995.2024.2303090

7. Siddique S, Wang R, Yasin F, et al. USPSTF colorectal cancer screening recommendation and uptake for individuals aged 45 to 49 years. JAMA Netw Open. 2024;7(10):e2436358. doi:10.1001/jamanetworkopen.2024.36358

8. Jerant AF, Fenton JJ, Franks P. Determinants of racial/ethnic colorectal cancer screening disparities. Arch Intern Med. 2008;168(12):1317-1324. doi:10.1001/archinte.168.12.1317

9. May FP, Almario CV, Ponce N, Spiegel BMR. Racial minorities are more likely than whites to report lack of provider recommendation for colon cancer screening. Am J Gastroenterol. 2015;110(10):1388-1394. doi:10.1038/ajg.2015.138

10. Kane WJ, Fleming MA II, Lynch KT, et al. Associations of race, ethnicity, and social determinants of health with colorectal cancer screening. Dis Colon Rectum. 2023;66(9):1223-1233. doi:10.1097/DCR.0000000000002371

11. Bayly JE, Trivedi S, Mukamal KJ, Davis RB, Schonberg MA. Limited English proficiency and reported receipt of colorectal cancer screening among adults 45-75 in 2019 and 2021. Prev Med Rep. 2024:39:102638. doi:10.1016/j.pmedr.2024.102638

12. National Health Interview Survey. CDC. Accessed February 6, 2026. https://www.cdc.gov/nchs/nhis/index.htm

13. 2023 National Health Interview Survey (NHIS) Questionnaire. CDC. Accessed February 6, 2026. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Survey_Questionnaires/NHIS/2023/EnglishQuest-508.pdf