The Best Screening Colon Cancer Screening Test Is the One You Actually Get

The American Cancer Society just expanded its recommended options for colorectal cancer screening. Whether your insurance will cover them is another matter.

• Colonoscopy is still the gold standard. Most people don’t get one.

• If screening catches it early, 90% survive.

• More options only matter if people can afford them.

Colonoscopy is still the gold standard. Most people don’t get one.

The American Cancer Society just released updated screening guidelines. If you’re 45 or older, you should be screened for colorectal cancer. A colonoscopy is still the best test. Doctors can see polyps and remove them on the spot, years before they turn cancerous. Nearly all colon cancers start as polyps. The lead time can be 10 to 15 years. Catch it early, remove it, and you’ve prevented the cancer entirely.

About one in three eligible Americans isn’t getting screened at all. Colonoscopies require prep, sedation, a chaperone, and time off work. For many people, those barriers are enough to skip it.

So the ACS is now saying: give patients a real choice. The updated guideline adds two categories of alternatives. The first is at-home stool tests. The newer multi-target versions, Cologuard (which tests for DNA markers) and ColoSense (which tests for RNA markers), look for blood and molecular fragments shed by tumors and precancerous growths. A 2024 study in the New England Journal of Medicine found Cologuard detected 94% of colorectal cancers. It was less sensitive for precancerous polyps, picking up about 43%. That matters. But done every three years, these tests still catch cancers at a stage when treatment works.

The second category is a blood test. Shield, made by Guardant Health, detects tumor DNA in the blood. It’s convenient — a simple blood draw at the doctor’s office. But it misses 87% of precancerous lesions and has limited detection of early-stage cancers. The ACS recommends it only for people who refuse both colonoscopy and stool tests. A last resort is better than no test at all.

If screening catches it early, 90% survive.

When colorectal cancer is found at an early stage, 90% of patients are alive five years later. Screening also prevents cancers from developing in the first place, by catching and removing polyps before they become malignant.

If you get a colonoscopy, the schedule is once every 10 years. Multi-target stool tests, every three years. Simpler stool tests like FIT, every year. Any positive result from a stool or blood test means you need a colonoscopy to follow up.

Colorectal cancer is now the leading cause of cancer death in Americans under 50, with rates climbing about 3% a year. Each generation born after 1950 carries progressively higher risk. Something in our environment — possibly diet, obesity, alcohol consumption, changes to the gut microbiome, microplastics, endocrine disruptors — is driving the trend, but researchers don’t have a definitive answer yet.

The ACS lowered the recommended screening age from 50 to 45 in 2018. Screening rates in the 45-to-49 age group are still only about 33%.

More options only matter if people can afford them.

The ACS guidelines run into a coverage problem.

Under the Affordable Care Act, private insurers must cover preventive screenings recommended by the U.S. Preventive Services Task Force, with no out-of-pocket cost to patients. The USPSTF’s current recommendation, issued in 2021, includes colonoscopy, FIT, and the original Cologuard. Those are covered.

But ColoSense and Shield are not on the USPSTF list. Neither is the next-generation version of Cologuard. Medicare has made its own coverage decisions for older adults. But for the under-65 population — the same group seeing the fastest rise in colorectal cancer — private insurance coverage for these newer tests depends on whether their insurer decides to cover them voluntarily.

The USPSTF would need to meet, review the evidence, and update its recommendation for these tests to ensure coverage. That is not happening. The task force hasn’t met in over a year. Three consecutive meetings were canceled or postponed under HHS Secretary Robert F. Kennedy Jr., half the panel’s 16 seats are empty, and Kennedy fired the chair and vice chair on May 11. He is seeking new members, with a start date expected in July.

The ACS doesn’t name the USPSTF directly, but the signal is hard to miss. Lisa Lacasse, president of the ACS Cancer Action Network, said, “expanding screening options only matters if people can actually access them. Coverage and affordability remain among the biggest factors in whether eligible individuals get screened for colorectal cancer.” In other words, recommending new tests doesn’t help if people have to pay out of pocket for them. The USPSTF is the only body that can change that.

The ACS can recommend all the tests it wants. Until the federal body that triggers insurance coverage is allowed to function, many of those options won’t be covered.