Cologuard vs. Colonoscopy: A GI Doctor Reveals Which Colon Cancer Screening Is Better for Women 45+

It’s a rite of passage we don’t look forward to: Once we turn 45, it’s recommended that we get a colonoscopy to screen for polyps and colon cancer. This is especially important as rates of the disease are increasing among younger adults. And it’s as pressing an issue as ever for those of us in midlife. Beloved Home Alone and Schitt’s Creek star Catherine O’Hara reportedly passed away at 71 from a pulmonary embolism, with rectal cancer listed as an underlying cause. And Dawson’s Creek actor James Van Der Beek died at 48 following a battle with colorectal cancer. But what about the prescription at-home stool test, Cologuard, which also screens for cancer—when might this less invasive option be warranted? We asked a leading gastroenterologist to explain the pros and cons of Cologuard vs. colonoscopy screenings and how to pinpoint which one might be right for you.

Cologuard vs. colonoscopy: Which is more accurate?

When comparing these two colorectal cancer screenings, one thing that’s definitely not up for debate: “A colonoscopy is clearly better,” declares Anish A. Sheth, MD, chief of gastroenterology at Penn Medicine, Princeton Medical Center and author of What’s Your Poo Telling You? “It’s better at picking up polyps, and it has a much longer track record [than Cologuard].”

It’s also worth noting that Cologuard tests typically have a higher false positive rate than more traditional colonoscopy screenings. The real question, then, is when is Cologuard sufficient?

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When a Cologuard test might be right for you

Here, Dr. Sheth reveals two groups of people who might consider the at-home, stool-based test, emphasizing that this is only for people without symptoms. “We’re not talking about anyone experiencing blood in their stool, abdominal pain or changes in bowel habits.”

If you’re 75 or older

The ideal person for Cologuard is someone age 75 or older who is low-risk for colon cancer, reveals Dr. Sheth. “That likely means they’ve had one or two colonoscopies in the past with nothing remarkable found, and now they’re wondering what to do next for colon cancer prevention.”

“In this group, because they’re low-risk and largely because the risks of colonoscopy can increase somewhat with age [particularly because of anesthesia], a less invasive option as a first step is reasonable,” he acknowledges. “So for patients roughly between ages 75 and 85, Cologuard is worth discussing with their doctor.”

If you can’t undergo a colonoscopy

The other category is people for whom a colonoscopy isn’t a good option for various reasons, Dr. Sheth continues. “I think Cologuard works well as a second-line option for people who are unwilling or unable to undergo colonoscopy—often because they can’t get past the idea of the prep, the anesthesia or the whole process. In these cases, it’s clearly better to do something rather than nothing.”

“We always say that the best screening test is the one a patient will actually do,” he emphasizes. “You don’t want to give someone only one option if it means they’ll avoid screening altogether.”

Other people who might opt for Cologuard over a colonoscopy are those with significant heart disease or lung conditions, for whom anesthesia could be dangerous. “Sometimes, it’s just not appropriate to screen someone for colon cancer [with a colonoscopy] because the test itself could pose too great a risk,” says Dr. Sheth, adding that screening for cancerous and precancerous cells is most appropriate for people with a reasonable life expectancy who could benefit from detecting a small polyp.

When a colonoscopy is the best option for colon cancer screening

You already know a colonoscopy is the gold standard for colon cancer screening. Here’s why—and who should make it their first choice.

If you’re in your 40s or 50s

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While Cologuard is over 90 percent effective at detecting colon cancer and very large polyps, it’s only about 30 percent effective at finding the smaller polyps that can lead to a tumor. “That’s why if you’re in your 40s or 50s and have never had a colonoscopy before, [Cologuard] just isn’t good enough to buy you the 10-year [peace of mind] you would get from a colonoscopy,” he says.

If you’re at higher risk for colon cancer

“People with a history of colon cancer or inflammatory bowel disease [IBD] are the two big categories of people we screen more frequently, and we start earlier,” he reveals. People at average risk or who have a family history of colon cancer would also benefit more from a colonoscopy vs. a Cologuard test.

The bottom line on Cologuard vs. colonoscopy

According to the National Cancer Institute’s Cancer Trends Progress Report, only a little more than 70 percent of adults over 50 have been screened for colon cancer. “The biggest benefit of Cologuard is reaching the remaining 25 to 30 percent who haven’t yet been screened,” says Dr. Sheth. “Sometimes people say, ‘Okay, I’ll do the stool test,’ when they might have put off other testing. That, I think, is the real value of Cologuard: capturing the people we still haven’t reached.”