Colorectal cancer statistics, 2026

Abstract

Colorectal cancer (CRC) is the second most common cancer‐related death in the United States and ranks first in adults younger than 50 years. Every 3 years, the American Cancer Society reports on CRC occurrence based on incidence from population‐based cancer registries and mortality from the National Center for Health Statistics. Overall, CRC incidence declined by 0.9% annually during 2013–2022 driven by decreases of 2.5% annually in adults aged 65 years and older. In sharp contrast, incidence rates increased by 3% annually in adults aged 20–49 years and by 0.4% annually in adults aged 50–64 years dominated by tumors in the distal colon and rectum. Consequently, overall rectal cancer incidence increased by 1% annually from 2018 to 2022 after decades of decline and now accounts for 32% of all CRC, up from 27% in the mid‐2000s. Increasing CRC incidence in adults aged 50–64 years was confined to regional and distant‐stage diagnosis (1.1%–1.3% annually during 2013–2022), likely contributing to an upturn in mortality in this age group of 1% annually since 2019 that was steepest (2.3% annually) in White individuals. Mortality has increased in adults younger than 50 years by 1% annually since 2004, whereas rates have decreased in adults 65 years and older by 2.3% annually since 2012. Despite steady progress for older adults, both CRC incidence and mortality are increasing in adults younger than 65 years who are in the prime of life, underscoring an urgent need for etiologic research to discover the cause of the rising trend. Meanwhile, morbidity and mortality could be mitigated with earlier diagnosis, through screening and educating clinicians and the general public about CRC symptoms, and greater attention to the unique needs of younger patients, including discussion about the preservation of fertility and sexual health.

INTRODUCTION

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in both men and women and the second leading cause of cancer‐related death in the United States. ¹ More than one half of all CRCs are attributable to modifiable risk factors, such as smoking, an unhealthy diet, high alcohol consumption, physical inactivity, and excess body weight, and thus potentially preventable. ² Many additional cases and deaths are preventable through appropriate screening and access to high‐quality treatment. ³ , ⁴ Goddard et al. recently estimated that 940,000 CRC deaths were averted from 1975 to 2020 because of a combination of cancer prevention, screening, and treatment advances. ⁵

Despite substantial progress against CRC in the United States overall, incidence and mortality are rising in individuals born after circa 1950, and CRC is now the leading cause of cancer death in adults younger than 50 years for reasons that remain largely unknown. ⁶ This article presents a comprehensive overview of current CRC statistics in the United States, including estimated numbers of new cases and deaths in 2026 and incidence, survival, and mortality rates and trends by age, race, and ethnicity based on incidence data through 2022 and mortality data through 2023. It also provides CRC screening prevalence among adults aged 45 years and older nationally for 2023 and by state for 2024.

MATERIALS AND METHODS

Data sources

Population‐based cancer incidence data in the United States are collected by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and the Centers for Disease Control and Prevention's National Program of Cancer Registries. Combined SEER and National Program of Cancer Registries data for 1998–2022, provided by the North American Association of Central Cancer Registries, cover >99% of the population and are the source for all contemporary incidence data. ⁷ , ⁸ Historical incidence (1975–1999) and survival (1995–1997) data are based on data from the nine oldest SEER registries (Connecticut, Iowa, Hawaii, New Mexico, Utah, and the metropolitan areas of Atlanta, San Francisco‐Oakland, Seattle‐Puget Sound, and Detroit), representing approximately 9% of the US population. ⁹ Contemporary 5‐year relative survival (2015–2021) and incidence (2000–2022) data are based on all SEER 21 registries, excluding Illinois for survival, representing 46% of the US population with vital status follow‐up through 2022. ¹⁰ Mortality data (1930–2023) are based on the underlying cause of death reported on death certificates and were obtained from the Centers for Disease Control and Prevention's National Center for Health Statistics, with detailed information on decedent race and ethnicity confined to deaths occurring from 1990 onward. ¹¹ , ¹² , ¹³

National CRC screening prevalence in 2023 was obtained from the National Center for Health Statistics' National Health Interview Survey ¹⁴ conducted by the US Census Bureau to provide nationally representative prevalence estimates for health behaviors. Data are collected through computer‐assisted in‐person and telephone interviews of noninstitutionalized adults aged 18 years and older. CRC screening prevalence at the state level was obtained from the 2024 Behavioral Risk Factor Surveillance System public‐use data set. ¹⁵ The Behavioral Risk Factor Surveillance System was designed to provide state prevalence estimates for health behaviors and is conducted by individual state health departments in coordination with the Centers for Disease Control and Prevention. Data are collected from computer‐assisted telephone interviews with adults aged 18 years and older.

Projected new cases and deaths in 2026

The most recent cancer incidence and mortality data lag from 2 to 4 years behind the current year because of the time required for data collection, compilation, quality control, and dissemination. Therefore, the American Cancer Society projects the number of new cancer cases and deaths in the United States in the current year to estimate the contemporary cancer burden. These estimates cannot be used for tracking cancer occurrence over time because their methodology changes periodically, most recently in 2021, to incorporate improvements in statistical methods, increased cancer registration coverage, and covariate information. The methods for projecting the number of new CRC cases and deaths that will occur in 2026 overall and by age are described in detail elsewhere. ¹⁶ , ¹⁷

Statistical analysis

CRC cases were classified according to International Classification of Diseases for Oncology codes as colon (C18.0, C18.2–C18.9, and C26.0) or rectum (C19.9 and C20.9). ¹⁸ Colon tumors were further categorized by anatomic location as proximal (C18.0 and C18.2–C18.5), distal (C18.6–C18.7), or not otherwise specified (C18.8, C18.9, and C26.0). All incidence rates exclude appendix (C18.1), and mortality data do not delineate deaths from colon versus rectal cancer because of the historically high rate of misclassification. ¹⁹ Misclassification on death certificates does not affect the calculation of relative survival, which is based on tumor subsite information in cancer registry data. To mitigate racial misclassification on medical records, all statistics presented by race are exclusive of Hispanic ethnicity. Racial misclassification for the American Indian and Alaska Native (AIAN) population was further mitigated by restricting incidence rates to Purchased/Referred Care Delivery Area counties and adjusting nationally representative mortality rates using classification ratios previously published by the National Center for Health Statistics. ²⁰

Incidence and mortality rates are age standardized to the 2000 US population (19 age groups for incidence and 20 age groups for mortality) and are expressed per 100,000 persons. The National Cancer Institute's SEER*Stat software (version 9.0.42.0) was used for all cancer occurrence data calculations. ²¹ Temporal incidence trends were adjusted for delays in case reporting to provide a more accurate reflection of cancer trends in the most recent time period. ²² Changes in incidence and mortality over time were quantified using the National Cancer Institute's Joinpoint regression program (version 5.4.0.0). ²³ Trends were described as increasing or decreasing when the annual percent change was statistically significant based on a two‐sided p value < .05 and otherwise were described as stable. Trend and lifetime risk analyses exclude cancer incidence in 2020 because the Joinpoint modeling program was not designed to accurately accommodate the large drop in diagnosis (mostly asymptomatic cancer) that occurred because of pandemic‐related disruptions to routine care. ²⁴

Relative survival accounts for normal life expectancy by comparing the survival among individuals with cancer versus that among the general population, controlling for age, race, sex, and year. It is calculated as the ratio of observed all‐cause survival among a group of patients who have cancer to their expected survival in the absence of a cancer diagnosis. For this analysis, we used the Ederer II method to calculate expected survival. ²⁵ CRC screening prevalence estimates were weighted to be either state or nationally representative and age adjusted to the 2000 US standard population based on three age groups (ages 45–49 years, 50–64 years, and 65 years and older or 65–75 years), as appropriate, except estimates stratified by age and health insurance status. All screening analyses were performed using SAS‐callable SUDAAN software, version 9.4 (RTI), which accounts for complex survey design.

SELECTED FINDINGS

Estimated cases and deaths in 2026

There will be an estimated 158,850 new cases of CRC in the United States in 2026, including 108,860 colon tumors and 49,990 rectal tumors (Table 1). Nearly one half (45%) of new diagnoses are currently in individuals younger than 65 years, up from 27% in 1995. In addition, an estimated 55,230 individuals will die from CRC in 2026, nearly one third of whom will be younger than 65 years.

TABLE 1.

Estimated numbers of new invasive colorectal cancer cases and deaths by age, 2026, United States.

Age, years	Cases												Deaths a
	Colon and rectum b				Colon b				Rectum				Colon and rectum
	Male	Female	Total	%	Male	Female	Total	%	Male	Female	Total	%	Male	Female	Total	%
Birth to 49	12,670	11,970	24,640	16	7290	7520	14,810	14	5380	4450	9830	20	2250	1640	3890	7
50–64	27,800	19,800	47,600	30	16,910	12,680	29,590	27	10,890	7120	18,010	36	8240	5240	13,480	24
≥65	43,690	42,920	86,610	55	31,210	33,250	64,460	59	12,480	9670	22,150	44	19,620	18,240	37,860	69
All ages	84,160	74,690	158,850	100	55,410	53,450	108,860	100	28,750	21,240	49,990	100	30,110	25,120	55,230	100

Note: Estimates are rounded to the nearest 10. Percentages may not sum to totals because of rounding.

^a Colon and rectal cancer deaths are not presented separately because of the large rate of misclassification.

^b Includes appendiceal cancer.

Incidence

Figure 1 compares age‐specific CRC incidence rates in 1995, before widespread colonoscopy screening, with those in 2022. In the contemporary curve, the natural disease pattern is disrupted by screening initiation and the detection of prevalent asymptomatic cancers among individuals aged 45–54 years. This curve also reflects a much younger age distribution because incidence has increased in younger adults and decreased in older adults.

FIGURE 1.

Age‐specific colorectal cancer incidence rates, 1995 versus 2022, United States. Incidence rates exclude appendiceal cancer, are age adjusted to the 2000 US standard population, and are adjusted for delays in case reporting.

Incidence is 32% higher in men than in women overall (40.5 vs. 30.7 cases per 100,000; Figure 2), ²⁰ but sex differences in risk vary by age and tumor location. For example, CRC incidence rates in men are only 19% higher than in women younger than 50 years versus 44% higher in those aged 50–64 years (Table 2). Likewise, for all ages combined, incidence is 9% higher in men for proximal colon tumors but 41% higher for distal colon tumors and 57% higher for rectal tumors. Notably, the rate of distal colon cancer in individuals younger than 50 years is equivalent in men and women. Sex differences likely reflect variation in carcinogenic and hormonal exposures combined with distinct etiologic mechanisms across anatomic subsites. ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ Approximately one third of the sex disparity is attributed to differences in the prevalence of established risk factors. ³¹

FIGURE 2.

Colorectal cancer incidence (2018–2022) and mortality (2019–2023) rates by sex, race, and ethnicity, United States. Incidence rates exclude appendiceal cancer and are adjusted for delays in case reporting. All rates are age adjusted to the 2000 US standard population. AANHPI indicates Asian American, Native Hawaiian, and other Pacific Islander; AI, American Indian; AN, Alaska Native. ^aTo reduce racial misclassification, incidence rates are limited to Purchased/Referred Care Delivery Area counties, and mortality rates are adjusted using factors published by the National Center for Health Statistics (Arias et al., 2021 ²⁰ ).

TABLE 2.

Colorectal cancer incidence rates by tumor subsite and age, 2018–2022, United States.

Tumor subsite	Incidence rate
	Overall			Aged 20–49 years			Aged 50–64 years			Aged ≥65 years
	Sexes combined	Male	Female	Sexes combined	Male	Female	Sexes combined	Male	Female	Sexes combined	Male	Female
Colorectum	35.3	40.5	30.7	13.1	14.3	12.0	68.0	80.6	55.8	153.1	174.9	135.4
Colon	24.2	26.7	22.0	7.5	7.9	7.0	41.2	47.6	35.0	116.5	127.0	107.8
Proximal	13.3	13.9	12.7	2.9	3.2	2.6	18.8	20.7	16.9	73.1	74.2	72.0
Distal	8.7	10.3	7.3	4.1	4.1	4.0	19.4	23.2	15.7	31.5	39.5	25.2
Rectum	11.1	13.8	8.8	5.7	6.4	4.9	26.8	33.0	20.8	36.6	47.9	27.6
Large intestine, NOS	2.2	2.5	1.9	0.5	0.6	0.5	3.1	3.7	2.5	11.9	13.3	10.6

Note: Incidence rates exclude appendiceal cancer, are per 100,000 persons, are age adjusted to the 2000 US standard population, and are adjusted for delays in case reporting.

Abbreviation: NOS, not otherwise specified.

Incidence rates also vary by race and ethnicity, ranging from 28.5 per 100,000 in people who are Asian American, Native Hawaiian, or Other Pacific Islander (AANHPI) to 80.9 per 100,000 in Alaska Native people, with parallel disparities in mortality. For more information on racial and ethnic differences in CRC, see the section racial and ethnic disparities.

Trends

Overall CRC incidence has decreased by 45% from the peak rate in 1985 through 2022, with trends strikingly similar in men and women (Figure 3). This progress is attributed to the cumulative effect of changing patterns in risk factors and protective factors, such as reductions in smoking and increased use of nonsteroidal anti‐inflammatory drugs, and the uptake of CRC screening among individuals aged 50 years and older. ³² Widespread colonoscopy screening is credited with accelerated declines in incidence of 4%–5% per year among adults aged 65 years and older from 2002 to 2012 after Medicare expanded coverage to all beneficiaries in 2001 (Table 3). ³³ , ³⁴ , ³⁵ Overall, the decline in incidence slowed from 1.3% per year during 2011–2017 to 0.6% per year during 2017–2022.

FIGURE 3.

Trends in colorectal cancer incidence (1975–2022) and mortality (1930–2023) rates by sex, United States. Mortality includes deaths from cancer of the small intestine because of changes in International Classification of Diseases coding over time. Incidence rates exclude appendiceal cancer, are age adjusted to the 2000 US standard population, and are adjusted for delays in case reporting. Incidence data for 2020 are shown separate from trend lines.

TABLE 3.

Trends in colorectal cancer incidence rates by age and stage, 1998–2022, United States.

Disease stage	Trend 1		Trend 2		Trend 3		Trend 4		Trend 5		AAPC
	Years	APC	Years	APC	Years	APC	Years	APC	Years	APC	2013–2022	2018–2022
All ages
All stages	1998–2001	−1.3 a	2001–2008	−2.7 a	2008–2011	−4.1 a	2011–2017	−1.3 a	2017–2022	−0.6 a	−0.9 a	−0.6 a
Localized	1998–2006	0.1	2006–2017	−4.4 a	2017–2022	−1.2					−2.6 a	−1.2
Regional	1998–2022	−2.5 a	2002–2005	−7.0 a	2005–2013	−2.9 a	2013–2016	2.6	2016–2022	−0.6 a	0.5	−0.6 a
Distant	1998–2016	−1.1 a	2016–2022	0.9 a							0.2	0.9 a
Unknown/unstaged	1998–2001	−0.4	2001–2007	−6.7 a	2007–2013	−3.1 a	2013–2016	2.6	2016–2022	−2.3 a	−0.7	−2.3 a
20–49 years
All stages	1998–2019	1.3 a	2019–2022	6.4 a							3.0 a	5.1 a
Localized	1998–2007	3.1 a	2007–2019	−1.3 a	2019–2022	12.4 a					3.1 a	8.8 a
Regional	1998–2011	0.4	2011–2022	3.4 a							3.4 a	3.4 a
Distant	1998–2022	2.7 a									2.7 a	2.7 a
Unknown/unstaged	1998–2011	−2.3 a	2011–2022	1.9 a							1.9 a	1.9 a
50–64 years
All stages	1998–2005	−1.2 a	2005–2011	−2.6 a	2011–2022	0.4 a					0.4 a	0.4 a
Localized	1998–2007	0.9 a	2007–2011	−4.6 a	2011–2022	−1.1 a					−1.1 a	−1.1 a
Regional	1998–2002	−1.9 a	2002–2005	−5.9 a	2005–2011	−2.7 a	2011–2019	2.1 a	2019–2022	−0.1	1.3 a	0.4
Distant	1998–2010	−0.7 a	2010–2017	0.3	2017–2022	1.7 a					1.1 a	1.7 a
Unknown/unstaged	1998–2000	6.4	2000–2007	−6.0 a	2007–2013	−1.2	2013–2016	6.8	2016–2022	−2.6 a	0.4	−2.6 a
≥65 years
All stages	1998–2002	−2.2 a	2002–2008	−3.8 a	2008–2012	−4.7 a	2012–2022	−2.5 a			−2.5 a	−2.5 a
Localized	1998–2006	−0.4	2006–2017	−5.5 a	2017–2022	−3.6 a					−4.5 a	−3.6 a
Regional	1998–2002	−3.1 a	2002–2005	−8.0 a	2005–2013	−4.1 a	2013–2016	1.3	2016–2022	−2.3 a	−1.1 a	−2.3 a
Distant	1998–2016	−2.2 a	2016–2022	−0.6							−1.1 a	−0.6
Unknown/unstaged	1998–2001	−1.2	2001–2007	−7.0 a	2007–2013	−3.8 a	2013–2018	0.0	2018–2022	−3.7 a	−1.7 a	−3.7 a

Note: Trends are based on incidence rates that exclude appendiceal cancer, are age adjusted to the 2000 US standard population, adjusted for delays in reporting, and analyzed by the Joinpoint Regression Program, version 5.4.0.0 (National Cancer Institute), allowing up to four joinpoints.

Abbreviations: AAPC, average annual percent change; APC, annual percent change.

^a The APC or AAPC is significantly different from zero (p < .05).

Longstanding declines in CRC overall are driven by the oldest adults, who have the highest rates, and mask trends in younger ages. Incidence in individuals 20–49 years (early onset) has risen by 1%–2% annually since the mid‐1990s driven mostly by advanced‐stage diagnoses and left‐sided tumors (Figures 4 and 5). ³⁶ The pace accelerated to 3% per year from 2013 to 2022 because of a spike in localized‐stage diagnoses since 2019 as a result of screening uptake and the detection of prevalent asymptomatic cancer in mostly unscreened individuals aged 45–49 years, as we previously reported. ³⁷ , ³⁸ This pattern mirrors the bump in localized‐stage disease that occurred in older adults during widespread colonoscopy uptake in the early 2000s (Figure 4). The recommended age to begin screening for average‐risk individuals was lowered from 50 to 45 years in 2018 by the American Cancer Society and in 2021 by the US Preventive Services Task Force. ³⁹ , ⁴⁰ Despite the recent uptick in local‐stage disease, incidence of both regional‐stage and distant‐stage diagnoses increased in individuals 20–49 years by about 3% per year since 2011 and at least 1998, respectively (Table 3).

FIGURE 4.

Trends in colorectal cancer incidence rates by age and stage at diagnosis, 1998–2022, United States. Incidence rates exclude appendiceal cancer, are age adjusted to the 2000 US standard population, and are adjusted for delays in case reporting. Incidence data for 2020 are shown separate from trend lines.

FIGURE 5.

Trends in colorectal cancer incidence rates by age and tumor subsite, 1998–2022, United States. Incidence rates exclude appendiceal cancer, are age adjusted to the 2000 US standard population, and are adjusted for reporting delays. Incidence data for 2020 are shown separate from trend lines. NOS indicates not otherwise specified.

Incidence in adults younger than 50 years is increasing in every racial and ethnic group in the United States, ranging from 2% annually in Black individuals to 3% annually in AANHPI, AIAN, and White individuals and 4% annually in Hispanic individuals from 2013 to 2022 (Figure 6). Globally, incidence is increasing in individuals younger than 50 years in at least 14 countries where rates are simultaneously stable or declining in adults aged 50 years and older. ⁴¹ , ⁴² CRC incidence is not increasing in young adults per se but, rather, in every generation born after circa 1950 in the United States ⁴³ , ⁴⁴ and circa 1960 in Canada, Australia, and England. ⁴¹ This phenomenon is referred to as a birth‐cohort effect because risk is more closely associated with when you were born than when you are diagnosed. Incidence in adults aged 50–64 years has increased by 0.4% per year from 2011 to 2022 after declining by 2.6% per year from 2005 to 2011 (Table 3) because individuals born in the 1960s, who are at the beginning of the upturn, have entered middle age. Rising incidence in individuals aged 50–64 years is confined to regional‐stage and distant‐stage disease, both of which increased by 1% per year from 2013 to 2022, whereas rates of localized‐stage disease continued to decline (Figure 4 and Table 3). This pattern is notable given that two in three individuals in this age group are up to date with CRC screening. ⁴⁵ Increasing incidence in younger generations alongside decreasing risk in older adults has rapidly shifted the patient population younger. In 2022, 22% of CRCs were diagnosed in individuals younger than 55 years, which is twice that in 1995 (11%), despite the size of this age group shrinking in the general population according to US Census Bureau estimates.

FIGURE 6.

Trends in early onset colorectal cancer incidence rates by race and ethnicity, 1998–2022, United States. Incidence rates exclude appendiceal cancer, are age adjusted to the 2000 US standard population, and are adjusted for reporting delays. Incidence data for 2020 are shown separate from trend lines. Individual race categories are exclusive of Hispanic ethnicity and data for AIAN people are limited to Purchased/Referred Care Delivery Area counties. ^aAdvanced stage includes regional and distance stage disease. AANHPI indicates Asian American, Native Hawaiian, and Other Pacific Islander; AIAN, American Indian, Alaska Native.

The birth‐cohort effect for CRC is most evident in incidence trends by anatomic subsite because increased risk is dominated by tumors in the distal colon, especially the sigmoid colon, and rectum (Figure 5). For example, the incidence rate nearly doubled from 1998 to 2022 for cancer in the sigmoid colon (from 2.1 to 3.7 per 100,000) and the rectum (3.6 to 6.6 per 100,000) in individuals aged 20–49 years, compared with a 26% increase in proximal tumors. Similarly, the increasing trend in individuals aged 50–64 years is confined to tumors in the distal colon and rectum, whereas the incidence of proximal tumors continues to decline, despite an increase in the transverse colon of 0.8% per year since 2011 (Table 4). Even among individuals aged 65 years and older, rectal cancer has become 21% more common than distal colon cancer (Figure 5), reversing historic patterns. Among all ages combined, rectal cancer incidence increased by 1% per year from 2018 to 2022 (Table 4) after decades of declining trends and, in 2022, accounted for one in three (32%) CRCs, up from 27% in 2004.

TABLE 4.

Trends in colorectal cancer incidence rates by age and tumor subsite, 1998–2022, United States.

Tumor subsite	Trend 1		Trend 2		Trend 3		Trend 4		Trend 5		AAPC
	Years	APC	Years	APC	Years	APC	Years	APC	Years	APC	2013–2022	2018–2022
All ages
Proximal colon	1998–2001	0.1	2001–2008	−2.3 a	2008–2011	−4.3 a	2011–2022	−1.9 a			−1.9 a	−1.9 a
Cecum	1998–2001	−1.2	2001–2007	−2.7 a	2007–2010	−4.5 a	2010–2022	−2.5 a			−2.5 a	−2.5 a
Appendix	1998–2012	5.1 a	2012–2016	16.2 a	2016–2022	2.5 a					6.9 a	2.5 a
Ascending colon	1998–2004	0.7 a	2004–2012	−2.8 a	2012–2022	−1.9 a					−1.9 a	−1.9 a
Hepatic flexure	1998–2001	−0.3	2001–2008	−3.5 a	2008–2012	−6.5 a	2012–2022	−1.0 a			−1.0 a	−1.0 a
Transverse colon	1998–2008	−1.8 a	2008–2011	−3.9	2011–2022	−0.8 a					−0.8 a	−0.8 a
Distal colon	1998–2004	−2.8 a	2004–2012	−4.3 a	2012–2019	−1.1 a	2019–2022	0.4			−0.6	0.0
Splenic flexure	1998–2004	−2.6 a	2004–2013	−4.8 a	2013–2019	−1.7 a	2019–2022	1.9			−0.5	1.0
Descending colon	1998–2012	−2.8 a	2012–2022	−1.2 a							−1.2 a	−1.2 a
Sigmoid colon	1998–2001	−2.2 a	2001–2007	−3.8 a	2007–2012	−4.8 a	2012–2019	−0.9 a	2019–2022	0.2	−0.5	−0.1
Rectum and rectosigmoid junction	1998–2007	−2.1 a	2007–2011	−2.9 a	2011–2018	−0.4 a	2018–2022	1.0 a			0.2	1.0 a
Large intestine, NOS	1998–2010	−3.6 a	2010–2022	−1.0 a							−1.0 a	−1.0 a
20–49 years
Proximal colon	1998–2019	0.5 a	2019–2022	3.0							1.3	2.4
Cecum	1998–2022	−0.0									−0.0	−0.0
Appendix	1998–2011	4.7 a	2011–2016	20.6 a	2016–2022	2.2 a					8.0 a	2.2 a
Ascending colon	1998–2003	4.1 a	2003–2019	0.5 a	2019–2022	4.3					1.8	3.4
Hepatic flexure	1998–2006	0.9	2006–2013	−3.1 a	2013–2022	2.8 a					2.8 a	2.8 a
Transverse colon	1998–2012	0.5	2012–2022	2.4 a							2.4 a	2.4 a
Distal colon	1998–2019	1.4 a	2019–2022	8.2 a							3.6 a	6.4 a
Splenic flexure	1998–2014	−0.8 a	2014–2022	2.6 a							2.2 a	2.6 a
Descending colon	1998–2019	1.3 a	2019–2022	8.3							3.6 a	6.5
Sigmoid colon	1998–2019	1.6 a	2019–2022	8.1 a							3.8 a	6.5 a
Rectum and rectosigmoid junction	1998–2018	1.8 a	2018–2022	5.7 a							3.5 a	5.7 a
Large intestine, NOS	1998–2012	−0.5	2012–2022	1.1 a							1.1 a	1.1 a
50–64 years
Proximal colon	1998–2004	−0.3	2004–2011	−3.1 a	2011–2022	−0.6 a					−0.6 a	−0.6 a
Cecum	1998–2004	−1.0 a	2004–2010	−3.5 a	2010–2022	−1.3 a					−1.3 a	−1.3 a
Appendix	1998–2013	5.5 a	2013–2016	10.6	2016–2022	2.5 a					5.1 a	2.5 a
Ascending colon	1998–2003	1.9 a	2003–2012	−2.5 a	2012–2015	1.5	2015–2022	−1.9 a			−1.1	−1.9 a
Hepatic flexure	1998–2003	−0.7	2003–2012	−4.5 a	2013–2022	0.7					0.7	0.7
Transverse colon	1998–2008	−1.4 a	2008–2011	−4.7 a	2011–2022	0.8 a					0.8 a	0.8 a
Distal colon	1998–2007	−2.0 a	2007–2011	−4.2 a	2011–2022	0.7 a					0.7 a	0.7 a
Splenic flexure	1998–2004	−1.9	2004–2011	−4.8 a	2011–2019	−0.7	2019–2022	4.7			1.1	3.3
Descending colon	1998–2006	−1.4 a	2006–2010	−3.6 a	2010–2022	0.4 a					0.4 a	0.4 a
Sigmoid colon	1998–2008	−2.2 a	2008–2011	−4.8 a	2011–2022	0.8 a					0.8 a	0.8 a
Rectum and rectosigmoid junction	1998–2005	−0.8 a	2005–2011	−1.6 a	2011–2014	2.0	2014–2022	0.7 a			0.9 a	0.7 a
Large intestine, NOS	1998–2009	−3.5 a	2009–2022	−0.1							−0.1	−0.1
≥65 years
Proximal colon	1998–2001	−0.3	2001–2008	−2.6 a	2008–2011	−4.7 a	2011–2022	−2.6 a			−2.6 a	−2.6 a
Cecum	1998–2007	−2.6 a	2007–2010	−5.2 a	2010–2022	−3.1 a					−3.1 a	−3.1 a
Appendix	1998–2013	4.5 a	2013–2016	10.6 a	2016–2022	3.4 a					5.7 a	3.4 a
Ascending colon	1998–2004	0.4	2004–2014	−3.1 a	2014–2022	−2.4 a					−2.5 a	−2.4 a
Hepatic flexure	1998–2001	−0.7	2001–2008	−3.8 a	2008–2012	−6.9 a	2012–2022	−1.9 a			−1.9 a	−1.9 a
Transverse colon	1998–2001	−0.5	2001–2012	−2.8 a	2012–2022	−1.8 a					−1.8 a	−1.8 a
Distal colon	1998–2003	−3.4 a	2003–2013	−5.7 a	2013–2022	−3.1 a					−3.1 a	−3.1 a
Splenic flexure	1998–2004	−3.2 a	2004–2014	−5.6 a	2014–2022	−2.1 a					−2.5 a	−2.1 a
Descending colon	1998–2003	−2.7 a	2003–2010	−4.4 a	2010–2022	−3.2 a					−3.2 a	−3.2 a
Sigmoid colon	1998–2003	−3.5 a	2003–2013	−6.1 a	2013–2022	−3.2 a					−3.2 a	−3.2 a
Rectum and rectosigmoid junction	1998–2004	−3.3 a	2004–2012	−4.4 a	2012–2018	−2.3 a	2018–2022	−1.4 a			−1.9 a	−1.4 a
Large intestine, NOS	1998–2010	−4.0 a	2010–2022	−1.6 a							−1.6 a	−1.6 a

Note: Trends are based on incidence rates that exclude appendiceal cancer, are age adjusted to the 2000 US standard population, adjusted for delays in reporting, and analyzed by the Joinpoint Regression Program, version 5.4.0.0 (National Cancer Institute), allowing up to four joinpoints.

Abbreviations: AAPC, average annual percent change; APC, annual percent change; NOS, not otherwise specified.

^a The APC or AAPC is significantly different from zero (p < .05).

Cancer trends in young adults are the first sign of contemporary exposures that influence disease risk. ⁴⁶ The strength and timing of the CRC birth‐cohort effect suggest that behavioral changes in carcinogenic exposures occurred around the middle of the 20th century. Likely contributors include established risk factors (Table 5), ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ such as obesity, ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ physical inactivity, ⁶⁰ , ⁶¹ and reduced dietary quality, ⁶² , ⁶³ as well as yet unknown etiologic factors. Inflammatory bowel disease is associated with increased CRC risk, and pediatric onset may be increasing, ⁶⁴ but population‐based incidence is unknown because inflammatory bowel disease is not a reportable condition. Established risk factors based on disease associations in older cohorts do not appear to fully explain contemporary disease patterns. For example, obesity and physical inactivity are more strongly associated with tumors in the colon than in the rectum, ⁵¹ , ⁶⁰ but the increasing trend is driven by rectal cancer. Much of the ongoing research focuses on the gut biome and inflammation associated with contemporary exposures, such as ultraprocessed foods, ⁶⁵ , ⁶⁶ , ⁶⁷ microplastics, ⁶⁸ , ⁶⁹ and antibiotics, ⁷⁰ , ^{71 , 72} Increased detection of asymptomatic cancer through advances in imaging technology is unlikely to play a major role in rising early onset CRC because detection generally requires a proper bowel cleansing, and incidental detection increases with age ⁷³ and mostly detects early stage disease, contrary to incidence patterns.

TABLE 5.

Established colorectal cancer risk factors.

Risk factors	Relative risk
Factors that increase risk
Hereditary and medical history
Family history
At least one first‐degree relative (Roos 2019 47 )	1.7–2.2
At least one first‐degree relative with diagnosis before age 50 years (Roos 2019 47 )	3.3–3.6
At least two first‐degree relative relatives (Roos 2019 47 )	2.4–2.8
At least one second‐degree relative (Roos 2019 47 )	1.1–1.9
Inflammatory bowel disease (Lutgens 2013 48 )	1.7
Type 2 diabetes (Zhang 2021 49 )	1.3
Behavioral factors
Very heavy alcohol consumption: Daily average ≥3 drinks (McNabb 2020 50 )	1.3
Obesity: Body mass index ≥30 kg/m2 (Zhang 2021 49 )	1.3
Colon (Xue 2017 51 )
Male	1.5
Female	1.1
Rectum (Xue 2017 51 )
Male	1.3
Female	1.1
Red meat consumption: High vs. low (Schwingshackl 2018 52 )	1.1
Processed meat consumption: High vs. low (Schwingshackl 2018 52 )	1.1
Smoking: Current vs. never (Zhang 2021 49 )	1.2
Factors that decrease risk
Lifetime physical activity: Colon (Hidayat 2019 53 )	0.8
Dairy consumption: High vs. low (Schwingshackl 2018 52 )	0.8
Whole grains: High vs. low (Schwingshackl 2018 52 )	0.9
Total dietary fiber: High vs. low (Reynolds 2019 54 )	0.8

Note: The range for certain relative risk estimates indicates the inclusion of case–control and cohort studies separately. Dietary relative risks are based on large meta‐analyses, and umbrella reviews were used to confirm consistency and strength of the evidence.

Early onset

Although a higher proportion of CRC diagnosed before age 50 years (16%–20%) is the result of genetically predisposed disease because of germline mutations (e.g., mutations in DNA mismatch‐repair genes associated with Lynch syndrome), ⁷⁴ , ⁷⁵ , ⁷⁶ the majority of cases are sporadic. It is hypothesized that the genesis of sporadic cancers reflects unique epigenetic interactions that may produce distinct somatic patterns in young patients and provides clues to etiology. ⁷⁷ , ⁷⁸ , ⁷⁹ For example, a study of global data suggests molecular differences in hypermutated, early onset tumors, including a higher mutational burden, that may support an alternative carcinogenic pathway. ⁸⁰ These tumors also demonstrate distinct mutational signatures, including POLE‐related hypermutation, highlighting potentially unique biologic mechanisms that warrant further investigation. ⁷⁹

The preponderance of left‐sided tumors in young adults has led to some differences in clinical presentation compared to older patients. For example, younger patients are more likely to present with hematochezia (e.g., 41% vs. 26%), iron deficiency anemia, and abdominal pain. ⁷⁷ , ⁸¹ , ⁸² Three in four patients younger than age 50 are diagnosed with advanced disease, including 27% with distant metastases versus 21%–23% of older patients (Figure 7). This is partly because of less screening, but it also reflects diagnostic delays. One study indicated a 40% longer time to diagnosis among individuals younger than 50 years compared with older individuals, including both longer symptom duration and work‐up time, often because of misdiagnosis with more common conditions. ⁸¹ Additional barriers include lower symptom awareness and health insurance‐related delays in diagnosis, which are more common among younger adults. ⁸³ , ⁸⁴

FIGURE 7.

Colorectal cancer stage distribution (%) by age, race, and ethnicity, 2018–2022, United States. Stage distribution excludes appendiceal cancer. Individual race categories are exclusive of Hispanic ethnicity. ^aLimited to Purchased/Referred Care Delivery Area counties. AANHPI indicates Asian American, Native Hawaiian, and other Pacific Islander; AIAN, American Indian, Alaska Native.

Despite later stage diagnosis, individuals younger than 50 years have similar or higher 5‐year relative survival than older patients, with the largest gap for distant‐stage disease (23% vs. 17% in those aged 50–64 years and 10% in individuals aged 65 years and older; Figure 8). Factors that contribute to higher survival include fewer comorbidities, ⁸⁵ more physical activity after treatment, ⁸⁶ , ⁸⁷ and more aggressive treatment, including more extensive surgery, multiagent systemic therapy, and adjuvant or neoadjuvant therapies. ⁸⁸ , ⁸⁹ , ⁹⁰ , ⁹¹ However, more intensive treatment does not always produce better outcomes and is typically associated with additional toxicity and long‐term side effects. Overtreatment of early onset disease is an increasing concern and is the focus of ongoing clinical trials. ⁹² , ⁹³

FIGURE 8.

Colorectal cancer 5‐year relative survival (%) by age, race, and ethnicity, 2015–2021, United States. Relative survival excludes appendiceal cancer and is based on cases diagnosed from 2015 to 2021, all followed through 2022. Individual race categories are exclusive of Hispanic ethnicity. ^aLimited to Purchased/Referred Care Delivery Area counties. AANHPI indicates Asian American, Native Hawaiian, and other Pacific Islander; AIAN, American Indian, Alaska Native.

It is also critical that providers gain a better understanding of the unique needs of younger patients. For example, treatment conversations that include patient preferences about sexual and reproductive health outcomes should be standard practice, especially given the preponderance of rectal tumors, for which treatment typically has more functional consequences. One study indicated that less than one half of patients diagnosed with CRC before age 50 years discussed fertility preservation with their physician before starting treatment. ⁹⁴ Additional gaps in care for young patients include managing the psychosocial challenges of diagnosis and treatment, ⁹⁵ financial insecurity and employment disruption, and caregiving burdens. ⁹⁶ Long‐term survivorship challenges are extensive and include persistent neuropathy, sexual dysfunction, body image issues, bowel dysfunction, cardiotoxicity, subsequent primary cancer, and other chronic treatment‐related sequelae that are increasingly recognized in this population. ⁹⁷

Survival

The 5‐year relative survival for CRC has increased from 50% in the mid‐1970s to 65% during 2015–2021, ¹ with the largest gains for distant‐stage rectal cancer, for which 5‐year survival improved from 8% during the mid‐1990s to 18%. ¹ These survival gains reflect earlier detection through routine clinical examinations (e.g., digital rectal examination) and screening, ⁹⁸ , ⁹⁹ more accurate staging through advances in imaging (e.g., positron emission tomography), ¹⁰⁰ advances in surgical technique and increased cancer‐directed surgery for advanced disease, ¹⁰¹ advances in the treatment of liver metastases, ¹⁰² , ¹⁰³ , ¹⁰⁴ , ¹⁰⁵ and advances and refinement in chemotherapy, radiation, targeted therapy, and immunotherapy. ⁸⁹ , ¹⁰⁶ , ¹⁰⁷ , ¹⁰⁸ , ¹⁰⁹ As of January 1, 2025, there were more than 1.4 million CRC survivors in the United States. ⁹⁷

Stage at diagnosis is the most important predictor of survival, with 5‐year relative survival ranging from 91% for localized disease to 15% for distant disease (Figure 8). The most common diagnosis in 2018–2022 was regional‐stage disease (Figure 7), for which 5‐year survival ranges from 69% in patients aged 65 years and older to 81% in those younger than 50 years. Men have a similar overall 5‐year relative survival rate (64%) compared with women (65%) despite a more favorable tumor subsite distribution. For example, men have a higher proportion of rectal cancers (34% vs. 27% for colon cancer), which have better overall survival (67% vs. 63% for colon cancer) independent of histologic and molecular characteristics. ¹¹⁰ , ¹¹¹ However, women continue to have higher survival for rectal cancer (69% vs. 65% in men). These persistent differences are thought to be influenced by sex‐specific risk factors like estrogen, which appears to have a protective influence on tumor development and progression. ¹¹² , ¹¹³ There are also sex differences in tumor molecular characteristics that likely influence response to treatment. ¹¹³

Mortality

Historically, CRC mortality was higher in women than in men, but the rate also began declining nearly 4 decades earlier in women (Figure 3). Higher death rates in women suggest higher incidence given the lack of effective treatment in the early 20th century, although population‐based incidence data are unavailable before the 1970s. In contrast, the death rate during 2019–2023 was 42% higher in men (15.3 vs. 10.8 per 100,000; Figure 2), and contemporary trends are very similar by sex. Overall CRC mortality declined by a total of 56% between 1970 (29.1 per 100,000) and 2023 (12.7 per 100,000; Figure 3), reflecting declines in incidence, screening uptake, and improved treatment. Similar to slowing progress for incidence, the mortality rate declined by about 2% annually from 2005 to 2020, but remained stable from 2020 to 2023 (Table 6).

TABLE 6.

Trends in colorectal cancer mortality rates by race, ethnicity, and age, 1990–2023, United States.

	Trend 1		Trend 2		Trend 3		Trend 4		Trend 5		AAPC
	Years	APC	Years	APC	Years	APC	Years	APC	Years	APC	2014–2023	2019–2023
All races and ethnicities
All ages	1990–2002	−1.8 a	2002–2005	−3.8 a	2005–2012	−2.5 a	2012–2020	−1.7 a	2020–2023	−0.6	−1.3 a	−0.9 a
20–49 years	1990–1998	−1.0 a	1998–2001	2.3	2001–2004	−2.5	2004–2023	1.1 a			1.1 a	1.1 a
50–64 years	1990–2002	−2.0 a	2002–2005	−4.1 a	2005–2019	−0.7 a	2019–2023	1.2 a			0.2	1.2 a
≥65 years	1990–2001	−1.8 a	2001–2012	−3.4 a	2012–2023	−2.3 a					−2.3 a	−2.3 a
White
All ages	1990–2002	−1.8 a	2002–2005	−3.9 a	2005–2011	−2.5 a	2011–2020	−1.6 a	2020–2023	−0.1	−1.1 a	−0.5
20–49 years	1990–2004	−0.2	2004–2023	1.6 a							1.6 a	1.6 a
50–64 years	1990–2002	−2.1 a	2002–2005	−4.7 a	2005–2019	−0.4 a	2019–2023	2.3 a			0.8 a	2.3 a
≥65 years	1990–2001	−1.8 a	2001–2011	−3.5 a	2011–2023	−2.2 a					−2.2 a	−2.2 a
Black
All ages	1990–2001	−0.7 a	2001–2023	−2.6 a							−2.6 a	−2.6 a
20–49 years	1990–2023	−0.6 a									−0.6 a	−0.6 a
50–64 years	1990–1999	−0.6	1999–2023	−1.8 a							−1.8 a	−1.8 a
≥65 years	1990–2001	−0.7 a	2001–2023	−3.2 a							−3.2 a	−3.2 a
Asian American, Native Hawaiian, or Pacific Islander
All ages	1990–2023	−1.7 a									−1.7 a	−1.7 a
20–49 years	1990–2009	−0.6	2009–2023	1.1 a							1.1 a	1.1 a
50–64 years	1990–2004	−2.3 a	2004–2023	−0.1							−0.1	−0.1
≥65 years	1990–2023	−2.2 a									−2.2 a	−2.2 a
American Indian/Alaska Native (combined) b
All ages	1990–2009	0.4	2009–2023	−1.5 a							−1.5 a	−1.5 a
20–49 years	1990–2023	2.6 a									2.6 a	2.6 a
50–64 years	1990–2023	0.7 a									0.7 a	0.7 a
≥65 years	1990–2011	−0.0	2011–2023	−3.2 a							−3.2 a	−3.2 a
American Indian b , c
All ages	1990–1997	4.3	1997–2023	−0.8 a							−0.8 a	−0.8 a
20–49 years	1990–2023	2.6 a									2.6 a	2.6 a
50–64 years	1990–2023	0.8 a									0.8 a	0.8 a
≥65 years	1990–2008	0.6	2008–2023	−2.7 a							−2.7 a	−2.7 a
Alaska Native
All ages	1990–2023	−0.5									−0.5	−0.5
20–49 years d
50–64 years	1990–2023	−0.3									−0.3	−0.3
≥65 years	1990–2023	−0.9									−0.9	−0.9
Hispanic
All ages	1990–2001	0.1	2001–2016	−1.7 a	2016–2023	−0.8 a					−1.0 a	−0.8 a
20–49 years	1990–2005	−0.8	2005–2023	1.9 a							1.9 a	1.9 a
50–64 years	1990–2018	−0.8 a	2018–2023	1.2							0.3	1.2
≥65 years	1990–2001	0.3	2001–2023	−2.0 a							−2.0 a	−2.0 a

Note: Trends are based on mortality rates age adjusted to the 2000 US standard population and analyzed by the Joinpoint Regression Program, version 5.4.0.0 (National Cancer Institute), allowing up to four joinpoints. Individual race categories are exclusive of persons of Hispanic ethnicity.

Abbreviations: AAPC, average annual percent change; APC, annual percent change.

^a The APC or AAPC is significantly different from zero (p < .05).

^b To reduce racial misclassification, mortality rates are adjusted using factors published by the National Center for Health Statistics.

^c Excludes Alaska.

^d Could not analyze age group because of sparse data.

Stabilizing mortality likely reflects increasing trends in younger adults because the rate continued to decrease steadily in individuals aged 65 years and older by 2.3% per year from 2012 to 2023. The death rate in individuals younger than 50 years has increased by 1% per year overall since 2004, but the trend varies by racial and ethnic group from a decline of 0.6% per year in Black individuals over the past decade (2014–2023) to increases of 1.6% per year in White individuals, 1.9% per year in Hispanic individuals, and 2.6% per year in American Indian individuals. For the first time, the death rate is also increasing among individuals aged 50–64 years by 1.2% per year overall from 2019 to 2023, including increases of 0.8% per year in American Indian individuals and 2.3% per year in White individuals; the rate also increased among Hispanic individuals in this age group (1.2% per year from 2018 to 2023) but was not yet statistically significant (Table 5). This pattern is consistent with the birth‐cohort effect observed for incidence and the higher disease risk in generations born since 1950 who have entered middle age.

Racial and ethnic disparities

Marked racial and ethnic disparities in CRC in the United States reflect differences in exposure to risk factors and access to high‐quality screening and treatment. Among the five racial‐ethnic groups illustrated in Figure 2, AIAN individuals have the highest incidence and mortality rates, followed by Black individuals. While Black–White disparities in incidence have narrowed from 22% higher rates in Black individuals in 2013 to 11% higher in 2022, AIAN–White disparities have widened from 39% to 48% higher rates because of stable versus declining trends. ⁸ Additional disparities are hidden within these broadly defined, heterogeneous racial and ethnic groups. For example, although CRC mortality is 29% lower in AANHPI individuals than in White individuals nationally, Native Hawaiian and Other Pacific Islander individuals specifically have 32% higher CRC mortality than White individuals in Hawaii. ¹¹⁴

Alaska Native individuals have the highest CRC incidence and mortality in the world. ¹¹⁵ , ¹¹⁶ Contemporary incidence rates in Alaska Native individuals are more than twice those in White individuals (80.9 vs. 35.2 per 100,000), and mortality rates are nearly two and one half times higher (31.5 vs. 12.9 per 100,000; Figure 2). Reasons for the elevated risk remain unclear but may include a higher prevalence of risk factors, such as tobacco use, vitamin D deficiency from limited sun exposure, poor access to healthy foods, obesity, ¹¹⁷ , ¹¹⁸ and potentially Helicobacter pylori infection. ¹¹⁹ , ¹²⁰ The high CRC burden among Alaska Natives is compounded by the limited access to endoscopic services across much of Alaska, ¹¹⁸ , ¹²¹ , ¹²² which has contributed to historically lower screening prevalence in this population. However, targeted initiatives within the Alaska Tribal Health System have improved screening uptake in recent years, ¹¹⁸ , ¹²² , ¹²³ although mortality has yet to decline (Table 6).

Larger disparities in mortality than in incidence reflect later stage diagnosis and lower 5‐year relative survival among Black and AIAN individuals compared with White individuals. Later stage at diagnosis remains one of the most important drivers of racial and ethnic disparities, ¹²⁴ as survival differences are smallest for local‐stage disease (Figure 8). Black individuals are most likely to be diagnosed with metastatic CRC (26% vs. 22% of White individuals; Figure 7) and also have the lowest overall 5‐year relative survival (59% vs. 65% among White individuals). Later stage diagnosis often reflects inadequate screening. For example, Black individuals are less likely to receive physician recommendation for screening, timely follow‐up of a positive stool test and high‐quality colonoscopy. ¹²⁵ , ¹²⁶

Additional contributors to mortality disparities include higher comorbidity burden, unfavorable tumor characteristics, and limited access to high‐quality care. ¹²⁷ , ¹²⁸ , ¹²⁹ Black patients are less likely to be represented in clinical trials and to receive molecular tumor profiling necessary for the use of targeted therapies against the epidermal growth factor and programmed death 1 receptors. ¹³⁰ One study estimates that tumor characteristics (e.g., grade, anatomic location) explain about 25% of the Black–White survival disparity. ¹³¹ Another study using the National Cancer Database indicated that, among patients who had early onset CRC, Black individuals had 18% and 27% higher odds of not receiving guideline‐concordant care for colon and rectal cancer, respectively, and lack of health insurance was the largest contributor to this disparity. ¹³² Although disproportionate development of right‐sided tumors has been suggested as a contributor to higher mortality and, in turn, lower survival, ¹³¹ population‐based cancer registry data indicate that the distribution is similar to that of White individuals, consistent with contemporary literature. ¹³³ , ¹³⁴ Some studies indicate that Black patients with equal access to care have treatment and survival comparable to those of White patients ¹³⁵ whereas others do not, ¹³⁶ , ¹³⁷ , ¹³⁸ highlighting the need for parity across the cancer continuum in addressing disparities. ¹³⁹ Doubeni and colleagues recently reported the successful elimination of racial disparities in CRC mortality at a large health care system with the implementation of a continuum‐of‐care screening program that included equitable, timely delivery of treatment. ¹⁴⁰

Geographic disparities

The CRC burden varies substantially worldwide, highlighting the large influence of lifestyle, environmental, and structural factors on disease occurrence. ¹⁴¹ Likewise, rates in the United States range from 45 per 100,000 in Mississippi and Kentucky to 28 per 100,000 in Utah for incidence and from 18 per 100,000 in Mississippi to 10 per 100,000 in Massachusetts and Connecticut for mortality (Table 7). In general, CRC occurrence is highest in Appalachia, the South, and parts of the Midwest, and it is lowest in the Northeast and the Western regions. These differences reflect wide variation in the prevalence of CRC risk factors, such as smoking and excess body weight, as well as differences in access to high‐quality screening and treatment. State‐level patterns are generally similar for Black and White individuals, particularly for mortality.

TABLE 7.

Colorectal cancer incidence (2018–2022) and mortality rates (2019–2023), and screening prevalence (2024) by state, United States.

	Incidence rate				Mortality rate				Up‐to‐date screening: Aged ≥45 years, % a
	All races	White	Black	Hispanic	All races	White	Black	Hispanic	All races	White	Black	Hispanic	45–54 years
Alabama	38.5	37.7	44.7	15.9	14.5	13.9	18.3	4.3	69	68	71	— b	52
Alaska	40.2	35.7	35.1	29.7	14.4	12.4	— c	9.5	63	63	65	59	46
Arizona	31.5	30.8	33.4	34.8	12.3	12.2	16.0	12.5	65	68	80	56	44
Arkansas d	41.6	40.3	54.9	25.3	15.5	15.4	20.9	6.2	66	67	69	45	48
California	33.1	33.2	37.9	32.1	12.0	12.4	16.3	11.0	64	70	65	56	48
Colorado	29.6	28.9	32.5	33.5	11.4	10.8	15.3	14.2	70	73	72	60	55
Connecticut	33.0	32.1	39.1	35.6	10.3	10.3	13.0	9.4	76	79	80	73	64
Delaware	32.1	33.5	30.9	21.4	12.3	12.7	13.2	8.7	72	73	76	56	53
Washington DC	34.9	24.7	43.9	24.7	13.5	7.9	19.0	4.9	73	76	72	76	57
Florida	35.7	36.7	39.2	33.9	12.0	12.1	15.8	10.9	66	70	67	62	45
Georgia	38.2	37.6	42.7	30.3	13.7	13.5	16.4	8.0	68	69	75	57	52
Hawaii	36.6	36.3	34.8	68.7	12.1	12.0	15.2	20.6	67	72	— b	64	53
Idaho	33.8	33.1	— c	34.6	12.4	12.6	— c	10.6	67	68	— b	48	48
Illinois	37.5	37.3	46.3	31.6	13.3	13.3	19.4	9.0	66	68	71	54	49
Indiana e	39.2	39.7	42.0	28.8	14.9	15.1	17.3	8.6	68	70	72	52	54
Iowa	38.1	38.2	50.5	31.5	13.3	13.4	22.3	7.9	69	70	78	51	53
Kansas	37.3	37.2	38.1	31.6	13.9	14.2	14.9	9.4	69	69	77	59	53
Kentucky	44.5	45.3	43.5	24.5	16.5	16.7	18.4	6.5	69	70	78	49	53
Louisiana	42.7	40.9	50.6	21.1	15.4	14.5	19.7	5.6	72	70	77	71	60
Maine	33.4	33.7	— c	— c	12.5	12.6	— c	— c	73	74	— b	76	58
Maryland	33.7	34.3	36.0	20.7	12.5	12.4	15.0	6.5	73	74	75	64	60
Massachusetts	30.3	30.7	30.8	25.3	10.1	10.2	11.3	7.3	76	79	73	69	62
Michigan	34.3	33.6	39.7	33.2	13.5	13.2	17.1	11.1	72	74	74	58	56
Minnesota	34.3	34.5	39.5	31.8	11.4	11.4	12.2	8.7	71	73	65	52	53
Mississippi	45.0	43.0	51.0	22.8	17.7	16.1	22.0	6.6	65	64	69	— b	47
Missouri	38.9	39.2	42.5	20.9	14.1	14.1	17.7	6.3	67	68	68	76	50
Montana	35.1	34.6	— c	22.9	12.4	12.1	— c	12.8	65	66	— b	70	49
Nebraska	36.7	37.0	35.0	30.9	14.5	15.0	14.4	8.7	69	71	66	48	53
Nevada	34.2	34.0	42.3	30.2	13.9	14.5	16.4	10.8	63	65	65	54	42
New Hampshire	31.9	32.3	— c	27.4	10.9	11.0	15.5	8.5	74	75	— b	72	61
New Jersey	36.7	37.8	42.8	32.3	11.7	12.3	15.4	8.8	70	73	75	65	52
New Mexico	32.6	29.7	30.6	35.5	12.2	10.9	13.1	14.2	59	61	— b	57	39
New York	34.1	34.2	36.1	31.8	10.9	11.2	12.9	8.3	71	74	72	69	56
North Carolina	34.4	34.7	37.7	24.3	12.8	12.6	16.2	6.2	70	72	77	41	54
North Dakota	38.3	36.2	— c	— c	12.5	12.3	— c	— c	68	69	— b	— b	52
Ohio	36.8	37.0	37.3	24.1	13.7	13.9	15.2	7.6	70	71	71	57	55
Oklahoma	39.2	37.0	41.0	31.8	16.4	16.3	18.7	9.8	65	67	69	47	47
Oregon	31.1	31.1	31.7	26.0	12.1	12.4	13.3	9.0	70	73	— b	60	52
Pennsylvania	35.5	35.4	35.5	33.0	13.0	13.0	15.6	9.7	70	71	68	65	52
Rhode Island	30.3	30.7	26.4	21.1	10.8	11.4	9.0	5.4	78	80	78	69	63
South Carolina	34.5	33.8	38.7	24.7	13.7	12.9	17.7	7.8	71	72	72	65	55
South Dakota	38.2	37.7	— c	26.0	13.7	13.3	— c	— c	65	68	— b	63	46
Tennessee	37.2	37.4	41.1	18.8	15.2	15.0	18.7	5.8	—	—	—	—	—
Texas	37.3	36.8	44.3	38.0	13.9	14.2	18.2	12.9	66	70	73	60	48
Utah	27.7	27.1	30.2	32.9	11.0	11.1	13.6	10.3	68	71	— b	60	51
Vermont	30.6	30.9	— c	— c	12.9	13.0	— c	— c	72	73	— b	— b	56
Virginia	32.3	32.3	37.1	20.1	13.1	13.1	17.0	6.7	69	69	73	71	51
Washington	32.4	32.3	35.2	28.6	12.1	12.3	14.8	9.2	69	72	65	62	53
West Virginia	42.9	43.6	40.8	— c	16.6	16.8	17.1	— c	67	68	64	— b	51
Wisconsin	33.0	32.4	43.3	29.3	11.6	11.6	17.8	6.9	72	73	77	61	59
Wyoming	34.2	34.2	— c	30.2	14.5	14.3	— c	13.2	60	61	— b	51	44
Puerto Rico f	—	—	—	—	—	—	—	—	65	— b	— b	65	48
United States g , h	35.3	35.2	40.4	32.7	12.9	12.9	16.6	10.6	69	70	72	60	52

Note: Screening prevalence is age adjusted to the 2000 US standard population (for more information, see Materials and Methods) and does not distinguish between examinations for screening and diagnosis. Tennessee was excluded because it did not meet the minimum requirements for reporting in the 2024 Behavioral Risk Factor Surveillance System. Incidence and mortality rates are per 100,000 population and age adjusted to the 2000 US standard population. Incidence rates are also adjusted for delays in case reporting except for the state of Kansas. White and Black race are exclusive of persons of Hispanic ethnicity.

Abbreviation: DC, District of Columbia.

^a Defined as a fecal occult blood test/fecal immunochemical test, a multitarget stool DNA test, sigmoidoscopy, colonoscopy, or computed tomography colonography in the past 1, 3, 5, 10, and 5 years, respectively.

^b Estimates were suppressed if the denominator sample size (no.) was <50 or the relative standard error was ≥30%.

^c Rates were suppressed if there were fewer than 25 cases or 10 deaths.

^d Incidence rates are based on cases diagnosed during 2016–2020.

^e Incidence rates are based on cases diagnosed during 2017–2021.

^f Incidence and mortality rates are not available by race/ethnicity.

^g Incidence rates do not include Kansas or Puerto Rico.

^h Screening prevalence is the median of state values.

Colorectal cancer screening

CRC screening reduces mortality by preventing cancer through the identification and removal of precancerous lesions and by detecting asymptomatic early stage cancer that is more effectively treated. Observational studies suggest that colonoscopy reduces CRC incidence by about 40% and mortality by about 60%. ¹⁴² , ¹⁴³ , ¹⁴⁴ A recent study estimated that prevention and/or screening accounted for 79% of the 940,000 total CRC deaths averted during 1975–2020. ⁵ Screening was recommended to begin at age 50 years in average‐risk individuals by every major organization until 2018, when the American Cancer Society lowered the age to 45 years based on increasing risk at younger ages and microsimulation modeling that demonstrated greater benefit than harm from earlier screening. ⁴⁰ , ¹⁴⁵ The US Preventive Services Task Force also reached this decision in 2021, ³⁹ , ¹⁴⁶ and findings from numerous studies published since support the efficacy of screening adults aged 45–49 years, who represent 50% of diagnoses before age 50. For example, the prevalence of advanced adenomas and sessile serrated lesions is similar among average‐risk adults aged 45–49 and 50–54 years at first screening, ¹⁴⁷ , ¹⁴⁸ and several studies have reported reductions in CRC incidence (by 21%–50%) and mortality (39%) associated with screening before age 50 years. ¹⁴⁹ , ¹⁵⁰ , ¹⁵¹

The prevalence of self‐reported, up‐to‐date screening with any recommended test among individuals aged 45 years and older was 65% in 2023, ranging from 56% among Hispanic individuals to 67% among White individuals (Table 8). Although uptake remains low in individuals aged 45–49 (37%) and 50–54 (55%) years, these were the only two age groups to experience a statistically significant increase since 2019, ³⁸ up from 20% and 52%, respectively. ¹⁵² Other characteristics associated with low screening prevalence include residence in the United States for less than 10 years (43%), being uninsured (25%), and having less than a high school education (51%). Screening also varies widely by state, with prevalence in 2024 ranging from 59% to 63% in New Mexico, Wyoming, Nevada, and Alaska to 76% to 78% in Massachusetts, Connecticut, and Rhode Island (Figure 9 and Table 7).

TABLE 8.

Colorectal cancer screening prevalence(%) among adults aged 45 years and older, 2023, United States.

Variable	Stool test, % a			Colonoscopy, % b	Up‐to‐date, % c
	≥45 years			≥45 years	≥45 years	45–75 years
	Overall	sDNA	FOBT or FIT
Overall	16	10	9	56	65	63
Sex
Men	16	10	9	56	64	62
Women	16	10	9	57	65	64
Age, years
45–49	11	6	6	28	37	37
50–54	16	10	9	44	55	55
55–64	16	10	9	64	73	73
65–75	—	—	—	—	—	82
65–74	21	13	13	74	82	—
≥75	15	9	8	68	72	—
Race/ethnicity
Hispanic	19	9	14	46	56	53
White only	15	11	8	59	67	67
Black only	16	9	10	60	66	64
Asian only	18	6	14	46	58	57
AIAN only or multiple	18	12	11	49	59	57
Sexual orientation
Gay/lesbian	16	10	10	66	74	73
Straight	16	10	9	56	65	64
Bisexual	21	14	14	59	69	66
Immigration status
Born in United States/US Territory	16	11	8	59	68	67
In United States <10 years	17	— d	11	27	43	41
In United States ≥10 years	18	8	13	48	58	56
Education
Less than high school	15	7	10	42	51	49
High school diploma	15	10	8	52	59	57
Some college	17	11	10	58	67	65
College graduate	16	10	9	64	73	71
Income level
<100% FPL	15	9	9	44	51	49
100% to <200% FPL	17	10	10	49	58	57
≥200% FPL	16	10	9	60	68	66
Insurance status
Uninsured	7	3	5	18	25	24
Private	14	10	8	60	68	68
Medicaid/public/dual eligible	19	10	13	49	59	59
Medicare, aged ≥65 years	21	13	12	71	78	83
Other	21	13	13	59	70	70

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 (for more information, see Materials and Methods).

Abbreviations: AIAN, American Indian, Alaska Native; CT, computed tomography; FIT, fecal immunochemical test; FOBT, fecal occult blood test; FPL, federal poverty level; sDNA, stool DNA.

^a FOBT or FIT within the past 1 year or multitarget sDNA test within the past 3 years.

^b Within the past 10 years.

^c For groups aged ≥45, 45–49, and 50–54 years, FOBT/FIT, sDNA, sigmoidoscopy, colonoscopy, or CT colonography in the past 1, 3, 5, 10, and 5 years, respectively; for groups aged 45–75 years, FOBT/FIT, sDNA, sigmoidoscopy, colonoscopy, or CT colonography in the past 1, 3, 5, 10, and 5 years, respectively, or sigmoidoscopy in the past 10 years with FOBT/FIT in the past 1 year.

^d Estimates were suppressed if the denominator sample size (no.) was <50 or the relative standard error was ≥30.0%.

FIGURE 9.

Up‐to‐date colorectal cancer screening prevalence(%) adults aged 45 years and older by state, 2024, United States. Tennessee was excluded because it did not meet the minimum requirements for reporting in the 2024 Behavioral Risk Factors Surveillance System data. Up‐to‐date screening was defined as a fecal occult blood test/fecal immunochemical test, multitarget stool DNA test, sigmoidoscopy, colonoscopy, or computed tomography colonography in the past 1, 3, 5, 10, and 5 years, respectively. Prevalence does not distinguish between screening and diagnostic examinations. ^aAge‐adjusted to the 2000 US standard population. DC indicates District of Columbia.

Although stool testing is a less commonly used screening test in the United States than in most other countries, its uptake increased from 6.6% in 2019 to 10.1% in 2021, largely offsetting pandemic‐related declines in colonoscopy use and thereby preventing a drop in CRC screening, unlike the decreases observed for breast and cervical cancer. ⁴⁵ In addition, stool testing is preferred among young and marginalized racial‐ethnic groups (Table 8), likely at least in part because of lower cost and greater convenience than colonoscopy. Evidence from a randomized non‐inferiority clinical trial in Spain suggested that individuals are more likely to participate in screening when offered stool testing with the fecal immunochemical test (39.9%) versus colonoscopy (31.8%), with no difference between the two tests in CRC‐related mortality at 10 years with timely follow‐up of abnormal tests with colonoscopy. ¹⁵³ Timely colonoscopy follow‐up of positive tests is a critical step in complete screening and a recent study of nearly 33,000 individuals who had a positive stool test reported that only 53% received a colonoscopy within 1 year. ¹⁵⁴ Stool testing as recommended is a particularly good option for younger adults at average risk of CRC because they have a lower absolute risk of disease compared with older adults. The multitarget stool DNA test is a relatively newer alternative to the annual fecal immunochemical test, with a 3‐year screening schedule, although the per test cost to the healthcare system remains substantially higher than that of other stool tests. ¹⁵⁵ Newer blood‐based tests have yet to be included among recommended tests by major organizations. Although these tests appear to provide lower benefit at a higher cost, ¹⁵⁵ , ¹⁵⁶ the convenience of testing with a single blood draw may contribute to higher screening rates through uptake among adults who have not shown willingness to use historically recommended screening options.

CONCLUSION

The landscape of CRC in the United States is changing rapidly. Mortality is now increasing in adults younger than 65 years alongside incidence, confirming an increase in the underlying risk of CRC in individuals born after circa 1950. As these generations age, the CRC burden in these cohorts will continue to swell like a tsunami moving through time, underscoring an urgent need for etiologic research to discover the cause of rising incidence. In the near term, many cases and deaths could be averted through increased efforts to achieve broad initiation of screening at ages 45 years (or earlier in individuals with a family history that increases risk), regular screening, and timely workup of individuals with positive noncolonoscopy test results. Risk can also be mitigated through educational campaigns to increase awareness of red flag symptoms for the disease (rectal bleeding, abdominal pain, diarrhea, iron‐deficiency anemia) among clinicians and the general public to facilitate earlier detection and timely treatment, and also to help destigmatize the disease. Finally, greater attention is needed to increase adoption of healthy lifestyle habits and address the unique needs of younger patients, including provider conversations about the side effects of treatment and opportunities for the preservation of reproductive and sexual health.

CONFLICT OF INTEREST STATEMENT

All authors are employed by the American Cancer Society, which receives grants from private and corporate foundations, including foundations associated with companies in the health sector, for research outside of the submitted work. The authors are not funded by or key personnel for any of these grants, and their salary is solely funded through American Cancer Society funds. The authors disclosed no conflicts of interest.