Aligning Kentucky Practice With United States Multisociety Task Force (MSTF) Guidelines to Advance Colorectal Cancer Prevention
(Effective January 1, 2026)
By Whitney F. Jones, M.D., William B. Evans, M.D., FACG, Sandy Kavalucas, M.D., FACS, Wayne B. Tuckson, M.D., FASCRS, and Gerald W. Dryden, M.D., PhD, MSc
Introduction: Kentucky’s Progress and Continuing Challenge
Over the past two decades, Kentucky has transformed from ranking near the bottom of national colorectal cancer (CRC) screening rates to one of the top 20 states for CRC screening. This extraordinary public health success resulted from cooperation between multiple clinical partners involved in the cancer screening process across the Commonwealth.
Despite this early progress, participation in screening has plateaued. Kentucky still experiences one of the highest CRC incidence and mortality rates in the nation. Kentucky is also home to a nation-leading proportion—approximately 1 in 5—of residents with an increased familial risk of CRC. This highlights the need for on-time screenings that adhere to guidelines for high-risk individuals, as well as timely screenings starting at age 45 for those at average risk.
Rates of early-age-onset CRC (EAO-CRC) remain especially high in both Appalachian and urban Black communities, driven by overall lower compliance and under-recognition of familial or hereditary high risk. Alignment with the US Multi-Society Task Force (MSTF) refocuses efforts to emphasize CRC prevention by identifying and removing precancerous lesions, in addition to early-stage detection.³
KRS 304.17A-257 and US MSTF Alignment
KRS 304.17A-257, passed unanimously by the Kentucky legislature, was signed into law in 2025. Effective January 1, 2026, this law modernizes preventive-service coverage for CRC screening across the vast majority of commercial insurance plans and all Medicaid managed-care plans. This comprehensive law mandates access to screening and surveillance colonoscopies, provides better access to effective bowel preparations, and removes both cost-sharing and prior-authorization barriers.
This law aligns Kentucky’s coverage with the evidence-based standards of the US Multi-Society Task Force on Colorectal Cancer, composed of the American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE), selected by state prevention leaders and legislators as the most science-driven framework.³
Expanded Definition of High Risk
Individuals with a first-degree relative (FDR) who has been diagnosed with colorectal cancer, an advanced adenoma with villous features or high-grade dysplasia, or a sessile serrated adenoma/polyp (SSA/P) ≥10 mm are now defined as high risk for CRC, regardless of the relative’s age at diagnosis.
Screening should begin at age 40, or 10 years before the youngest affected relative:
● If the FDR was diagnosed before age 60, screening colonoscopy is preferred and should be repeated every 5 years unless higher-risk findings are present.
● If the FDR was diagnosed at age 60 or older, any approved modality (colonoscopy, FIT, or a genomic-based stool test) may be used; however, screening still begins at age 40.
Given Kentuckians’ elevated baseline risk, colonoscopy or genomic-based stool testing is favored for superior detection of advanced adenomas and serrated lesions. Colonoscopy following a positive stool-based test must be billed as screening, not diagnostic. This protection has been in place since 2015 and was reaffirmed under KRS 304.17A-257.
Low-Volume Split-Dose Bowel Preparations (Preps): Removing Barriers
Bowel preparation quality is a major determinant of adenoma detection rate (ADR) and successful procedure completion. Traditional high-volume single-dose bowel preps have long deterred participation. Low-volume split-dose (LV-SD) preps improve both cleansing and patient tolerance, raising adequate preparation rates from 77% to 91% while reducing cancellations by 23%.⁴–⁷ The MSTF recommends split-dose preps for all elective colonoscopies in medically appropriate patients.³
Under KRS 304.17A-257, all FDA-approved LV-SD preps are covered with no cost-sharing or prior-authorization requirements, aligning Kentucky practice with AGA/ACG/ASGE standards and enhancing efficiency across endoscopy units.
Key Updates Under KRS 304.1 ZA-257
• High-risk definition expanded: includes BOTH advanced and sessile serrated
adenomas/polyps (SSAIP) in addition to CRC.
• Age restriction removed: a FDR diagnosis of CRC or AA at any age qua ifies a
FDR as high-risk.
• Modern preps covered: alll FDA-approved LV-SD preps covered-no PA, no
copay.
• Follow-up colonoscopy for +SBT cover.age confirmed: colonoscopy, after a
positive stool-based test remains coded and reimbursed as screening, not
diagnostic, with no out-of-pocket costs.
Modern Noninvasive Screening Options
In addition to high-quality colonoscopy, noninvasive options can expand access,
particularly in communities with limited endoscopy capacity or high patient hesitation.
Alternatives include the fecal immunochemical test (FIT), which detects human
hemoglobin as a marker of occult bleeding; genomic-based stool tests (such as
multitarget stool DNA or emerging RNA-based assays) that analyze molecular markers
of both cancer and precancerous lesions; and blood-based tests that detect circulating
tumor DNA or methylation signatures.
Genomic-based stool tests detect both CRC and precursor lesions with higher
sensitivity and better serial adherence than FIT and require testing only once every
three years.¹,¹⁰ These tests are FDA approved, MSTF endorsed, and covered under
KRS 304.17A-257.
Fecal immunochemical testing (FIT), though effective in modeling studies, depends on
annual serial completion. The most organized systems (eg, Kaiser Permanente, and
others) achieve 75%–86% completion per screening round with substantial investment
in navigation services.¹,⁸,⁹ Yet, real-world adherence declines to approximately
10%–15% after 3 years in national claims data.¹² FIT also fails to detect most sessile
serrated adenomas (approximately 95%) and many advanced precancers. Serrated
adenoma–colorectal cancer pathways account for approximately 20% of colorectal
cancers.¹³
While blood-based CRC tests improve accessibility, they remain a third-tier option as
they primarily detect existing cancer rather than precancerous polyps. Kentucky’s
prevention strategy prioritizes tests that identify and lead to the removal of advanced
adenomas and sessile serrated lesions. Programmatic stool- and colonoscopy-based
screening remain the preferred prevention pathways.
CT Colonoscopies (CTC) are also effective in screening for advanced adenomas in
addition to CRC, thus qualify as a “modern screening method.14 Due to local expertise
and logistics for same-day colonoscopy after positive tests, CTCs are infrequently used.
Key Implementation Steps for 2026 and Beyond
● Education and Communication: Partner with KMA, KHA, and other
stakeholders to align understanding of risk definitions, coding, and coverage.
● EHR Optimization: Capture FDR risk for CRC and advanced adenomas and
prompt age 40/10-year screening. Order sets updates to modern bowel preps.
● Formulary Readiness: Ensure availability of all FDA-approved LV-SD bowel
preparations by January 1, 2026.
● Coder Training: Reinforce that a colonoscopy for US MSTF high-risk individuals
and a completion colonoscopy after a positive stool or blood test must BOTH be
coded as screening.
● Quality Metrics: Monitor HEDIS screening completion and adequate preparation
rates.
● Public Messaging: Emphasize prevention and on-time screening based on risk
rather than detection alone.
Conclusion
The enactment of KRS 304.17A-257 marks a pivotal shift from detection to prevention,
aligning Kentucky with MSTF standards, guaranteeing access to modern bowel
preparations, and removing financial barriers to comprehensive CRC screening.
Approximately 68% of colorectal cancer deaths could be prevented by fully adhering
to recommended screening and surveillance, especially through the detection and
removal of advanced adenomas and serrated precursors before they undergo
malignant transformation.¹¹
By emphasizing early identification and removal of precancerous polyps through
risk-based screening and modern genomic tools, Kentucky can dramatically reduce the
burden of this lethal disease. Achieving this outcome will require full participation from
every stakeholder in Kentucky’s screening ecosystem—primary care providers, gastroenterologists, surgeons, coders, payors, and health systems—to fully and
consistently implement KRS 304.17A-257.
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Authors Note
Whitney Jones, MD, is a gastroenterologist, long-time colorectal cancer prevention
advocate, and the founder of the Colon Cancer Prevention Project. He previously
chaired the Kentucky Colon Cancer Screening and Prevention Program Advisory
Committee.
William B. Evans, MD, FACG, is a gastroenterologist at Norton Healthcare, a board
member of the Colon Cancer Prevention Project, and a member of the KCCSPP
Advisory Committee.
Sandy Kavalucas, MD, FACS, is a colorectal surgeon, an Assistant Professor at the
University of Louisville, and a board member of the Colon Cancer Prevention Project.
Wayne B. Tuckson, MD, FASCRS is a board member of the Colon Cancer Prevention
Project
Gerald W. Dryden, MD, PhD, MSc, is a gastroenterologist and Professor of Medicine at
the University of Louisville and a board member of the Colon Cancer Prevention
Project.