Should We Screen Sooner? Elevated CRC Incidence in Solid Organ Transplant Recipients in the United States Before and After the COVID ‐19 Pandemic

Background Solid organ transplant (SOT) recipients have an elevated malignancy risk due to long‐term immunosuppression; however, the risk of colorectal cancer (CRC) is not well characterized, and current screening guidelines are not tailored to this population. Methods We used the TriNetX U.S. Collaborative Network to identify adults with SOT (kidney, liver, heart, or lung transplantation) between 2005 and 2025. SOT patients were propensity‐score matched 1:1 to non‐transplant controls, and CRC incidence at the 10‐year and 20‐year follow‐up was compared. Sensitivity analyses evaluated CRC incidence before (2015–2019) and after (2020–2024) the COVID‐19 pandemic onset. Results We identified 90 510 SOT recipients (matched to 90 510 controls from 9.8 million general patients). After matching, the baseline characteristics were balanced. SOT recipients had a higher cumulative incidence of CRC than controls at both 10 years (0.17% of kidney transplant patients vs. 0.02% of controls; p < 0.001) and 20 years posttransplantation. This elevated risk was observed across the kidney, liver, lung, and heart transplant cohorts (odds ratios: 1.3 for CRC in SOT vs. non‐SOT at 10–20 years). Additionally, CRC incidence was higher in the post‐COVID era compared to the pre‐2019 era in all SOT groups (e.g., kidney 0.25% vs. 0.14%). This increase was most pronounced in older recipients (≥ 70 years) and Hispanic patients. Conclusion SOT recipients in the United States exhibit a significantly higher long‐term CRC risk, a disparity that appears to have widened after the pandemic. These findings underscore the need to revisit CRC screening strategies in SOT recipients, particularly older and long‐term transplant survivors.