Early Colorectal Cancer: Missing the Clues?

Third Annual Early Age Onset – Colorectal Cancer Symposium; March 12, 2017

Toni L. Kamins, MA

Disclosures

March 29, 2017

In 2012, teacher Kristen McRedmond was the picture of health; by February 2017 she was deceased. Given that snippet of information alone, the story does not seem all that uncommon, but Kristen was only 38 years old when she died, and the cause of death was colorectal cancer (CRC).[1]

Josh Lambeth returned to his family doctor many times over the course of 3 years with the same rectal bleeding symptoms. The doctor told him he was healthy, chalked it up to hemorrhoids, and said that at age 30 he was too young for it to be anything serious. Even the gastroenterologist thought it would be nothing more than irritable bowel syndrome or ulcerative colitis. But the results of his colonoscopy proved far more devastating—stage II rectal cancer. And Josh was only 31 years old.[2]

Of course, virtually any disease can present outside the usual patient cohort, but CRC in younger adults is no longer unusual and has, in fact, become common enough to have earned its own name. In fact while CRC overall has been on the decline in the United States for decades, its incidence has increased dramatically in those under 50.

 
[F]oremost for all of the attendees was the absolute necessity of early detection.
 

The Third Annual Early Age Onset-Colorectal Cancer (EAO-CRC) Symposium, which was held at New York's NYU Langone Medical Center on March 12, provided an opportunity for patients, clinicians, researchers, and caregivers to discuss and brainstorm a number of issues related to care and treatment. But foremost for all of the attendees was the absolute necessity of early detection.

A February 2017 article in the Journal of the National Cancer Institute (JNCI) [3] provides some sobering figures:

...colon cancer incidence rates increased by 1.0% to 2.4% annually since the mid-1980s in adults age 20 to 39 years and by 0.5% to 1.3% since the mid-1990s in adults age 40 to 54 years; rectal cancer incidence rates have been increasing longer and faster (e.g., 3.2% annually from 1974–2013 in adults age 20–29 years).

Since 1974, the incidence of rectal cancer in adults 55 years of age or older has declined. Since the mid-1980s, the same is true of colon cancer. But between 1989-1990 and 2012-2013, incidence rates of rectal cancer in adults 50-54 years old increased from half that of the 55-59 rate, to the equivalent (24.7 vs 24.5 per 100,000 persons: incidence rate ratio (IRR), 1.01; 95% confidence interval [CI], 0.92-1.10). At the same time, the number of rectal cancer diagnoses in those younger than 55 doubled, from 14.6% (95% CI, 14.0%-15.2%) to 29.2% (95% CI, 28.5%-29.9%).[3]

 
CRC is up significantly in those under age 50.
 

As a result, people born after 1990 have about double the risk of getting colon cancer at a younger age than those born in 1950 (IRR, 2.40; 95% CI, 1.11-5.19) and quadruple the risk of early rectal cancer (IRR, 4.32; 95% CI, 2.19-8.51).[3]

The conclusions? Although the cause or causes of the increase are unknown, CRC is up significantly in those under age 50, and the increase of CRC in young adults in their 20s and 30s is alarming.

The Primary Care Connection

Early detection is where the primary care doctor plays a critical role.

For primary care doctors, the increase in the number of CRC diagnoses raises many questions and concerns: when to screen, how to increase awareness of symptoms, the need for better and more detailed family medical histories, and the recognition that a referral to a gastroenterologist for a colonoscopy should not be ruled out even when the patient is young.

The symposium's takeaway was this: When CRC-like symptoms are present, regardless of a patient's age, it is important not to dismiss them or chalk them up to more benign causes simply because the patient is under 50, 30, or, sadly, even under 20.

Dr Joshua Raff, director of the Digestive Cancer Program at White Plains Hospital in New York, who attended the symposium, told Medscape that "attitudes toward symptomatic young patients—for example, those with gastrointestinal bleeding or change in bowel habits—are important. This requires more attention on the part of primary care doctors, to allow them to consider a GI referral more readily." In addition, said Raff, "gastroenterologists need to be more considerate of the possibility of a GI malignancy in younger patients once referred." Family history must be taken more thoroughly too and updated on a regular basis, perhaps annually. But a negative family history does not obviate the need to proceed with a workup for concerning symptoms.

Making Connections for Early Detection

Lynch syndrome. In the case of CRC, family history is vital.

While "most colorectal cancer is sporadic," some "3% to 5% of all cases of colorectal cancer are thought to be due to Lynch syndrome," according to Cancer.Net.[4]

Cancer.Net lists the following factors that can suggest Lynch syndrome, again demonstrating the critical role of family medical history in diagnosing CRC as early as possible:

  • Developing colorectal cancer younger than age 50;

  • Developing colorectal cancer and other cancers—endometrial, uterine, gastric, ovarian, small bowel, pancreatic, urinary tract, kidney, bile duct—linked with Lynch syndrome separately or at the same time;

  • Developing colorectal cancer with tumor features linked to Lynch syndrome at an age younger than 60;

  • Colorectal cancer in one or more first-degree relatives who also have or have had another Lynch syndrome–related cancer, with one of these cancers developing before age 50; and

  • Colorectal cancer in two or more first- or second-degree relatives with another Lynch syndrome-related cancer.

If a patient presents with symptoms that suggest CRC, and a family history does exist, a referral to a geneticist in addition to a gastroenterologist may be warranted.

Changing the screening guidelines. Cindy Borassi of the Colon Cancer Challenge Foundation said that the National Colorectal Cancer Roundtable EAO-CRC Task Force is spearheading the development of an addendum to the CRC screening Clinicians' Toolbox and Guide. This "will provide a logical model and the specific implementation steps needed to transform practices in order to improve their ability to collect family history." Advocates of earlier detection strategies hope that this will increase CRC screening for those at familial or genetic risk, and increase diagnostic testing for young adults who present with symptoms.

"The goal," she said, "is to bridge the knowledge gap and to provide a step-by-step, detailed tool" to practitioners so that they can improve collection of family history data as well as act appropriately on the information. The authors of the JNCI article explain that "reversing increasing trends in adults age 50 to 54 years requires not only increased adherence to screening guidelines but also screening before age 50 years because the full benefit of polypectomy for preventing CRC requires about a decade to realize."[3]

Although evidence in support of screening patients under the age of 45 has not yet been substantiated, Siegel and colleagues[3] note that in 2013 there were some 10,400 new cases of CRC diagnosed in adults between the ages of 40 and 49 and 12,800 cases in the 50-54 age group.

The article goes on to state this from the Cancer Intervention and Surveillance Modeling Network (CISNET): Beginning screening at the age of 45 is "more effective and provided a more favorable balance between life-years gained and screening burden than starting at age 50 years. Endoscopic screening could be particularly useful in stemming the tide of tumors in the distal colon and rectum, which are preponderant in young patients."[3]

At 44, Stacy Hurt had no risk factors when her stage IV cancer was diagnosed in her rectum, liver, lungs, and lymph nodes. At the symposium, she told Medscape that colon cancer was the last thing her doctor suspected and she remembers her saying, "this is probably irritable bowel syndrome or internal hemorrhoids. But let's order a colonoscopy just to be sure."

Hurt wants doctors to think about colonoscopies the same way they think of other diagnostic tests. "When a woman visits her doctor, no matter what her age, if she has a lump in her breast, the first thing a doctor does is send her for a mammogram to rule out breast cancer. If a person comes in complaining of headaches, dizziness, and blurred vision, the first thing a doctor does is send that patient for a CT scan to rule out a brain tumor." But Hurt noted that when a person comes in complaining of abdominal pain, blood in their stool, and fatigue, for some reason, doctors hesitate to send patients for colonoscopies. "Why is that?" she asked. "It's almost like they think it can be anything else. I was 44, athletic, a non-smoker of normal weight, and otherwise perfectly healthy. I didn't fit the profile of a colon cancer patient." Hurt is grateful that her doctor did not hesitate because that colonoscopy saved her life. But she speaks routinely with other patients and knows that the hesitation on the part of doctors is there, and that misdiagnosis is far too common.

"Patients need to know their own bodies and realize when something is not normal. They need to take action, see a doctor, and become an advocate for their own care." Physicians can help this process by asking the right questions, listening for clues, sending reminders about keeping regular appointments, and referring patients to other specialists.

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