Elsevier

Mayo Clinic Proceedings

Volume 89, Issue 2, February 2014, Pages 216-224
Mayo Clinic Proceedings

Special article
The Increasing Incidence of Young-Onset Colorectal Cancer: A Call to Action

https://doi.org/10.1016/j.mayocp.2013.09.006Get rights and content

Abstract

In the United States, colorectal cancer (CRC) is the third most common and second most lethal cancer. More than one-tenth of CRC cases (11% of colon cancers and 18% of rectal cancers) have a young onset (ie, occurring in individuals younger than 50 years). The CRC incidence and mortality rates are decreasing among all age groups older than 50 years, yet increasing in younger individuals for whom screening use is limited and key symptoms may go unrecognized. Familial syndromes account for approximately 20% of young-onset CRCs, and the remainder are typically microsatellite stable cancers, which are more commonly diploid than similar tumors in older individuals. Young-onset CRCs are more likely to occur in the distal colon or rectum, be poorly differentiated, have mucinous and signet ring features, and present at advanced stages. Yet, stage-specific survival in patients with young-onset CRC is comparable to that of patients with later-onset cancer. Primary care physicians have an important opportunity to identify high-risk young individuals for screening and to promptly evaluate CRC symptoms. Risk modification, targeted screening, and prophylactic surgery may benefit individuals with a predisposing hereditary syndrome or condition (eg, inflammatory bowel disease) or a family history of CRC or advanced adenomatous polyps. When apparently average-risk young adults present with CRC-like symptoms (eg, unexplained persistent rectal bleeding, anemia, and abdominal pain), endoscopic work-ups can expedite diagnosis. Early screening in high-risk individuals and thorough diagnostic work-ups in symptomatic young adults may improve young-onset CRC trends.

Section snippets

Young-Onset CRC Incidence and Mortality

In Americans younger than 50 years, CRC incidence per 100,000 individuals ranges from 0.85 (ages 20-24 years) to 28.8 (ages 45-49 years).17 Although these rates are substantially lower than those in older age groups, the incidence has increased significantly in younger individuals and decreased in older individuals (Figure 1).18 The national 1987-2006 Surveillance, Epidemiology, and End Results (SEER) data (Figure 2, A-C) reveal increased colon and rectal cancer incidence in all 5-year age

Why is Young-Onset CRC Increasing?

Drivers of increasing young-onset CRC incidence are not well understood. In the absence of rigorous epidemiologic studies, it is noteworthy that young-onset CRC incidence increased, whereas CRC risk factors, such as sedentary lifestyle, obesity, and diabetes mellitus, were common or increasing.23, 24, 25 Each 5-unit increase in body mass index is associated with an estimated 13% to 18% increase in CRC risk.3, 26 Diabetes mellitus has been associated with up to a 38% (summary relative risk 95%

Distinctive Biology and Genetics of Young-Onset CRC

Single-institution and population-based studies have found distinctive tumor location, stage at presentation, and histologic features in young-onset CRC.10, 30, 31, 32, 33 These tumors occur more often than later-onset tumors in the distal colon and the rectum (69.0% vs 57.7%, P<.001).10 In individuals 35 to 39 years of age, 32% of CRC tumors occurred in the rectum. The percentages decreased in subsequent age groups to a low of 15.1% in the 85 years and older group.19 The proportion of rectal

High-Risk Individuals: Early Screening for Young Adults With Family History, Predisposing Conditions, or Hereditary Syndromes

A family history of CRC or advanced adenomatous polyps in a first-degree relative (FDR), particularly if the CRC occurred before 60 years of age, can increase an individual’s CRC risk up to 4-fold.42 Approximately 10% to 15% of American adults have at least 1 FDR with CRC and are therefore at increased risk for this disease (Table 2).42 Individuals with an FDR younger than 60 years diagnosed as having CRC should begin screening either at 40 years of age or 10 years earlier than the youngest age

Evaluation of Colorectal Symptoms in Young Individuals

Screening is relevant only for asymptomatic individuals. Once CRC symptoms arise, however, an expeditious work-up is essential for all patients. Unfortunately, lack of awareness of the increasing incidence of young-onset CRC and, consequently, a low suspicion of cancer may delay the thorough symptom evaluation needed to effectively establish or rule out young-onset CRC.

Patients with young-onset CRC and their physicians both appear to contribute to delayed diagnosis. On average, symptomatic

Should Average-Risk CRC Screening be Initiated Earlier?

Population-based CRC screening for asymptomatic, average-risk individuals starting at 50 years of age is supported by the US Preventive Services Task Force, the Agency for Healthcare Policy and Research, the US Multi-Society Task Force, and various specialty organizations.46, 47, 64, 65, 66 From 1975 to 2000, screening has been credited with approximately half of the 22% decrease in CRC incidence and the 26% reduction in CRC mortality, with treatment and risk factor reductions accounting for

Conclusion

In the United States, CRC incidence and mortality are increasing at a significant rate each year in men and women younger than 50 years and steadily decreasing in all other age groups. Primary care physicians can play a critical role in decreasing the incidence and mortality of young-onset CRCs by changing their approach to evaluating and educating their younger patients. Primary care physicians can use readily available tools to obtain a detailed family history, taken well before the age of 50

References (69)

  • S.J. Winawer et al.

    Colorectal cancer screening: clinical guidelines and rationale

    Gastroenterology

    (1997)
  • D.K. Rex et al.

    Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology

    Am J Gastroenterol

    (2000)
  • L.C. Richardson et al.

    Vital signs: colorectal cancer screening among adults aged 50-75 years—United States, 2008

    MMWR Morb Mortal Wkly Rep

    (2010)
  • Cancer Facts & Figures 2012

    (2012)
  • R. Siegel et al.

    Cancer statistics, 2012

    CA Cancer J Clin

    (2012)
  • C. Eheman et al.

    Annual report to the nation on the status of cancer, 1975-2008, featuring cancers associated with excess weight and lack of sufficient physical activity

    Cancer

    (2012)
  • B.K. Edwards et al.

    Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates

    Cancer

    (2010)
  • D. Eddy

    ACS report on the cancer-related health checkup

    CA Cancer J Clin

    (1980)
  • M. Sarfaty et al.

    The effect of HEDIS measurement of colorectal cancer screening on insurance plans in Pennsylvania

    Am J Manag Care

    (2008)
  • National Cancer Institute. State Cancer Profiles. http://statecancerprofiles.cancer.gov/recenttrend/recenttrend.html....
  • Y.N. You et al.

    Young-onset colorectal cancer: is it time to pay attention?

    Arch Intern Med

    (2012)
  • J.E. Meyer et al.

    Increasing incidence of rectal cancer in patients aged younger than 40 years: an analysis of the Surveillance, Epidemiology, and End Results database

    Cancer

    (2010)
  • R.L. Siegel et al.

    Increase in incidence of colorectal cancer among young men and women in the United States

    Cancer Epidemiol Biomarkers Prev

    (2009)
  • E.J. Dozois et al.

    Young-onset colorectal cancer in patients with no known genetic predisposition: can we increase early recognition and improve outcome?

    Medicine

    (2008)
  • J.B. O’Connell et al.

    Do young colorectal cancer patients have worse outcomes?

    World J Surg

    (2004)
  • J.R. Varma et al.

    Colorectal cancer in patients aged less than 40 years

    J Am Board Fam Pract

    (1990)
  • Surveillance Epidemiology and End Results. Fast Stats. http://seer.cancer.gov/faststats/selections.php?#Output....
  • Surveillance Epidemiology and End Results. Fast Stats....
  • D.M. Davis et al.

    Is it time to lower the recommended screening age for colorectal cancer?

    J Am Coll Surg

    (2011)
  • Surveillance Epidemiology and End Results. Fast Stats. http://seer.cancer.gov/faststats. Accessed November...
  • Surveillance Epidemiology and End Results. Fast Stats....
  • Surveillance Epidemiology and End Results. Fast Stats....
  • Trends in leisure-time physical inactivity by age, sex, and race/ethnicity—United States, 1994-2004

    MMWR Morb Mortal Wkly Rep

    (2005)
  • K.M. Flegal et al.

    Prevalence and trends in obesity among US adults 1999-2000

    JAMA

    (2002)
  • Cited by (0)

    Grant Support: This work was supported by the Colon Cancer Alliance and partially supported by the University of Texas MD Anderson Cancer Center G. S. Hogan Gastrointestinal Cancer Research Fund (Y.N.Y.).

    Potential Competing Interests: Dr Ahnen serves on the scientific advisory boards of EXACT Sciences and CM&L Pharma. Dr Jones is a member of the Salix Pharmaceuticals speaker’s bureau and a partner in Premier Surgical Center, Louisville, KY. Dr You receives funding from the University of Texas MD Anderson Cancer Center G. S. Hogan Gastrointestinal Cancer Research Fund. Ms Guiffre, Dr Mendoza Silveiras, Mr Spiegel, and Ms Greenamyer are employees of the Colon Cancer Alliance, and Ms Wade serves as a consultant to the Colon Cancer Alliance. Dr Sifri and Ms Axilbund have no conflicts of interest to disclose.

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