Researchers outline framework to address rising rates of early-onset colorectal cancer
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Worldwide prevalence of sporadic colorectal cancer— long viewed as a disease of older individuals — has increased steadily among those aged younger than 50 years during the past decade, according to a review paper in The Lancet Oncology.
“This review is one of three papers The Lancet decided to focus on regarding the early-onset colorectal cancer patient population,” Cathy Eng, MD, FACP, FASCO, David H. Johnson endowed chair in the division of surgical and medical oncology and professor of medicine in the department of hematology and oncology at Vanderbilt University Medical Center, said during an interview with Healio.
“The subject matter is of interest to many of us who treat colorectal cancer because it is startling to see a young adult in our clinic diagnosed with sporadic colorectal cancer,” Eng added. “I have been seeing these patients for second opinions in my office for many years now.”
Eng spoke with Healio about how the review paper came about, the potential underlying causes of sporadic colorectal cancer among young adults, and what oncologists and other clinicians can do to help these patients.
Healio: What prompted this review?
Eng: Greater recognition is now being given to early-onset colorectal cancer. We are concerned that young adult survival is significantly less than that of the average-age patient because this younger population is presenting with late-stage disease. The purpose of these papers is to further promote education and awareness — not only by trying to prevent the development of colorectal cancer, but determining how can we optimize care of younger patients who receive this diagnosis, other than just treating it surgically or with radiation or chemotherapy.
Healio: What are the potential underlying causes?
Eng: We do not know the exact etiology, but it is likely multifactorial. Most of these patients are not going to be diagnosed with an inherited form of colorectal cancer. I see patients in my clinic who are in their 20s to early 40s, which means that they are not of screening age. Most people develop a polyp before it becomes cancerous. The polyp takes between 5 and 10 years to progress to adenocarcinoma. Being diagnosed with a polyp at such a young age could mean there is an environmental factor at play, and obesity plays a factor, as well. There is also a lot of interest in how the microbiome plays into this, too.
We also know that patients with left-sided tumors are expected to do better than those with right-sided tumors. Yet, it is interesting because most young-adult patients have left-sided tumors. We do not know why this is happening and we do not have enough answers, which is why many of us are so interested in ongoing research and trying to learn more about these patients.
Healio: What is treatment like for these younger patients?
Eng: Patients diagnosed with colon cancer will go directly to resection. For rectal cancers, depending upon the degree of tumor involvement, radiation therapy is given. This is all for the average young patient and it all depends on how many lymph nodes are involved and where the tumor is located. A patient with metastatic colon cancer may be on chemotherapy indefinitely and that is always a difficult subject, especially for younger individuals who are often starting out on a pivotal aspect of their life.
Healio: What psychological and quality-of-life impacts does colorectal cancer have on younger patients?
Eng: We have specifically considered the psychosocial challenges of being diagnosed with colorectal cancer at younger age and the potential financial toxicity that might ensue. Even for those patients diagnosed with early-stage disease, some of the chemotherapy can cause neuropathy, which may linger and can be permanent. So, we have to be very careful about treatment in this setting. We also use this treatment in the metastatic setting, and for patients with metastatic disease who cannot go on to surgery, the duration of most chemotherapy is indefinite. The risk for toxicities in these patients can be quite high and some of the treatment regimens can cause hair loss. Some patients may also end up with a permanent colostomy, which impacts body image and quality of life. Despite our best efforts, some patients who receive radiation therapy experience radiation toxicities that can significantly impact sexual, urinary and bowel function.
With the diagnosis alone, patients may feel hopeless at times and need social support of others who can identify with what they are going through, so that they do not feel like they are alone. Moreover, if the patient is young and loses their job and insurance, they may not be able to complete their cancer care appropriately. They deal with financial instability and financial stress unimaginable to someone at such a young age.
Healio: What would you advise oncologists to do for these patients?
Eng: Do your best to connect with the patient every time they come into your office. Ask how they are doing and see if you can refer them to the appropriate person or clinic to help with whatever unmet needs they may have. Every oncologist is extremely busy and it is even harder to do this with COVID, but it is so important to take the time and make that connection with the patient and get them to open up.
I also hope that with continued awareness, more internal medicine physicians will understand the importance of recognizing early symptoms and sending these patients to be screened, even those who appear to be in perfect health but are having irregular bowel habits, for example. Most patients will tell us in retrospect that they did notice blood in their stool for several weeks or months. Irregular bowel motility and increased frequency of gas, bloating and night sweats in a young patient are concerning, as well. Additionally, it should not be presumed that anemia in a young woman can be attributed to her menses. If there is persistent iron deficiency, I would highly encourage further workup. By educating others and getting the word out, the hope is that family practitioners and internal medicine physicians will recognize that young patients can be diagnosed with colorectal cancer, and if something is not improving after a few weeks, it should be worked up. The ultimate hope is that we can diagnose these patients earlier.
Healio: Do you have anything else that you would like to mention?
Eng: This paper is meant to highlight what is occurring in the real-world setting. My hope is that others will recognize this is a potentially growing problem. We also need to improve our approach and not assume that every patient with colorectal cancer is the same, regardless of age. The reality is that our young adult patients have very different personal obstacles in their lives that may be attributed to their diagnosis, and we also need to recognize that they not only want to survive but they want to live. We need to help them live.
For more information:
Cathy Eng, MD, FACP, FASCO, can be reached at Vanderbilt University Medical Center, 2220 Pierce Ave., Nashville, TN 37232; email: cathy.eng@vumc.org.
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