Episode 183: Colorectal Cancer in Young Adults Future Dr. Avila and Dr. Arreaza present evidence-based information about the screening and diagnosis of colorectal cancer and explain the increasing incidence among young adult and the importance to screen early in high risk groups. Written by Jessica Avila, MS4, American University of the Caribbean School of Medicine. Edits and comments by Hector Arreaza, MD.
Episode 183: Colorectal Cancer in Young Adults
Future Dr. Avila and Dr. Arreaza present evidence-based information about the screening and diagnosis of colorectal cancer and explain the increasing incidence among young adult and the importance to screen early in high risk groups.
Written by Jessica Avila, MS4, American University of the Caribbean School of Medicine. Edits and comments by Hector Arreaza, MD.
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Introduction
Jessica: Although traditionally considered a disease only affecting older adults, colorectal cancer (CRC) has increasingly impacted younger adults (defined as those under 50) at an alarming rate. According to the American Cancer Society, CRC is now the leading cause of cancer-related death in men under 50 and the second leading cause in women under 50 (American Cancer Society, 2024).
Arreaza: Why were you motivated to talk about CRC in younger patients?
Jessica: Because despite advancements in early detection and treatment, younger patients are often diagnosed at later stages, resulting in poorer outcomes. We will discuss possible causes, risk factors, common symptoms, and why early screening and prevention are important.
Arreaza: This will be a good reminder for everyone to screen for colorectal cancer because 1 out of every 5 cases of colorectal cancer occur in adults between the ages of 20 and 54.
The Case of Chadwick Boseman
Jessica: Many people know Chadwick Boseman from his role as T'Challa in Black Panther. His story highlights the worrying trend of increasing CRC in young adults. He was diagnosed with stage III colorectal cancer at age 39. This diagnosis was not widely known until he passed away at 43. His case shows how silent and aggressive young-onset CRC can be. Like many young adults with CRC, his symptoms may have been missed or thought to be less serious issues. His death drew widespread attention to the rising burden of CRC among young adults and emphasized the critical need for increased awareness and early screening efforts.
Arreaza: Black Panther became a hero not only in the movie, but also in real life, because he raised awareness of the problem in young AND in Black adults.
Epidemiology
Jessica: While rates of CRC in older populations have decreased since the 1990s, adults under 50 have seen an increase in CRC rates of nearly 50%. (Siegel et al., 2023). Currently, one in five new CRC diagnoses occurs in individuals younger than 55 (American Cancer Society, 2024).
Arreaza: What did you learn about the incidence by ethnic groups? Are there any trends?
Jessica: Yes, certain ethnic groups are shown to have higher rates of CRC. Black Americans, Native Americans, and Alaskan Natives have the highest incidence and mortality rates from CRC (American Cancer Society, 2024). Black Americans have a 20% higher incidence and a 40% higher mortality rate from CRC compared to White Americans, primarily due to disparities in access to screening, healthcare resources, and early diagnosis. Hispanic and Asian American populations are also experiencing increasing CRC rates, though to a lesser extent.
Arreaza: It is important to highlight that Black Americans have the highest rate of both diagnoses and deaths of all groups in the United States. Who gets colorectal cancer?
Risk Factors
Jessica: Anyone can get colorectal cancer, but some are at higher risk. In most cases, environmental and lifestyle factors are to blame, but early-onset CRC are linked to hereditary conditions.
Arreaza: There is so much to learn about colorectal cancer risk factors. Tell us more.
Jessica: The following are key risk factors:
Modifiable risk factors:
Arreaza: As a recap, processed foods, obesity, sedentarism, and gut microbiome. We also have to mention smoking and high alcohol consumption as major risks factors, but the strongest risk factor is a family history of the disease.
Non-modifiable risk factors:
Arreaza: Also, there is a difference in incidence per gender assigned at birth, which is also not modifiable. The rate in the US was 33% higher in men (41.5 per 100,000) than in women (31.2 per 100,000) during 2015-2019. So, if you are a man, your risk for CRC is slightly higher. Protective factors, according to the ACS, are physical activity (no specification about how much and how often) and dairy consumption (400g/day). Jessica, let’s talk about how colon cancer presents in our younger patients.
Clinical Presentation and Challenges in Diagnosis
Jessica: Young-onset CRC is often diagnosed at advanced stages due to delayed recognition of symptoms. Common symptoms include:
Arreaza: All those symptoms can also be explained by benign conditions, and colorectal cancer can often be present without clear symptoms in its early stages.
Jessica: Yes, in young adults, symptoms may be dismissed by healthcare providers as benign conditions such as irritable bowel syndrome (IBS), hemorrhoids, or dietary intolerance, leading to significant diagnostic delays.
Arreaza: We must keep a low threshold for ordering a colonoscopy, especially in patients with the risks we mentioned previously.
Jessica: We may also be concerned about the risk/benefit of colonoscopy or diagnostic methods in younger adults, given the traditional low likelihood of CRC. Approximately 58% of young CRC patients are diagnosed at stage III or IV, compared to 43% of older adults (American Gastroenterological Association, 2024). Early recognition and prompt evaluation of persistent symptoms are crucial for improving outcomes. Empowering and informing young adults about concerning symptoms is the first step in better recognition and better outcomes for these individuals.
Arreaza: This is when the word “follow up” becomes relevant. I recommend you leave the door open for patients to return if their common symptoms worsen or persist. Let’s talk about screening.
Screening and Prevention
Jessica: Due to the trend of CRC being identified in younger populations, the U.S. Preventive Services Task Force (USPSTF) lowered the recommended screening age for CRC from 50 to 45 in 2021 (USPSTF, 2021). Off the record, some Gastroenterologists also foresee the USPSTF lowering the age to 40.
Arreaza: That is correct, it seems like everyone agrees now that the age to start screening for average-risk adults is 45. It took a while until everyone came to an agreement, but since 2017, the US Multi-Society Task Force had recommended screening at age 45, the American Cancer Society recommended the same age (45) in 2018, and the USPSTF recommended the same age in 2021. This podcast is a reminder that the age of onset has been decreased from 50 to 45, for average-risk patients, according to major medical associations.
Jessica: For individuals with additional risk factors, including a family history of CRC or chronic gastrointestinal symptoms, screening starts at age 40 or 10 years before the diagnosis of colon cancer in a first-degree relative. Dr. Arreaza, who has the lowest and the highest rate of screening for CRC in the US?
Arreaza: The best rate is in Massachusetts (70%) and the lowest is California (53%). Let’s review how to screen:
Jessica: Recommended Screening Methods:
Arreaza: Computed tomographic colonography (CTC) is another option, it is less common because it is not covered by all insurance plans, it examines the whole colon, it is quick, with no complications.
Conclusion:
Colorectal cancer is rapidly emerging as a serious health threat for young adults. The increase in cases over the past three decades highlights the urgent need for increased awareness, early symptom detection, and proactive screening. While healthcare providers must weigh the risk/benefit of testing for CRC in younger adults, patients must also be equipped with knowledge of concerning signs so that they may also advocate for themselves. Early detection remains the most effective tool in preventing and treating CRC, emphasizing the importance of screening and risk factor modification.
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