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).
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.
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) 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%).
"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).
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.