Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Clinicians Struggle to Understand Dramatic Rise in Early Onset Colorectal Cancer
Tony Peregrin
December 4, 2024
15 MinPrintShare
Bookmark
The number of colorectal cancer cases is increasing at an alarming rate for Generation Z, Millennials, and Generation X—young adults in their mid-20s to late 50s. And while this surge remains a perplexing medical mystery for clinicians, diet and lifestyle are suspected to be driving factors of this disease.1,2
According to a 2023 report released by the American Cancer Society, colorectal cancer cases among adults younger than 55 increased from 11% (1 in 10) in 1995 to 20% (1 in 5) in 2019.3
Building on those findings, a 2024 study, also from the American Cancer Society, looked at 23.6 million Americans who were diagnosed with 34 types of cancer from 2000 to 2019.4 Investigators found the probability of developing 17 types of cancers, including colorectal cancer, increased for individuals during early adulthood and middle age. “Each successive generation born during the second half of the 20th century has had increased incidences of many common cancer types of heterogeneous etiologies compared with preceding generations in the USA,” noted the study authors.4
For early onset colorectal cancer, a troubling conundrum for clinicians is tethered to the question of “Why?,” because some of these young patients present as healthy individuals with no family history of the disease, engaging in regular exercise and consuming a healthy diet. In fact, many of the patients are not obese, which is long considered a primary risk factor for colorectal cancer among adults younger than 55.
High-profile cases of early onset colorectal cancer in individuals who were notably active (and not obese) include Broadway actor Quentin Oliver Lee, who died of stage IV colon cancer at 34 in 2022, and Chadwick Boseman, star of the trailblazing film “Black Panther” who died in 2020 from colon cancer at 43.5,6 More recently, actor James Van Der Beek, 47, was diagnosed with colorectal cancer.
“In colorectal surgery, we were used to seeing younger people—but there was almost always a reason for it because of underlying conditions such as ulcerative colitis or inherited cancer syndromes,” said Steven D. Wexner, MD, FACS, director of the Ellen Leifer Shulman and Steven Shulman Digestive Disease Center at the Cleveland Clinic Florida in Weston, and past-Regent of the ACS. “The shift was in seeing patients who didn’t have an underling risk factor, either based on their own disease or their family history and genetic disposition.”
Confronting the stark reality of seemingly healthy young people seeking treatment for colorectal cancer continues to be a disconcerting experience for many surgeons.
“I remember seeing the first wave of these patients, if you will, and it just seemed like an anomaly, like one-offs—and it was awful,” said Sonia Ramamoorthy, MD, FACS, chief of colorectal surgery at the University of California San Diego and president of the American Society of Colon and Rectal Surgeons. “But this phenomenon started to become more and more commonplace. And I remember saying to our genetics counselor, ‘What is going on? We’re seeing so many more rectal cancers in young patients—what is happening here?’”
A right hemicolectomy specimen recently removed from a patient.
Red Flags for Patients with Early Onset Colorectal Cancer
A scientific review of 81 studies and nearly 25 million colorectal cancer patients under age 50 published in the Journal of the American Medical Association in 2024 revealed that the most common warning for the disease in this cohort is passing blood in the stool.7,8 Abdominal pain, anemia, and altered bowel habits also were identified as common indications of the disease.
Researchers noted delays in diagnosis were common—up to 6 months from initial presentation of symptoms. Due to these delays, younger adults tend to have more advanced disease, which is typically more challenging to treat.
“The physicians who see these patients before we do—the family practitioners, internists, gynecologist, and gastroenterologist—need to be aware that when a patient presents with rectal bleeding, abdominal pain, diarrhea, unexplained weight loss, or iron deficiency anemia—these symptoms should trigger a colonoscopy,” said Dr. Wexner.
Developing an awareness for the red flags that frequently present with early onset colorectal cancer can save lives, especially considering this disease is one of the only cancers that can be prevented with screening.
“If you’re 39 and you’re having these symptoms, you’re not thinking, ‘I have colon cancer,’” added Dr. Ramamoorthy. “You’re thinking, ‘I ate something. I’m working too hard.’ If you’re tired and you’re stressed out, you’re thinking, ‘It'll go away.’ People are presenting later because they’re just not attributing their symptoms to something that could be serious. If you’re a surgeon or a GI doc and you’re getting the referral for this patient—you really need to get the patient in quickly for an evaluation.”
In fact, colorectal surgeons are in a unique position to screen select patients presenting with a variety of conditions. “When we see patients coming in for hemorrhoids or diverticular complaints or a hernia repair, we can use these opportunities to suggest a colonoscopy as well for patients older than 45,” Dr. Ramamoorthy said.
Colonoscopy—the Gold Standard—Outshines Other Approaches
While colorectal cancer rates continue to climb among younger adults, rates have declined for adults 60 and older, primarily due to one essential difference between the two cohorts: older adults are much more likely to get a colonoscopy, which is the most accurate way to detect the disease.9
The colorectal cancer screening guidelines developed by the American Cancer Society for individuals at average risk recommend regular screening starting at age 45, either through a stool-based test or a visual test (colonoscopy).10 Unfortunately, less than 60% of eligible candidates have had their recommended screening.
“The colonoscopy is the gold standard of screening because it provides the opportunity to diagnose, treat, and prevent,” explained Dr. Wexner. “This screening is exceptionally effective. The problem is people don’t always think they have a reason to be screened, particularly younger people who are asymptomatic.”
Additional barriers to screening for this age group could include not having a primary care provider or lack of health insurance to cover screening-related costs.
“My personal bias is that we could probably drop the screening age another 5 years—to age 40,” said Dr. Ramamoorthy. “I really think we would capture a lot of what we're currently seeing as early onset colorectal cancers. I understand there's a public health price to pay for that—but there’s a public health price for not screening this young population for a preventable disease.”
These images are taken from a video depicting a laparoscopic right procedure with colon cancer invading the abdominal wall.
Epigenetic Aging
Yin Cao, ScD, MPH, a cancer epidemiologist with the Washington University School of Medicine in St. Louis, Missouri, presented research earlier this year at the American Association for Cancer Research annual meeting suggesting that young adults with cancer are aging faster than their counterparts.
Dr. Cao and colleagues analyzed the association between biological age and cancer risk in 148,724 young adults via data extracted from the UK Biobank database. By examining nine blood biomarkers, including creatinine, C-reactive protein, lymphocyte proportion, and white blood cell count, their findings suggested that bodies with accelerated aging were linked to an increased risk of cancer.11
In fact, an expanding body of research suggests that looking beyond calendar age to examine biological or epigenetic aging might help clinicians improve prevention and early detection of cancers in adults younger than 55 years of age.
Cancer has typically been considered an aging-related disease. As the human body ages, it experiences more oxidative stress and DNA damage, which can lead to cell alteration and tumor growth. Research also suggests that during the aging process, the body is less adept at shedding old “senescent” cells, which can be inflammatory and promote tumor growth.
A primary driver of rapidly aging cells is diet, according to researchers from The Ohio State University in Columbus, who presented their findings at the American Society of Clinical Oncology’s annual conference in 2024. Specifically, a Western diet consisting of high intakes of prepackaged foods, refined grains, fried foods, and other products can agitate bacteria in the gastrointestinal tract, resulting in inflammation and accelerated aging of cells.
“The results of this study found that young adults who develop colorectal cancer are, on average, biologically 15 years older than their chronological age, which is fascinating,” suggested Dr. Wexner. “It’s thought to be related to diet and lifestyle. I like to tell my patients ‘What’s good for your heart is good for your colon’—for the most part. People need to adopt a healthy lifestyle, which means eliminating or at least limiting red meat intake and consuming a high-fiber diet with lots of raw fruits and vegetables.”
He noted that disrupting the gut microbiome with a consistently unhealthy diet is akin to “releasing the brake,” thereby providing an opportunity for tumors to grow.
“The risk factors for colorectal cancer have always been there and they haven’t changed—diet and exercise—but until recently, we’ve been more attentive to all the other things like family history and other diseases such as inflammatory bowel disease,” said Dr. Ramamoorthy. “As these cancers continue to affect our younger generations, we’re focusing on what’s being done to our food, how that’s affecting our microbiome, and how that is creating a chronic inflammatory state that is manifesting itself potentially in cancer in their gut.”
Surgeons’ Role in Educating Physicians and Public
The incidence rate of early onset colorectal cancer is expected to double by 2030, which means 10.9% of all colon cancers and 22.9% of all rectal cancers will be diagnosed in young adults—a stark comparison to 2010, when 4.8% and 9.5% respectively were diagnosed in this same cohort. These estimates underscore why this disease, particularly for those under the age of 55, should be a top public health priority, with an emphasis on education and screening similar to breast cancer awareness initiatives.
“I would like to see more surgeons and societies like the College and American Society of Colon and Rectal Surgeons be front and center in a marketing campaign to educate others on the US Preventive Services Task Force screening guidelines,” said Dr. Ramamoorthy. “I think when surgeons say something, people listen. They have the power to influence others and make a difference in the public health sector, and with patients and colleagues.”
Direct one-on-one conversations with surgeons and other healthcare professionals should underscore the consequences of ignoring the possibility that a young patient could have colorectal cancer.
“These patients are presenting with very obvious symptoms, like rectal bleeding and abdominal pain, and yet they’re getting dismissed,” Dr. Ramamoorthy added. “Alert the primary care doctors who are in your group or community practice about this phenomenon. Remind them that the screening age has dropped to 45, and encourage them to have anybody who’s coming in with some of these symptoms to get an evaluation.”
In fact, there are many opportunities to have touchpoint conversations with peers, including before and after hospital lectures, journal clubs, grand rounds, clinical conferences, and more.
“Have a HIPAA-compliant conversation with your colleagues,” advised Dr. Wexner. “Tell them, ‘I just happened to take care of a 30-year-old with a colon cancer—and it’s really a shame because for 6 months this person had bleeding and abdominal pain, and by the time the colonoscopy was obtained, the lesion had already spread to the liver.’ Let people know these real-life stories to help effect change.”
Dr. Steven Wexner uses a model of a colon during a patient consult.
Emerging Screening Tools
In July 2024, the US Food and Drug Administration (FDA) approved a blood test, called Shield, to screen for colon cancer. The test, previously available to doctors at an out-of-pocket cost of $895, is now more likely to be covered by Medicare and private insurance companies with FDA approval.
The test, which is the second blood test to screen for colon cancer, is most effective at identifying late-stage cancers and is not intended to replace colonoscopies. According to The New York Times and the manufacturer’s patient brochure, in a study published in March 2024, Shield found 83% of colorectal cancers but only 13% of polyps, compared with colonoscopies which found 95% of polyps.
“In my opinion, this exciting development will be the first of many such advances in noninvasive detection of colorectal cancers and polyps. However, the very low rate of polyp detection by the recently FDA-approved test is potentially concerning,” Dr. Wexner said, adding that several perquisites, such as “impeccable sensitivity and specificity” are necessary prior to universal adoption.
“Moreover, patients with positive tests will require a colonoscopy, and patients with negative tests may not undergo a potentially needed colonoscopy,” cautioned Dr. Wexner. “In this latter group of patients, the opportunity to remove precancerous polyps may be missed.”
Ideally, the expectation is that this new test, despite its limitations, could boost the number of people screened for colorectal cancer overall, especially individuals younger than age 45 who are too young for routine colonoscopies.
The development of more precise and reliable noninvasive detection tools, particularly self-administered tests, could be on the horizon; until then, the colonoscopy reigns supreme for identifying colorectal cancer.
“I think someday in our lifetime, we'll hopefully be able to have a home test that identifies the presence of colon cancer and colon polyps—a tool that will be an accurate-enough test that we can say, ‘Hey, that's a believable result,’” said Dr. Ramamoorthy.
Future research in the areas of prevention and treatment of early onset colorectal cancer should be multidisciplinary with studies that include diverse populations in order to uncover new mechanisms for identifying young adults who are at high risk for this disease.
To learn more about early onset colorectal cancer from Dr. Wexner and Matthew F. Kalady, MD, FACS, a widely recognized expert in colorectal cancer, listen to episode 44 of The House of Surgery podcast, “Colorectal Cancer Is on the Rise in Younger Adults,” at facs.org/houseofsurgery.
Surgeons Consider Red Flags for Early Onset Colorectal Cancer
Tony Peregrin is Managing Editor, Special Projects, Division of Integrated Communications, Chicago IL.
American Cancer Society. Generation X and millennials in US have higher risk of developing 17 cancers compared to older generations, new study suggests. Press release. July 31, 2024. Available at: https://pressroom.cancer.org/higherriskGenXandMillennials. Accessed August 30, 2024.
Sung H, Jiang C, Bandi P, Minihan A, et al. Differences in cancer rates among adults born between 1920 and 1990 in the USA: An analysis of population-based cancer registry data. The Lancet Public Health. 2024;9(8):e583-e593. Available at: https://www.thelancet.com/pdfs/journals/lanpub/PIIS2468-2667(24)00156-7.pdf. Accessed August 30, 2024.
Demb J, Kolb JM, Dounel J, et al. Red flag signs and symptoms for patients with early-onset colorectal cancer: A systematic review and meta-analysis. JAMA Netw Open. 2024;7(5):e2413157.
