Defying early-onset colorectal cancer, a disease increasingly affecting younger age groups

At 29, she wasn’t worried about cancer. She worked long hours, grabbing quick meals between meetings. Coffee got her through the mornings; alcohol helped her unwind at night. The bloating and constipation were easy to ignore, and the occasional streaks of blood on the toilet paper were dismissed as hemorrhoids.

A few months later, she was more tired than ever. Her bloodwork revealed low iron levels and she started taking iron pills. But after a year, the growing pains in her belly could no longer be ignored. She was sent for a colonoscopy. To her shock, she was diagnosed with advanced stage colorectal cancer.

Not all stories like this end in cancer. But for the ones that do, these moments are devastating. Colorectal cancer is now the third most common cause of death due to cancer. In Canada, it’s estimated that more than 25,000 people will be diagnosed with the disease this year. A disease that has become increasingly prevalent for those under 50.

Clinically, we know that younger patients with colorectal cancer experience a delay between symptom onset and initiation of treatment. Given their age, cancer is usually not the first diagnosis we think of. In addition, younger patients sometimes minimize their symptoms, delay seeking care and are not part of the age group receiving routine screening.

But the price to pay is high. The impact of a late diagnosis is a more advanced disease and an increased risk of death.

Currently, we are seeing a global rise of early-onset colorectal cancer. Researchers suspect that this trend is likely due to a combination of lifestyle and environmental changes.

Recent studies have linked red meats and processed meats to early-onset colorectal cancer; one study published earlier this year directly attributed more than 12,000 deaths from colorectal cancer to high red meat intake. In contrast, white meats such as chicken and fish, when unprocessed and consumed in moderation, appear to have a neutral or protective effect.

Healthy dietary practices are an important aspect of our life that we can modify. But we can only do so much to control our risk for colorectal cancer. Understanding that prevalence in the young is rising, clinicians may need to reconsider our approach to screening.

Currently, screening guidelines recommend a fecal immunochemical test (FIT) every two years for people between 50-74 with average risk for colorectal cancer. A colonoscopy is often recommended for higher risk patients or after an abnormal FIT. The FIT is safe and non-invasive but in Canada, screening typically starts at 50 years of age. For some patients, that’s far too late. The urgent need for the early detection of colorectal cancer has not gone unnoticed. Earlier this year, the Canadian Cancer Society, the country’s largest cancer charity, advocated for lowering the age of screening to 45. Prince Edward Island became the first province to officially lower screening age since the recommendation. Ontario will follow starting July 1 of this year.

With an even more personalized approach, we may be able to screen younger patients that are at high-risk. For patients where early detection is successful and the disease has yet to spread, there may be hope for a curative solution.

Some companies are already investing in new ways to detect colorectal cancer. For instance, Guardant Health offers a blood test to screen for colorectal cancer signals with Food and Drug Administration approval for adults 45 and older. Another company, Geneoscopy, developed a stool RNA test that demonstrated a 93 per cent sensitivity for detecting colorectal cancer with FDA approval for patients 45 and older. A startup called Freenome is leveraging machine learning to detect colorectal cancer by analyzing blood samples.

However, no test is perfect. In some instances, tests produce false positives leading to emotional distress and unnecessary colonoscopies that are not without risk. More research is needed to further develop novel screening tests. But despite these drawbacks, tests can still be powerful for patients with increased risk factors. Rather than basing screening on age, a risk factor approach with higher sensitivity minimally invasive tests may lead to better patient outcomes.

To truly defy early-onset colorectal cancer, we need to come to terms with the reality that colorectal cancer has now become a disease of the young. By doing so, we will be more intentional in lifestyle choices, diagnose earlier with tailored screening, and invest in the development of technology that can give years of quality life back to young people who would overwise succumb to a tragic disease.