Young-age onset of colorectal cancer in Israel

Early-onset colorectal cancer: A review of current knowledge

Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide. Although most prevalent among older people, its incidence above 50 years old has been decreasing globally in the last decades, probably as a result of better screening. Paradoxically, its incidence in patients below 50 years old [early-onset CRC (EO-CRC)] has been increasing, for reasons not yet fully understood. EO-CRC’s increasing incidence is genre independent but shows racial disparities and has been described to occur worldwide. It follows a birth-cohort effect which probably reflects a change in exposure to CRC risk factors. Its incidence is predicted to double until 2030, which makes EO-CRC a serious public health issue. Both modifiable and non-modifiable risk factors have been identified - some are potential targets for preventive measures. EO-CRC is often diagnosed at advanced stages and histological features associated with poor prognosis have been described. EO-CRC presents some distinctive features: Microsatellite in-stability is common, but another subtype of tumours, both microsatellite and chromosome stable also seems relevant. There are no age-specific treatment protocols and studies on EO-CRC survival rates have shown conflicting data. Due to the higher germline pathological mutations found in EO-CRC patients, an accurate genetic risk evaluation should be performed. In this review, we summarize the current evidence on epidemiological, clinical, histopathological and molecular features of EO-CRC and discuss the contribution of genetics and lifestyle risk factors. We further comment on screening strategies and specific dimensions to consider when dealing with a younger cancer patient.

Gastrointestinal Adenocarcinoma Incidence and Survival Trends in South Australia, 1990-2017

Simple Summary

This study from South Australia using the state’s Cancer Registry data provides compelling evidence for a significant increase in the incidence of young-onset (18–50 years) gastrointestinal (oesophageal, stomach, colon and rectum, and pancreas) adenocarcinomas over the last three decades. The trend observed in the young cohort was not mirrored in older individuals >50 years. This increased incidence, though noted in both sexes, was more pronounced in males compared to females. Survival in the young-onset adenocarcinoma cohort was only seen in patients with colorectal cancers, but not oesophagus, stomach and pancreas. This study calls for a concerted effort aimed at determining the sociodemographic factors underlying this disturbing trend with the aim of developing preventative strategies.

Abstract

Background & Aims: Globally, there has been a concerning rise in the incidence of young-onset cancers. The aim of this study was to provide trends in the incidence and survival of gastrointestinal adenocarcinomas (oesophagus, stomach, pancreas, and colorectal) in South Australia over a 27-year period. Methods: This is a cross-sectional analysis of a prospective longitudinal database including all cases of gastrointestinal adenocarcinomas prospectively reported to the South Australian (State) Cancer Registry from 1990 to 2017. Results: A total of 28,566 patients diagnosed with oesophageal, stomach, pancreatic, or colorectal adenocarcinoma between 1990 and 2017 were included in the study. While the overall incidence for gastrointestinal adenocarcinomas in individuals >50 years has decreased since 2000 (IRR of 0.97 (95% CI 0.94–1.00; p = 0.06)) compared to 1990–1999, the rate amongst individuals aged 18–50 has significantly increased (IRR 1.41 (95% CI 1.27–1.57; p < 0.001)) during the same reference time period. Although noted in both sexes, the rate of increase in incidence was significantly greater in males (11.5 to 19.7/100,000; p < 0.001). The overall survival from adenocarcinomas across all subsites improved in the >50-year cohort in the last decade (HR 0.89 (95% CI 0.86–0.93; p < 0.001)) compared to 1990–1999. In individuals aged 18–50 years, there has only been a significant improvement in survival for colorectal cancer (HR 0.82 (95% CI 0.68–0.99; p < 0.04)), but not the other subsites. A lower overall survival was noted for males in both age cohorts (18–50 years—HR 1.24 (95% CI 1.09–1.13; p < 0.01) and >50 years—HR 1.13 (95% CI 1.10–1.16; p < 0.001), respectively) compared to females. Conclusions: This study from South Australia demonstrates a significant increase in young-onset gastrointestinal adenocarcinomas over the last 28 years, with a greater increase in the male sex. The only significant improvement in survival in this cohort has been noted in colorectal cancer patients.

Impact of age and mismatch repair status on survival in colorectal cancer

Previous studies have suggested that deficiencies in mismatch repair genes (dMMR) often occur in patients with colorectal cancer (CRC) and contribute to disease etiology. Here, we looked for a correlation of MMR status to disease outcomes from a large number of Chinese CRC patients stratified by the age of onset of disease. A total of 2233 CRC patients were analyzed and tissue biopsies of surgically removed tumors scored for MMR gene status. The patient distribution after classification consisted of 188 younger aged patients (20-39 years of age), 1024 middle aged patients (40-59 years of age), and 1020 older aged patients (60-85 years of age). In this analysis, the expression of four MMR genes was assessed by immunohistochemistry (IHC). We found that the young group of CRC patients with dMMR had higher overall survival (OS) than the young group of patients with proficient MMR (pMMR) (77% vs. 56%, P = 0.03). Middle-aged patients with dMMR also had higher OS than middle-aged group patients with pMMR (78% vs. 68%, P = 0.012). However, we found no statistical difference in OS between dMMR and pMMR status in the older group of patients (75% vs. 71%, P = 0.224). Finally, the middle- and older-aged group set of patients had higher OS than the young group of patients (69% vs. 71% vs. 59%, P = 0.008). These data demonstrated that the age of disease onset can be an important factor to help evaluate the prognosis of CRC when combined with the analysis of MMR status within tumor biopsied tissue.

Octogenarian patients with colorectal cancer: Characterizing an emerging clinical entity

AIM

To characterize colorectal cancer (CRC) in octogenarians as compared with younger patients.

METHODS

A single-center, retrospective cohort study which included patients diagnosed with CRC at the age of 80 years or older between 2008-2013. A control group included consecutive patients younger than 80 years diagnosed with CRC during the same period. Clinicopathological characteristics, treatment and outcome were compared between the groups. Fisher’s exact test was used for dichotomous variables and χ² was used for variables with more than two categories. Overall survival was assessed by Kaplan-Meier survival analysis, with the log-rank test. Cancer specific survival (CSS) and disease-free survival were assessed by the Cox proportional hazards model, with the Fine and Gray correction for non-cancer death as a competing risk.

RESULTS

The study included 350 patients, 175 patients in each group. Median follow-up was 40.2 mo (range 1.8-97.5). Several significant differences were noted. Octogenarians had a higher proportion of Ashkenazi ethnicity (64.8% vs 47.9%, P < 0.001), a higher rate of personal history of other malignancies (22.4% vs 13.7%, P = 0.035) and lower rates of family history of any cancer (36.6% vs 64.6%, P < 0.001) and family history of CRC (14.4% vs 27.3%, P = 0.006). CRC diagnosis by screening was less frequent in octogenarians (5.7% vs 20%, P < 0.001) and presentation with performance status (PS) of 0-1 was less common in octogenarians (71% vs 93.9%, P < 0.001). Octogenarians were more likely to have tumors located in the right colon (45.7% vs 34.3%, P = 0.029) and had a lower prevalence of well differentiated histology (10.4% vs 19.3%, P = 0.025). They received less treatment and treatment was less aggressive, both in patients with metastatic and non-metastatic disease, regardless of PS. Their 5-year CSS was worse (63.4% vs 77.6%, P = 0.009), both for metastatic (21% vs 43%, P = 0.03) and for non-metastatic disease (76% vs 88%, P = 0.028).

CONCLUSION

Octogenarians presented with several distinct characteristics and had worse outcome. Further research is warranted to better define this growing population.

Colorectal cancer in young patients: is it a distinct clinical entity?

BACKGROUND

The incidence of colorectal cancer in young patients is increasing. It remains unclear if the disease has unique features in this age group.

METHODS

This was a single-center, retrospective cohort study which included patients diagnosed with colorectal cancer at age ≤40 years in 1997-2013 matched 1:2 by year of diagnosis with consecutive colorectal cancer patients diagnosed at age >50 years during the same period. Patients aged 41-50 years were not included in the study, to accentuate potential age-related differences. Clinicopathological characteristics, treatment, and outcome were compared between groups.

RESULTS

The cohort included 330 patients, followed for a median time of 65.9 months (range 4.7-211). Several significant differences were noted. The younger group had a different ethnic composition. They had higher rates of family history of colorectal cancer (p = 0.003), hereditary colorectal cancer syndromes (p < 0.0001), and inflammatory bowel disease (p = 0.007), and a lower rate of polyps (p < 0.0001). They were more likely to present with stage III or IV disease (p = 0.001), angiolymphatic invasion, signet cell ring adenocarcinoma, and rectal tumors (p = 0.02). Younger patients more frequently received treatment. Young patients had a worse estimated 5-year disease-free survival rate (57.6  vs. 70 %, p = 0.039), but this did not retain significance when analyzed by stage (p = 0.092). Estimated 5-year overall survival rates were 59.1 and 62.1 % in the younger and the control group, respectively (p = 0.565).

CONCLUSIONS

Colorectal cancer among young patients may constitute a distinct clinical entity. Further research is needed to validate our findings and define the optimal approach in this population.

Effect of Age on Survival Outcome in Operated and Non-Operated Patients with Colon Cancer: A Population-Based Study

Objective

To know the effect of age on survival outcome in operated and non-operated patients with colon cancer.

Methods

From the Surveillance, Epidemiology, and End Results database, we identified 123,356 patients with colon cancer who were diagnosed between 1996 and 2005, grouped them as older or younger than 40 years and analyzed their 5-year cancer-specific survival (CSS) data, along with some risk factors, using Kaplan–Meier methods and multivariable Cox regression models.

Results

The younger group had significantly higher pathological grades (P<0.001), more mucinous and signet-ring histology (P<0.001), advanced AJCC stage (P<0.001), and were more likely to undergo surgery (P<0.001). For surgically treated patients, age did not significantly affect 5-year CSS (younger: 66.7%; older: 67.3%; P = 0.86). Further analysis showed that age was an independent prognostic factor in stage I–IV disease (stage I: P = 0.001; P<0.001 for stages II–IV, in both uni- and multivariate analyses), but not for patients with unknown disease stage (P = 0.52). For non-surgically treated patients, age significantly affected 5-year CSS (younger: 16.2%; older: 12.9%; P<0.001) in univariate analysis; and was an independent prognostic factor (P<0.001) in multivariate analysis.

Conclusion

The CSS rate for younger CC patients was at least as high as for older patients, although they presented with higher proportions of unfavorable factors and more advanced disease.

The prognostic significance of age in operated and non-operated colorectal cancer

BACKGROUND

The prognostic significance of age in colorectal cancer remains controversial. Our purpose was to determine the impact of age at diagnosis on cause- specific survival and overall survival in patients with colorectal cancer.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER) population-based data, we identified 226,430 patients with colorectal cancer diagnosed between 1996 and 2005. Patients were separated into 10-year age groups. Five-year cancer cause-specific survival and overall survival data were obtained. Kaplan-Meier methods were adopted and multivariable Cox regression models were built for the analysis of long-term survival outcomes and risk factors.

RESULTS

In the operated group, those aged 51-60 had the best prognosis with 5-year cause-specific survival of 72.3% and 5-year overall survival of 68.3%.In the non-operated group, those of young age 15-30 had the best prognosis with 5-year cause-specific survival of 21.2% and 5-year overall survival of 18.2%, and there was continued worsening in cause-specific survival and overall survival with increasing age, except for a small increase in the 51-60 age group (P < 0.001). Multivariable analysis demonstrated a statistically significant disadvantage in cause-specific survival in patients older than 60 (P < 0.001), but the difference between the 51-60 age group and the younger age group (15-30, 31-40, 41-50) wasn't statistically significant (P > 0.05) in both operated and non-operated patients.

CONCLUSIONS

There was no apparent difference in survival in colorectal cancer patients 60 and younger, but in those older than 60 years, there was worsening in overall survival and cause-specific survival in both operated and non-operated patients.

Association of age with survival in patients with metastatic colorectal cancer: analysis from the ARCAD Clinical Trials Program

PURPOSE

This study addressed whether age is prognostic for overall survival (OS) or progression-free survival (PFS) in patients with metastatic colorectal cancer (mCRC).

PATIENTS AND METHODS

A total of 20,023 patients from 24 first-line clinical trials in the ARCAD (Aide et Recherche en Cancérologie Digestive) database were analyzed. Primary age effects and interactions with age,sex, performance status (PS), and metastatic site were modeled using Cox proportional hazards stratified by treatment arm within study.

RESULTS

Of total patients, 3,051 (15%) were age < or =50 years. Age was prognostic for both OS (P < .001)and PFS (P < .001), with U-shaped risk (i.e., highest risk was evident in youngest and oldest patients). Relative to patients of middle age, the youngest patients experienced 19% (95% CI, 7% to 33%) increased risk of death and 22% (95% CI, 10% to 35%) increased risk of progression. The oldest patients experienced 42% (95% CI, 31% to 54%) increased risk of death and 15% (95% CI, 7% to 24%) increased risk of progression or death. This relationship was more pronounced in the first year of follow-up. Age remained marginally significant for OS (P = .08) when adjusted forPS, sex, and presence of liver, lung, or peritoneal metastases, and age was significant in an adjusted model for PFS (P = .005). The age effect did not differ by site of metastatic disease, year of enrollment, type of therapy received, or biomarker mutational status.

CONCLUSION

Younger and older age are associated with poorer OS and PFS among treated patients with mCRC. Younger and older patients may represent higher-risk populations, and additional studies are warranted.

Young patients (≤ 35 years old) with colorectal cancer have worse outcomes due to more advanced disease: a 30-year retrospective review

An appropriate cutoff of age and the impact of age on colorectal cancer outcomes remain unclear and need to be explored, particularly in China.In total, 2460 colorectal cancer patients were studied retrospectively. All patients were divided into 6 groups according to their ages at the time of diagnosis: ≤ 30, 31 to 35, 36 to 40, 41 to 45, 46 to 50, and ≥ 50 years. A suitable cutoff age for defining young adult colorectal cancer was explored according to the distribution of survival in each group. Clinical characteristics and prognosis between the young adult group and the older group were then compared.According to the survival curves for each group, 35 years old was considered a suitable cutoff age for defining young adult colorectal cancer. There were 140 (5.7%) and 2320 (94.3%) cases in the young adult and older groups, respectively. The proportion of stage III-IV tumors was significantly higher in the young adult group (69.3%) than in the older group (46.4%) (P  =  0.000). The univariate analysis showed that the 5-year overall survival (OS) rate and the 10-year OS rate in the young adult group were 48.9% and 38.6%, respectively, whereas in the older group, they were 63.6% and 56.9%, respectively. The young adult group had a worse prognosis (P  =  0.000). The multivariate analysis showed that age was not an independent prognostic factor (relative risk 0.787, P  =  0.062). After adjusting for tumor stage, the hazard proportion of death in the young adult group increased by 27.6%, but this difference was not significant (P  =  0.053). Stratified analyses showed that the young adults with stage IV tumors had a worse survival rate (P  =  0.046).Patients ≤ 35 years who were diagnosed with colorectal cancer had a worse prognosis because of a higher proportion of advanced stage tumors. When stage-to-stage analysis was performed, it was found that young adult colorectal cancer patients had a worse outcome only if they had stage IV tumors.

Pathological features and survival outcomes of young patients with operable colon cancer: are they homogeneous?

OBJECTIVE

To compare the pathological features and survival outcomes at different age subgroups of young patients with colon cancer.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER) population-based data, we identified 2,861 young patients with colon cancer diagnosed between 1988 and 2005 treated with surgery. Patients were divided into four groups: group 1 (below 25 years), group 2 (26-30 years), group 3 (31-35 years) and group 4 (36-40 years). Five-year cancer specific survival data were obtained. Kaplan-Meier methods were adopted and multivariable Cox regression models were built for the analysis of long-term survival outcomes and risk factors.

RESULTS

There were significant different among four groups in pathological grading, histological type, AJCC stage, current standard (≥12 lymph nodes retrieval), mean number of lymph nodes examined and positive lymph nodes (p<0.001). The 5-year cause specific survival was 71.0% in group 1, 75.1% in group 2, 80.6% in group 3 and 82.5% in group 4, which had significant difference in both univariate (P = 0.002) and multivariate analysis (P = 0.041).

CONCLUSIONS

Young patients with colon cancer at age 18-40 years are essentially a heterogeneous group. Patients at age 31-35, 36-40 subgroups have more favorable clinicopathologic characteristics and better cancer specific survival than below 30 years.

Better long-term survival in young patients with non-metastatic colorectal cancer after surgery, an analysis of 69,835 patients in SEER database

Objective

To compare the long-term survival of colorectal cancer (CRC) in young patients with elderly ones.

Methods

Using Surveillance, Epidemiology, and End Results (SEER) population-based data, we identified 69,835 patients with non-metastatic colorectal cancer diagnosed between January 1, 1988 and December 31, 2003 treated with surgery. Patients were divided into young (40 years and under) and elderly groups (over 40 years of age). Five-year cancer specific survival data were obtained. Kaplan-Meier methods were adopted and multivariable Cox regression models were built for the analysis of long-term survival outcomes and risk factors.

Results

Young patients showed significantly higher pathological grading (p<0.001), more cases of mucinous and signet-ring histological type (p<0.001), later AJCC stage (p<0.001), more lymph nodes (≥12 nodes) dissected (p<0.001) and higher metastatic lymph node ratio (p<0.001). The 5-year colorectal cancer specific survival rates were 78.6% in young group and 75.3% in elderly group, which had significant difference in both univariate and multivariate analysis (P<0.001). Further analysis showed this significant difference only existed in stage II and III patients.

Conclusions

Compared with elderly patients, young patients with colorectal cancer treated with surgery appear to have unique characteristics and a higher cancer specific survival rate although they presented with higher proportions of unfavorable biological behavior as well as advanced stage disease.

Clinical characteristics and prognosis of young patients with colorectal cancer in Eastern China

AIM: To explore the clinical characteristics and prognosis of young patients with colorectal cancer patients in Eastern China.

METHODS: A total of 1335 patients with colorectal cancer treated from December 1985 to December 2005 at the Second Affiliated Hospital of Zhejiang University School of Medicine were studied retrospectively. The patients were divided into two groups, a younger group (aged ≤ 30 years) and an older group (aged > 30 years), and comparison was made in the clinical characteristics and prognosis between the two groups. Chi-square test was used for data analysis of all categorical variables, and overall survival (OS) was calculated by the Kaplan-Meier method. A multivariate analysis was performed using the Cox model.

RESULTS: There were 42 (3.1%) and 1293 (96.9%) cases in the younger group and older group, respectively. Univariate analysis showed that the 5- and 10-year OS in the younger group were 33.9% and 26.1%, respectively, and those in the older group were 60.1% and 52.2%, respectively. Younger group had poor survival (χ² = 14.146, P = 0.000). Multivariate analysis revealed that age was not a dependent factor for prognosis (OR = 0.866, 95%CI: 0.592-1.269, P = 0.461). Stratified analysis indicated that in stage III and IV disease, the 5- and 10-year OS were 24.6% and 14.8% in the younger group, and 40.4% and 33.3% in the older group, respectively, with a significant difference between the two groups (χ² = 5.101, P = 0.024). In the subgroup of radical surgery, the 5- and 10-year OS were 44.3% and 34.2% in the younger group, and 69.6% and 60.5% in the older group, with a difference being significant between the two groups (χ² = 7.830, P = 0.005).

CONCLUSION: Compared with older patients, the younger patients have lower survival, especially in the subgroups of stage III and IV disease and radical surgery.

Young colorectal carcinoma patients do not have a poorer prognosis: a comparative review of 2,426 cases

BACKGROUND

Colorectal cancer (CRC) in "young" patients under 50 years of age is uncommon. There have been conflicting reports regarding both the clinicopathological features of CRC in young patients and prognosis. The aim of this study was to review and compare the clinical characteristics, prognostic factors, and overall survival of patients in three different age groups (40 years and under, 41-50 years, over 50 years of age) and the prognosis of these patients.

METHODS

A total of 2,426 consecutive patients who had undergone surgical resection for sporadic colorectal cancer at Singapore General Hospital in the period from 2000 to 2005 were retrieved from a prospectively collected computer database. There were 73 patients (3.0 %) in Group 1 (40 years old or less), 257 (10.6 %) in Group 2 (41-50 years old), and 2,096 (86.4 %) in Group 3 (>50 years old). Clinicopathological features were assessed using univariate analysis to evaluate significant differences, survival curves were constructed using the Kaplan-Meier method, and multivariate analysis was performed to evaluate the independent prognostic factors.

RESULTS

Young CRC patients tend to present with a higher incidence of mucinous and signet ring cell tumors (Group 1-20.5 %, Group 2-8.2 %, Group 3-6.2 %, p < 0.001) and have more poorly differentiated tumors (Group 1-20.0 %, Group 2-9.7 %, Group 3-7.4 %, p = 0.014). Furthermore, young CRC patients tend to present with regional lymph node metastases (Group 1-65.7 %, Group 2-60.8 %, Group 3-51.0 %, p = 0.001) and distant metastases (Group 1-31.5 %, Group 2-24.1 %, Group 3-19.4 %, p = 0.006). Multivariate analysis reveals, however, that young age is not an independent prognostic factor for cancer-specific survival (CSS) (p = 0.392). Five-year CSS for Group 1 was 56.6 % (95 % confidence interval (CI) 44.8-68.4 %), Group 2 53.8 % (95 % CI 47.3-60.3 %), and Group 3 61.1 % (95 % CI 58.9-63.3 %).

CONCLUSIONS

Although presenting with advanced tumors and with poorer prognostic factors such as presence of mucin and poor histological differentiation, young CRC patients do not have a worse prognosis.

Clinical, endoscopic and pathogical characteristics of early-onset colorectal cancer in Vietnamese

BACKGROUND

The Asia Pacific consensus for colorectal cancer (CRC) recommends that screening programs should begin by the age of 50. However, there have been reports about increasing incidence of CRC at a younger age (i.e. early-onset CRC). Little is known about the features of early-onset CRC in the Vietnamese population.

AIM

To describe the clinical, endoscopic and pathological characteristics of early-onset CRC in Vietnamese.

METHOD

A prospective, cross-sectional study was conducted at the University Medical Center from March 2009 to March 2011. All patients with definite pathological diagnosis of CRC were recruited. The early-onset CRC group were analyzed in comparison with the late-onset (i.e.≥50-year-old) CRC group.

RESULTS

The rate of early-onset CRC was 28% (112/400) with a male-to-female ratio of 1.3. Some 22.3% (25/112) of the patients only experienced abdominal pain and/or change in bowel habit without alarming symptoms, 42.9% (48/112) considering their symptoms intermittent. The rate of familial history of CRC in early-onset group was significantly higher that of the late-onset group (21.4% versus 7.6%, p<0.001). The distribution of CRC lesions in rectum, distal and proximal colon were 51.8% (58/112), 26.8% (30/112) and 21.4% (24/112), respectively; which was not different from that in the late-onset group (χ2, p=0.29). The rates for poorly differentiated tumors were also not significantly different between the two groups: 12.4% (14/112) versus 8.3% (24/288) (χ2, p=0.25).

CONCLUSION

A high proportion of CRC in Viet Nam appear at an earlier age than that recommended for screening by the Asia Pacific consensus. Family history was a risk factor of early-onset CRC. Diagnosis of early-onset CRC needs more attention because of the lack of alarming symptoms and their intermittent patterns as described by the patients.