AGA Clinical Practice Update on Young Adult-Onset Colorectal Cancer Diagnosis and Management: Expert Review

Developing and Assessing a Scalable Digital Health Tool for Pretest Genetic Education in Patients With Early-Onset Colorectal Cancer: Mixed Methods Design

BACKGROUND

National guidelines recommend germline genetic testing (GT) for all patients with early-onset colorectal cancer. With recent advances in targeted therapies and GT, these guidelines are expected to expand to include broader groups of patients with colorectal cancer. However, there is a shortage of genetic professionals to provide the necessary education and support for informed consent. As such, there is a pressing need to identify alternative approaches to facilitate and expedite access to GT.

OBJECTIVE

This study describes the development of a pretest education intervention, Nest-CRC, to facilitate the uptake of germline GT among patients with early-onset colorectal cancer. Patients with early-onset colorectal cancer and health care providers reviewed Nest-CRC, and their reactions and recommendations were captured using a nested mixed methods approach.

METHODS

Using the learner verification approach, we conducted 2 sequential phases of surveys and interviews with English- and Spanish-speaking patients with early-onset colorectal cancer and health care providers. The surveys assessed participants' experiences with genetic services and provided immediate feedback on the Nest-CRC genetic education modules. Semistructured interviews evaluated participants' perceptions of self-efficacy, attraction, comprehension, cultural acceptability, and usability of Nest-CRC. Survey data were analyzed using descriptive statistics (mean, median, and proportions), while interview data were analyzed through line-by-line coding of the transcribed interviews. After each phase, Nest-CRC was refined based on participants' recommendations.

RESULTS

A total of 52 participants, including 39 patients with early-onset colorectal cancer and 13 providers, participated in the study. Of these, 19 patients and 6 providers participated in phase 1 (N=25), and 20 patients and 7 providers participated in phase 2 (N=27). Most participants (phase 1: 23/25, 92%, to 25/25, 100%; phase 2: 24/27, 89%, to 27/27, 100%) agreed that each of the 5 education modules was easy to understand and helpful; 13 patients reported no history of GT, with 11 (85%) expressing interest in GT and 2 (15%) remaining unsure after completing Nest-CRC. Participants reported that Nest-CRC provided sufficient information to help them decide about GT. The tool was deemed acceptable by individuals from diverse backgrounds, and participants found it visually attractive, easy to comprehend, and user-friendly.

CONCLUSIONS

The findings revealed that Nest-CRC is a promising strategy for facilitating pretest education and promoting GT. Nest-CRC has been refined based on participant recommendations and will be re-evaluated.

Beneficial microbiome and diet interplay in early-onset colorectal cancer

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer-related deaths worldwide. Although the risk of developing CRC increases with age, approximately 10% of newly diagnosed cases occur in individuals under the age of 50. Significant changes in dietary habits in young adults since industrialization create a favorable microenvironment for colorectal carcinogenesis. We aim here to shed light on the complex interplay between diet and gut microbiome in the pathogenesis and prevention of early-onset CRC (EO-CRC). We provide an overview of dietary risk factors associated with EO-CRC and contrast them with the general trends for CRC. We delve into gut bacteria, fungi, and phages with potential benefits against CRC and discuss the underlying molecular mechanisms. Furthermore, based on recent findings from human studies, we offer insights into how dietary modifications could potentially enhance gut microbiome composition to mitigate CRC risk. All together, we outline the current research landscape in this area and propose directions for future investigations that could pave the way for novel preventive and therapeutic strategies.

Clinical and pathological differences between early- and late-onset colorectal cancer and determinants of one-year all-cause mortality among advanced-stage patients: a retrospective cohort study in Medellín, Colombia

OBJECTIVE

To identify the differences between early- (EOCRC) and late-onset colorectal cancer (LOCRC), and to evaluate the determinants of one-year all-cause mortality among advanced-stage patients.

METHODS

A retrospective cohort study was carried out. CRC patients ≥ 18 years old were included. Chi-Square test was applied to compare both groups. Uni- and multivariate regressions were performed to evaluate the determinants of one-year all-cause mortality in all advanced-stage patients regardless of age of onset.

RESULTS

A total of 416 patients were enrolled; 53.1 % were female. Ninety cases (21.6 %) had EOCRC and 326 (78.4 %) had LOCRC. EOCRC cases were predominantly sporadic (88.9 %). Histology of carcinoma other than adenocarcinoma (p= 0.044) and rectum tumors (p= 0.039) were more prevalent in EOCRC. LOCRC patients were more likely to have smoking history (p < 0.001) and right colon tumors (p = 0.039). Alcohol consumption history (odds ratio [OR]: 3.375, 95 %CI: 1.022-11.150) and stage IV (OR: 12.632, 95 %CI: 3.506-45.513) were associated with higher one-year all-cause mortality among advanced-stage patients, the opposite was noted with left colon tumors (OR: 0.045, 95 %CI: 0.003-0.588).

CONCLUSION

EOCRC was predominantly sporadic and had more cases of uncommon histological subtypes and rectal tumors. LOCRC was characterized by a higher prevalence of smoking history. Multivariate regression revealed an association between higher one-year all-cause mortality and alcohol consumption history and stage IV in advanced-stage patients. CRC exhibited differences based on age of onset. The evaluated factors associated with CRC mortality provide valuable insights for healthcare professionals, emphasizing the importance of adequate clinical assessment and early CRC diagnosis.

ChatGPT on guidelines: Providing contextual knowledge to GPT allows it to provide advice on appropriate colonoscopy intervals

BACKGROUND AND AIM

Colonoscopy is commonly used in screening and surveillance for colorectal cancer. Multiple different guidelines provide recommendations on the interval between colonoscopies. This can be challenging for non-specialist healthcare providers to navigate. Large language models like ChatGPT are a potential tool for parsing patient histories and providing advice. However, the standard GPT model is not designed for medical use and can hallucinate. One way to overcome these challenges is to provide contextual information with medical guidelines to help the model respond accurately to queries. Our study compares the standard GPT4 against a contextualized model provided with relevant screening guidelines. We evaluated whether the models could provide correct advice for screening and surveillance intervals for colonoscopy.

METHODS

Relevant guidelines pertaining to colorectal cancer screening and surveillance were formulated into a knowledge base for GPT. We tested 62 example case scenarios (three times each) on standard GPT4 and on a contextualized model with the knowledge base.

RESULTS

The contextualized GPT4 model outperformed the standard GPT4 in all domains. No high-risk features were missed, and only two cases had hallucination of additional high-risk features. A correct interval to colonoscopy was provided in the majority of cases. Guidelines were appropriately cited in almost all cases.

CONCLUSIONS

A contextualized GPT4 model could identify high-risk features and quote appropriate guidelines without significant hallucination. It gave a correct interval to the next colonoscopy in the majority of cases. This provides proof of concept that ChatGPT with appropriate refinement can serve as an accurate physician assistant.

New stochastic devices for simultaneous analysis of mismatch repair proteins and KRAS in biological samples

Two stochastic microsensors based on the immobilization of inulins: inutec and frutafit in a paste obtained from a graphene decorated with nitrogen (10.8 %), and boron (2.6 %), and paraffin oil (IR purity) were designed, characterized and validated for the molecular recognition and analysis of mismatch repair proteins like MLH1, MSH2, MSH6, PMS2, and of KRAS in biological samples such as: whole blood, urine, saliva, and tumoral tissues. The sensor based on inutec exhibited the largest working concentration range (10 decades of concentration) and the lowest limit of determination (0.32fg mL-1) when used for the assay of MLH1, and the wider working concentration range (8 decades of concentration), and the lowest limit of determination (2.30fg mL-1) when used for the assay of MSH6. The sensor based on frutafit exhibited the largest working concentration range (10 decades of concentration) when used for the determination of KRAS, and the wider working concentration range (5 decades of concentration), and the lowest limit of determination (1.00fg mL-1) when used for the assay of PMS2. No influence of the modifier (inutec and frutafit) was recorded on the linear concentration range (10 decades of concentration), and on the limit of determination (1.00 fg mL-1) for the assay of MSH2. The recoveries of MLH1, MSH2, MSH6, PMS2, and of KRAS in whole blood, urine, saliva, and tumoral tissues were higher than 98.00 with RSD (%) values lower than 0.10 %.

Colorectal Cancer: From Risk Factors to Oncogenesis

Colorectal cancer is the second leading cause of cancer-related mortality worldwide. Numerous pathophysiological mechanisms, such as abnormal cell proliferation, cell differentiation, resistance to apoptosis, invasion of structures adjacent to colorectal tumor cells, and distant metastasis, are involved in colorectal carcinogenesis. These processes are initiated by the complex interaction of a number of genetic and environmental factors, including sedentary lifestyle, obesity, alcohol consumption, smoking, or gut microbiota. Despite the significant progress achieved in the diagnostic and therapeutic management of patients with colorectal cancer, there has been recently a noteworthy increase in the incidence of colorectal cancer in individuals below the age of 50 years. Early-onset colorectal cancer has a different frequency of oncogenic mutations, a higher prevalence of mucinous histology, a distinct deoxyribonucleic acid (DNA) methylation profile, a more distal location, and lower survival rates. A significant improvement in the prognosis of these patients can be achieved through the detection and removal of modifiable risk factors, along with the implementation of personalized screening strategies for individuals at high risk for this malignancy. Furthermore, gaining comprehension of the pathophysiological mechanisms by which these risk factors contribute to the process of oncogenesis may facilitate the discovery of novel therapeutic targets.

Young-onset colorectal cancer

In the past decades the incidence of colorectal cancer (CRC) in people under the age of 50 years has increased, which is referred to as early-onset CRC or young-onset CRC (YO-CRC). YO-CRC is expected to account for 11% of colon cancers and 23% of rectal cancers by 2030. This trend is observed in different parts of the world and in both men and women. In 20% of patients with YO-CRC, a hereditary cancer syndrome is found as the underlying cause; however, in the majority of patients no genetic predisposition is present. Beginning in the 1950s, major changes in lifestyle such as antibiotic use, low physical activity and obesity have affected the gut microbiome and may be an important factor in YO-CRC development. Owing to a lack of screening, patients with YO-CRC are often diagnosed with advanced-stage disease. Long-term treatment-related complications should be taken into account in these younger patients, making the more traditional sequential approaches of drug therapy not always the most appropriate option. To better understand the underlying mechanism and define relationships between environmental factors and YO-CRC development, long-term prospective studies are needed with lifestyle data collected from childhood.

Gastroenterology Specialist Supply and Early-Onset Colorectal Cancer Incidence and Mortality in the U.S., 2014-2018

Background and Aims

The burden of early-onset colorectal cancer (EoCRC) has been increasing among young adult populations in the U.S. The aim of this study was to investigate the relationship between the incidence and mortality of EoCRC and the supply of gastroenterology (GI) specialists and primary care physicians (PCP).

Methods

This was an ecological study of EoCRC cases among US counties that occurred between 2014 and 2018. Data was obtained from US cancer statistics. County-level data, including sociodemographic (eg, percentage of female, non-White residents, poverty rate, rurality) and physician supply (GI specialists and PCPs) was obtained from area health resources files. We estimated linear mixed-effects models with the county as a random effect to examine the association of physician supply with 5-year average age-adjusted EoCRC incidence and mortality. Models were adjusted for aggregate county-level socioeconomic characteristics. Multicollinearity was tested through variation inflation.

Results

Analysis included 855 US counties. Mean age-adjusted EoCRC incidence and mortality rates between 2014-2018 were 9.5 (standard deviation [SD]: 2.7) and 2.7 (SD: 0.8) per 100,000 persons, respectively. In the adjusted model, GI supply was associated with lower EoCRC incidence (-5.6 percentage-point change per SD; 95% confidence interval, -11.0 to -0.1) but not with EoCRC mortality (P = .558). PCP supply was associated with lower EoCRC mortality (-27.0 percentage-point change per SD; 95% confidence interval, -46.1 to -7.8) but not with EoCRC incidence (P = .077).

Conclusion

Greater GI specialist supply was associated with a reduction in EoCRC incidence but not improved mortality. Study findings suggest the need for early colorectal cancer screening efforts and the potential for expanding GI services and referrals in medically underserved areas.

Spectrum of Advanced Colorectal Neoplasia and Anticipated Yield of Average-Risk Screening in Veterans Under Age 50

The incidence of early onset colorectal cancer, or colorectal cancer (CRC) diagnosed before age 50, is increasing.¹ In response, multiple societal guidelines in the United States now recommend initiating CRC screening at age 45 in average-risk individuals (ie, those without high-risk clinical characteristics, such as bleeding, or iron deficiency anemia), inflammatory bowel disease, or family history of colorectal neoplasia.² The Veterans Health Administration (VHA) is the largest integrated health system in the United States and is contending with how best to expand CRC screening access to this younger population in the setting of limited colonoscopy resources. Understanding the rate and anatomic location of colorectal neoplasia in Veterans younger than age 50 can inform the expected yield of different screening modalities. Prior work has shown that individuals undergoing colonoscopy for low-risk diagnostic indications have equivalent risk of colorectal neoplasia as those undergoing average-risk screening.³ This study and a recent meta-analysis⁴ reported that 3.6% (95% confidence interval, 1.9%-6.7%) to 3.7% (95% confidence interval, 3.0%-4.7%) of average-risk individuals age 45-49 have advanced colorectal neoplasia (ACN), defined as an advanced polyp or carcinoma; however, data specific to the VHA population are lacking.

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.

Routine Immunohistochemical Analysis of Mismatch Repair Proteins in Colorectal Cancer—A Prospective Analysis

Simple Summary

Recognition of a hereditary colorectal cancer (CRC) syndrome is crucial. Our aim was to assess the value of routine immunohistochemistry screening for mismatch repair proteins deficiency in CRC patients under 70 years-old. In our cohort, this inclusive strategy allowed the identification of Lynch Syndrome patients that could otherwise be missed using a restrictive approach that relies only on Amsterdam and Bethesda criteria. This study strengthens current recommendations and highlights the role of universal CRC screening for MMR protein status.

Abstract

Recognition of a hereditary colorectal cancer (CRC) syndrome is crucial and Lynch Syndrome (LS) is the most frequent immunohistochemistry (IHC)—screening for mismatch repair proteins (MMR) deficiency in CRC is therefore advocated. An unicentric cohort study was conducted in a central Oncological Hospital to assess its results. All patients under 70 years-old admitted between July 2017–June 2019 and submitted to surgery for CRC were included. Of 275 patients, 56.0% were male, median age 61.0 (IQR:54.5–65.0), with synchronous tumors in six. Histology revealed high grade adenocarcinoma in 8.4%; mucinous and/or signet ring differentiation in 11.3%; and lymphocytic infiltration in 29.8%. Amsterdam (AC) and Bethesda (BC) Criteria were fulfilled in 11 and 74 patients, respectively. IHC revealed loss of expression of MMR proteins in 24 (8.7%), mostly MLH1 and PMS2 (n = 15) and PMS2 (n = 4). Among these, no patients fulfilled AC and 13 fulfilled BC. BRAF mutation or MLH1 promoter hypermethylation was found in four patients with MLH1 loss of expression. Genetic diagnosis was performed in 51 patients, 11 of them with altered IHC. LS was diagnosed in four, and BC was present in three. One patient would not have been diagnosed without routine IHC screening. These results strengthen the important role of IHC screening for MMR proteins loss of expression in CRC.

Risk Factors for Early-Onset Colorectal Cancer: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Despite the widespread increase in the incidence of early-onset colorectal cancer (EoCRC), the reasons for this increase remain unclear. The objective of this study was to determine risk factors for the development of EoCRC.

METHODS

We conducted a systematic literature review and meta-analysis of studies examining non-genetic risk factors for EoCRC, including demographic factors, comorbidities, and lifestyle factors. Random effects meta-analyses were conducted for risk factors that were examined in at least three studies. Heterogeneity was investigated using the Q-test and I² statistic.

RESULTS

From 3304 initial citations, 20 studies were included in this review. Significant risk factors for EoCRC included CRC history in a first-degree relative (RR 4.21, 95% CI 2.61-6.79), hyperlipidemia (RR 1.62, 95% CI 1.22-2.13), obesity (RR 1.54, 95% CI 1.01-2.35), and alcohol consumption (high vs. non-drinkers) (RR 1.71, 95% CI 1.62-1.80). While smoking was suggestive as a risk factor, the association was not statistically significant (RR 1.35, 95% CI 0.81-2.25). With the exception of alcohol consumption, there was considerable heterogeneity among studies (I² > 60%). Other potential risk factors included hypertension, metabolic syndrome, ulcerative colitis, chronic kidney disease, dietary factors, sedentary behaviour, and occupational exposure to organic dusts, but these were only examined in one or two studies.

CONCLUSIONS

The results of this study advance the understanding of the etiology of EoCRC. High-quality studies conducted on generalizable populations and that comprehensively examine risk factors for EoCRC are required to inform primary and secondary prevention strategies.

Predicting Distant Metastasis in Young-Onset Colorectal Cancer After Surgery: A Retrospective Study

Background

Although overall colorectal cancer (CRC) cases have been declining worldwide, there has been an increase in the incidence of the CRC among individuals younger than 50 years old, which is associated with distant metastasis (DM) and poor prognosis.

Methods

Young-onset CRC patients' postoperative data were collected from the Surveillance, Epidemiology, and End Results (SEER) database between January 2010 and December 2015. Data from the SEER database were divided into early stage and advanced stage according to whether chemoradiotherapy was recommended in the guidelines. Independent risk factors for DM were explored by using univariate and multivariate logistic regression separately. A predictive model was established and presented as nomogram in the training set of advanced stage. The model was internally verified in testing set and externally validated in a cohort of 145 patients from Zhongnan Hospital of Wuhan University. The accuracy, reliability, and clinical application value were assessed using the receiver operating characteristic curve (ROC), the area under the curve (AUC), calibration curve, and decision curve analysis (DCA), respectively. Different risk subgroups of DM were classified according to the scores of the nomogram in the training set of advanced stage.

Results

A total of 5,584 patients were eligible and enrolled in our study in which 1,277 were in early stage and 4,307 in advanced stage. Preoperative CEA positive was found to be an independent predictor of DM in early stage. Multivariate logistic regression analysis showed that tumor size, degree of differentiation, T stage, N stage, preoperative CEA, and whether radiation or chemotherapy performed were independent risk factors for DM (all, p < 0.05) in advanced stage. Great accuracies were achieved in our nomogram with AUC of 0.801 in training set, 0.811 in testing set, and 0.791 in the validation cohort, respectively. Calibration curves and DCA in internal validation and external validation both showed good stability and clinical utility values.

Conclusions

Preoperative CEA positive was a significant predictor of DM for young-onset CRC patients. A novel nomogram containing clinical and pathological features was established for predicting DM of advanced CRC in patients younger than 50 years old. This tool may serve as an early alert for clinicians to DM and make better clinical treatment regimens.

A comprehensive framework for early-onset colorectal cancer research

Sporadic colorectal cancer has traditionally been viewed as a malignancy of older individuals. However, as the global prevalence of the disease diagnosed in younger individuals (<50 years) is expected to increase within the next decade, greater recognition is now being given to early-onset colorectal cancer. The cause of the predicted rise in prevalence is largely unknown and probably multifactorial. In this Series paper, we discuss the potential underlying causes of early-onset colorectal cancer, the role of energy balance, biological and genomic mechanisms (including microbiome aspects), and the treatment of early-onset colorectal cancer. We have specifically considered the psychosocial challenges of being diagnosed with colorectal cancer at younger age and the potential financial toxicity that might ensue. This Series paper brings a comprehensive review based on the existing data in the hopes of optimising the overall outcomes for patients with early-onset colorectal cancer.

Development and validation of a nomogram to predict overall survival in young non-metastatic rectal cancer patients after curative resection: a population-based analysis

PURPOSE

This study aimed to establish and validate a nomogram for predicting overall survival (OS) in young non-metastatic rectal cancer (RC) patients after curative resection.

METHODS

Young RC patients (under 50 years of age) from 2010 to 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Those patients randomly assigned to a training cohort and a validation cohort at a ratio of 7:3. The independent prognostic factors for OS were identified by univariate and multivariate Cox regression analysis. A nomogram model was built based on the independent prognostic variables and was evaluated by concordance index (C-index), receiver operating characteristics (ROC) curves, calibration plot, and decision curve analysis (DCA).

RESULTS

A total number of 3026 young RC patients were extracted from SEER database. OS nomogram was constructed based on race, histological type, tumor grade, T stage, N stage, carcinoembryonic antigen (CEA) level, and number of lymph nodes (LN) examined. C-index, ROC curves, calibration plot, and DCA curves presented satisfactory performance of the above nomogram in predicting the prognosis of young non-metastatic RC patients after curative resection. The nomogram can identify three subgroups of patients at different risks, which showed different prognostic outcomes both in the training cohort and validation cohort.

CONCLUSION

We successfully established a reliable and insightful nomogram to predict OS for young non-metastatic RC patients after curative resection. The nomogram may provide accurate prognosis prediction to guide individualized follow-up and treatment plans.

Primary Care Provider Knowledge and Practice in Risk Assessment for Early Age Onset Colorectal Cancer: Opportunities for Improvement

Colorectal cancer (CRC) incidence and mortality are rising in individuals under age 50, termed early age onset (EAO) CRC. Lower endoscopy is recommended for all patients with unexplained iron deficiency anemia (IDA) or hematochezia to assess the EAO-CRC. For those without symptoms, professional societies recommend decreasing the age to start screening from 50 to 45. Primary care provider (PCP) knowledge and practices around EAO-CRC risk assessment and screening are unknown. We conducted a survey study in May, 2020 of multi-specialty PCPs from three large medical systems to assess PCP knowledge, risk stratification practices and barriers/facilitators they face to offer CRC screening in patients < 50. We conducted univariate analysis to assess factors associated with knowledge and diagnostic practices. Response rate was 27.7% (196/708). Although 77.6% of respondents were aware that EAO-CRC incidence is increasing, only 42.9% knew that EAO-CRC mortality is also increasing. Of note, 91.8% recommend starting average risk screening at age 50. For 40- to 49-year-old patients present with unexplained IDA or hematochezia, 71.9% and 50.5% of respondents, respectively, recommend a diagnostic colonoscopy. Trainees were less likely to be aware of rising EAO-CRC mortality (odds ratio, 0.42; 95% CI, 0.21 to 0.82) and non-internal medicine providers were less likely to recommend CRC screening in those with a first-degree relative with CRC (odds ratio, 0.82; 95% CI, 0.72 to 0.93). Ongoing education efforts will be required to improve recognition and management of high-risk symptoms, particularly among non-internists and trainees.

Colorectal cancer in 18- to 49-year-olds: rising rates, presentation, and outcome in a large integrated health system

BACKGROUND AND AIMS

Colorectal cancer (CRC) rates are increasing in young people, and new guidelines recommend screening should begin at age 45 years. We aimed to evaluate CRC detection rates in a large integrated healthcare system to assess treatment outcomes in younger CRC patients and to determine factors that could aid in identifying these individuals.

METHODS

We analyzed confirmed cases of CRC using a cancer database spanning from 1985 to 2017 from a large integrated healthcare system composed of 15 hospitals, 150 outpatient clinics, and 20 outpatient oncology clinics. Three cohorts were evaluated (18-44 years, 45-49 years, and ≥50 years).

RESULTS

Significant increases in CRC detection were seen in the cohort aged 18 to 44 (annual percentage change, 2.70%) and the cohort aged 45 to 49 (annual percentage change, 4.15%). A higher proportion of African American, Hispanic, and obese subjects were seen in the younger cohorts. A family history of CRC was found in 49% of patients aged 18 to 44 and 38% of patients aged 45 to 50. Patients younger than age 50 were more likely to have metastases at diagnosis (6.8%) versus the cohort over 50 (4.15%; P < .05). Survival was better in younger cohorts, and they were more likely to receive multimodality treatment (surgery with chemotherapy or radiation). Survival probability was similar in different ethnic groups.

CONCLUSIONS

CRC is increasing at similar rates in young people aged 18 to 44 and 45 to 49, and they are more likely to present with advanced disease needing multimodality treatment. A family history identifies some patients <50 years. Young patients presenting with changes in bowel habit, rectal bleeding, anemia, and weight loss should undergo colonoscopy. Rectal and anal symptoms should prompt careful physical and endoscopic evaluation.

Early age onset colorectal cancer

The incidence and mortality associated with colorectal cancer (CRC) diagnosed in patients under the age of 50 have been steadily increasing. The exact etiology of these epidemiologic trends is unclear. This chapter will provide a comprehensive review on the topic of early age onset colorectal cancer (EAO-CRC), defined as colorectal cancer (CRC) diagnosed in patients under the age of 50. Topics reviewed will include the epidemiology of EAO-CRC around the world, clinical and pathological features of EAO-CRC in contrast to later age onset CRC (CRC diagnosed on those over the age of 50) and the observed molecular and somatic characteristics. This chapter will review the etiologies to EAO-CRC and the established, as well as proposed risk factors for disease. Evidence-based approaches to prevention, early detection, treatment and survivorship will be presented.

The Inherited and Familial Component of Early-Onset Colorectal Cancer

Early-onset colorectal cancer (EOCRC), defined as that diagnosed before the age of 50, accounts for 10–12% of all new colorectal cancer (CRC) diagnoses. Epidemiological data indicate that EOCRC incidence is increasing, despite the observed heterogeneity among countries. Although the cause for such increase remains obscure, ≈13% (range: 9–26%) of EOCRC patients carry pathogenic germline variants in known cancer predisposition genes, including 2.5% of patients with germline pathogenic variants in hereditary cancer genes traditionally not associated with CRC predisposition. Approximately 28% of EOCRC patients have family history of the disease. This article recapitulates current evidence on the inherited syndromes that predispose to EOCRC and its familial component. The evidence gathered support that all patients diagnosed with an EOCRC should be referred to a specialized genetic counseling service and offered somatic and germline pancancer multigene panel testing. The identification of a germline pathogenic variant in a known hereditary cancer gene has relevant implications for the clinical management of the patient and his/her relatives, and it may guide surgical and therapeutic decisions. The relative high prevalence of hereditary cancer syndromes and familial component among EOCRC patients supports further research that helps understand the genetic background, either monogenic or polygenic, behind this increasingly common disease.

Polyposis and Oncologic Outcomes in Young-onset Sporadic Colorectal Cancer

Aim

The present study aimed to investigate the effect of the presence of polyposis in sporadic early-onset colorectal cancer (EOCRC) on clinicopathological and oncological outcomes.

Methods

The retrospective study included patients with sporadic colorectal cancer aged 16 to 50 years who underwent curative resection at the general surgery clinics in two healthcare centers between 2013 and 2019. Patients were divided into two groups: polyposis and nonpolyposis. Clinicopathological characteristics and oncological outcomes were compared between the two groups.

Results

A total of 127 patients were included, of whom 60.6% were men. There were 25 (19.68%) patients in the polyposis group and 102 (80.31%) patients in the nonpolyposis group. Seventy-one (69.6%) of the nonpolyposis group and 23 (92.0%) of the polyposis group had adenocarcinoma histological types. The total number of patients with mucinous tumor and signet ring cell carcinoma in the nonpolyposis and polyposis groups was 31 (30.4%) and 2 (8.0%), respectively (p = 0.042). Five-year overall survival (OS) was 60 and 72% in the nonpolyposis and polyposis groups, respectively, and no significant difference was found (p = 0.332). In univariate analysis, American Joint Committee on Cancer (AJCC) tumor stage (pT) ≥3–4, lymph node positivity, presence of mucinous tumor and signet ring cell carcinoma, lymphovascular invasion, and advanced tumor-lymph nodesmetastasis (TNM) stage (III–IV) were found to be significant negative prognostic factors for OS, whereas none of these parameters were found to be prognostic factors in multivariate analysis. The presence of polyposis was not a significant factor on both univariate and multivariate analyses.

Conclusion

Although the sporadic EOCRC cases developing on the basis of polyposis can have slightly better oncological outcomes, these outcomes are mostly similar to those of cases with nonpolyposis.

How to cite this article

Aday U, Kafadar MT, Oğuz A, et al. Polyposis and Oncologic Outcomes in Young-onset Sporadic Colorectal Cancer. Euroasian J Hepato-Gastroenterol 2021;11(1):6–10.