Early-Age-Onset Colorectal Cancer in Canada: Evidence, Issues and Calls to Action

Brief Report: Trends in Incidence, Mortality, and Disability-Adjusted Life Years for Early-Onset Colorectal Cancer in Canada Between 1990 and 2019

BACKGROUND

Colorectal cancer is the third most common malignancy globally. Early-onset colorectal cancer (EOCRC) is becoming a growing healthcare focus globally, particularly in North America. We estimated trends in incidence, mortality, and disability-adjusted life years (DALYs) for EOCRC in Canada between 1990 and 2019.

METHODS

We used the Global Burden of Diseases Study to evaluate trends in incidence, mortality, and DALYs for EOCRC in Canada between 1990 and 2019. Rates were estimated per 100,000 persons at risk with associated uncertainty intervals (UIs). Annual percentage changes (APC) were estimated using joinpoint regression with 95% confidence intervals (CIs).

RESULTS

In 2019, the incidence, mortality, and DALYs rates for EOCRC were 10.89 (95% UI 8.09, 14.34), 2.24 (95% UI 2.00, 2.51), and 111.37 (95% UI 99.34, 124.78) per 100,000 individuals, respectively. Incidence increased during the study period by 1.12%/year (95% CI 1.03%, 1.22%; p < 0.001). The largest increase in incidence in EOCRC occurred between 1990 and 2007, with an APC of 2.23% (95% CI 2.09%, 2.37%; p < 0.001). Mortality (APC 2.95%, 95% CI 1.89%, 4.02%; p < 0.001) and DALY (APC 2.96%, 95% CI 1.84%, 4.09%; p < 0.001) rates increased for males between 2001 and 2006.

CONCLUSIONS

Our study reveals a substantial burden in EOCRC in Canada, with a significant increase in incidence.

Exploring How Values of Colorectal Cancer Patients and their Caregivers Influence Treatment Decision-Making

BACKGROUND

As we adopt value models to inform drug reimbursement, coverage, clinical trials, and treatment choices, aligning these models to reflect patient values and preferences becomes increasingly relevant. In this study, we focus on colorectal cancer (CRC), which is highly prevalent and a leading cause of death in Canada, and new drug treatment options are costly.

OBJECTIVE

The aim of this study was to understand how the values and experiences of people with CRC and their caregivers inform their perspectives about new and emerging colorectal cancer drug treatments.

METHODS

We applied qualitative methods to identify key personal, social, and system factors about how the values of people with CRC and their caregivers' values influence their treatment decision-making in a more holistic manner. Canadian adults (>18 years) living with non-metastatic or metastatic CRC and caregivers were recruited from oncology clinics and Colorectal Cancer Canada (CCC) using purposive sampling. Participants engaged in structured interviews by telephone. Interviews were transcribed verbatim and analyzed thematically guided by a qualitative phenomenological approach and Sherwin's ethical theory of relational autonomy using NVivo software.

RESULTS

We conducted structured interviews with 12 people with CRC and six of their caregivers, and elicited patient and caregiver values and their influence on treatment decision-making context of key personal, social, and system factors. Thematic analysis of transcripts led to the development of four overarching and intersecting themes that were identified as influencing people with CRC and their caregivers' treatment decision-making: treatment outcomes and effectiveness, intrapersonal and interpersonal factors, quality of life, and survivorship and prognosis.

DISCUSSION

Our findings suggest intersecting influences of patient-, community-, and social network-, and systemic-level factors that influence patients' decisions on treatment. Perceived clinical benefit, requirements of treatment, available information, the impact of treatment on social relationships and daily life, and the impact of social support were key factors described by participants. To our knowledge, this is the first study to utilize the theory of relational autonomy to understand patient and caregiver values in the context of treatment decisions in CRC. Using these findings, a continued exploration of people with CRC's values in treatment decision-making and how much patients value or weight the different aspects of treatment would help further advance patient care and guide healthcare system decision-making.

Addressing the Rising Trend in Early-Age-Onset Cancers in Canada

A multi-disciplinary symposium on early-age onset cancer (EAOC) was held in October 2023 to explore challenges experienced by this rapidly growing population. A major outcome of the symposium was recognition of the remarkable similarities of EAOC patients' journeys across cancer sites. Prevention and early detection of cancer are hindered by a lack of awareness among patients and family doctors that cancer can and does occur in younger persons. Distinct characteristics of the disease-such as a later stage at diagnosis and more aggressive tumor biology-require more potent treatments, which result in profound physical and psychosocial consequences that are unique to this age group. EAOC patient empowerment emerged as another key theme of the symposium. The development of a greater number of specialized clinics was called for, and patient support groups were recognized for the vital role they play in empowering patients and their families. Leading-edge medical advancements hold tremendous hope across the spectrum of EAOC care. New technologies based on genomic profiling, immunotherapy and microbiome alteration contribute to the development of highly effective, personalized approaches to treatment. All symposium participants expressed their commitment to speak with one resounding voice to advocate for equitable access to leading care practices for EAOC patients; thus, a fourth symposium is planned for November 2024.

Patterns of Prescription Medication Use Before Diagnosis of Early Age-Onset Colorectal Cancer: Population-Based Descriptive Study

BACKGROUND

Colorectal cancer (CRC) is estimated to be the fourth most common cancer diagnosis in Canada (except for nonmelanoma skin cancers) and the second and third leading cause of cancer-related death in male and female individuals, respectively.

OBJECTIVE

The rising incidence of early age-onset colorectal cancer (EAO-CRC; diagnosis at less than 50 years) calls for a better understanding of patients' pathway to diagnosis. Therefore, we evaluated patterns of prescription medication use before EAO-CRC diagnosis.

METHODS

We used linked administrative health databases in British Columbia (BC), Canada, to identify individuals diagnosed with EAO-CRC between January 1, 2010, and December 31, 2016 (hereinafter referred to as "cases"), along with cancer-free controls (1:10), matched by age and sex. We identified all prescriptions dispensed from community pharmacies during the year prior to diagnosis and used the Anatomical Therapeutic Chemical Classification system Level 3 to group prescriptions according to the drug class. A parallel assessment was conducted for individuals diagnosed with average age-onset CRC (diagnosis at age 50 years and older).

RESULTS

We included 1001 EAO-CRC cases (n=450, 45% female participants; mean 41.0, SD 6.1 years), and 12,989 prescriptions were filled in the year before diagnosis by 797 (79.7%) individuals. Top-filled drugs were antidepressants (first; n=1698, 13.1%). Drugs for peptic ulcer disease and gastroesophageal reflux disease (third; n=795, 6.1%) were more likely filled by EAO-CRC cases than controls (odds ratio [OR] 1.4, 95% CI 1.2-1.7) and with more frequent fills (OR 1.8, 95% CI 1.7-1.9). We noted similar patterns for topical agents for hemorrhoids and anal fissures, which were more likely filled by EAO-CRC cases than controls (OR 7.4, 95% CI 5.8-9.4) and with more frequent fills (OR 15.6, 95% CI 13.1-18.6).

CONCLUSIONS

We observed frequent prescription medication use in the year before diagnosis of EAO-CRC, including for drugs to treat commonly reported symptoms of EAO-CRC.

COVID-related disruptions to colorectal cancer screening, diagnosis, and treatment could increase cancer Burden in Australia and Canada: A modelling study

COVID-19 disrupted cancer control worldwide, impacting preventative screening, diagnoses, and treatment services. This modelling study estimates the impact of disruptions on colorectal cancer cases and deaths in Canada and Australia, informed by data on screening, diagnosis, and treatment procedures. Modelling was used to estimate short- and long-term effects on colorectal cancer incidence and mortality, including ongoing impact of patient backlogs. A hypothetical mitigation strategy was simulated, with diagnostic and treatment capacities increased by 5% from 2022 to address backlogs. Colorectal cancer screening dropped by 40% in Canada and 6.3% in Australia in 2020. Significant decreases to diagnostic and treatment procedures were also observed in Australia and Canada, which were estimated to lead to additional patient wait times. These changes would lead to an estimated increase of 255 colorectal cancer cases and 1,820 colorectal cancer deaths in Canada and 234 cases and 1,186 deaths in Australia over 2020-2030; a 1.9% and 2.4% increase in mortality, respectively, vs a scenario with no screening disruption or diagnostic/treatment delays. Diagnostic and treatment capacity mitigation would avert 789 and 350 deaths in Canada and Australia, respectively. COVID-related disruptions had a significant impact on colorectal cancer screening, diagnostic, and treatment procedures in Canada and Australia. Modelling demonstrates that downstream effects on disease burden could be substantial. However, backlogs can be managed and deaths averted with even small increases to diagnostic and treatment capacity. Careful management of resources can improve patient outcomes after any temporary disruption, and these results can inform targeted approaches early detection of cancers.

Direct Medical Spending on Young and Average-Age Onset Colorectal Cancer before and after Diagnosis: a Population-Based Costing Study

BACKGROUND

Despite a better understanding of the increasing incidence of young-onset colorectal cancer (yCRC; age at diagnosis <50 years), little is known about its economic burden. Therefore, we estimated direct medical spending on yCRC before and after diagnosis.

METHODS

We used linked administrative health databases in British Columbia, Canada, to create a study population of yCRC and average-age onset colorectal cancer (aCRC; age at diagnosis ≥50 years) cases, along with cancer-free controls. Over the 1-year period preceding a colorectal cancer diagnosis, we estimated direct medical spending on hospital visits, healthcare practitioners, and prescription medications. After diagnosis, we calculated cost attributable to yCRC and aCRC, which additionally included the cost of cancer treatments (e.g., chemotherapy and radiotherapy) across phases of care.

RESULTS

We included 1,058 yCRC (45.4% females; age at diagnosis 42.4 ± 6.2 years) and 12,619 aCRC (44.8% females; age at diagnosis of 68.1 ± 9.2 years) cases. Direct medical spending on the average yCRC and aCRC case during the year before diagnosis was $6,711 and $8,056, respectively. After diagnosis, the overall average annualized cost attributable to yCRC significantly differed in comparison with aCRC for the initial ($50,216 vs. $37,842; P < 0.001), continuing ($8,361 vs. $5,014; P < 0.001), and end-of-life cancer phase ($86,125 vs. $61,512; P < 0.001) but not end-of-life non-cancer phase ($77,273 vs. $23,316; P = 0.372).

CONCLUSIONS

Reported cost estimates may be used as inputs for future economic evaluations pertaining to yCRC.

IMPACT

We provided comprehensive cost estimates for healthcare spending on young-onset colorectal cancer.

Breaking Down Barriers to Detection and Care in Early-Age-Onset Colorectal Cancer in Canada

The second Early-Age-Onset Colorectal Cancer Symposium, convened in October 2022, sought solutions to the barriers to early detection and care for colorectal cancer in Canada. This meeting built on a previous symposium, held in 2021 and reported in this journal. Early-age-onset colorectal cancer (EAOCRC) affects increasing numbers of people under the age of 50 in Canada and throughout the developed world. Two main themes emerged from the meeting: the importance of timely detection, and the need for a tailored approach to the care of EAOCRC. Early detection is crucial, especially in light of the later stage at diagnosis and unique tumour characteristics. Symposium participants were strongly in favour of reducing the age of eligibility for screening from 50 to 45, and promoting the development of non-invasive screening techniques such as testing for circulating tumour DNA and biomarkers. Leading approaches to care were described and discussed, which meet the unique treatment needs of younger CRC patients. Multidisciplinary practices within and outside Canada address such factors as fertility, family roles, education, careers and financial responsibilities. These models can be applied in treatment centres across the country.