Every Wednesday at 7 a.m., our dedicated team of cancer experts meets for the 'tumor board' at the Cleveland Clinic. We gather to address a pressing issue that has captured the attention of the medical community: Why are so many young people dying of colorectal cancer? This troubling trend first came to our attention about a decade ago when we observed an alarming number of patients significantly younger than the typical demographic. Colorectal cancer, generally associated with individuals over the age of 50, is increasingly affecting those in their 40s, 30s, and even 20s. Young people who should be preparing for milestones such as college graduations, weddings, and starting families are instead finding themselves in our offices, bewildered by their diagnosis.
Over the past ten years, it has become evident that this phenomenon is not merely a statistical anomaly. Early-onset colorectal cancer (EOCRC) is surging in the United States and globally, leading to significant consequences for this age group. While colorectal cancer is challenging at any age, its impact is particularly profound when it strikes young individuals in their prime. Below, we provide an overview of what we know about this disease, the factors contributing to its rise, and potential strategies to combat this growing epidemic.
Colorectal cancer is the fourth most common cancer in the U.S. and the second-leading cause of cancer deaths. The American Cancer Society estimates that in 2023, approximately 154,270 Americans will be diagnosed with colon cancer, and around 52,900 will succumb to the disease. Globally, colorectal cancer ranks as the second most prevalent cause of cancer-related deaths. In the UK, for instance, about 44,063 cases are diagnosed annually, leading to approximately 16,808 deaths each year.
Research indicates a concerning trend: early-onset colorectal cancer is rising by 2-4% each year in industrialized nations like the U.S. and the UK. Since the 1990s, the incidence of EOCRC has escalated by more than 50%, making it the leading cause of cancer death among men and the second-leading cause among women under 50. Colorectal cancer predominantly occurs in the sigmoid colon, the final segment of the colon before the rectum.
A survey by the Colorectal Cancer Alliance highlights common symptoms among young patients with EOCRC, including changes in bowel habits (such as diarrhea and constipation), unexplained weight loss, fatigue, and abdominal pain. The most concerning symptom is blood in the stool, which may appear on toilet paper or in the toilet bowl. Bright red blood often indicates a recent source of bleeding from the lower digestive tract, while darker blood may suggest an older bleed from higher up in the colon or stomach.
One significant challenge in diagnosing colorectal cancer in young patients is that these symptoms can often be attributed to less serious conditions like hemorrhoids or irritable bowel syndrome (IBS). For example, nearly half of all Americans will experience hemorrhoids at some point, and one in ten will be diagnosed with IBS. However, given the increasing incidence of EOCRC, any concerning symptoms in younger individuals should prompt further investigation rather than be dismissed.
Lifestyle factors such as smoking, alcohol consumption, diets high in red and processed meats, sedentary behavior, and obesity are well-documented risk factors for colorectal cancer. A recent study from our team at the Cleveland Clinic's Center for Young-Onset Colorectal Cancer revealed that young patients exhibit higher levels of compounds called metabolites from red and processed meats in their blood, which may contribute to cancer cell growth.
Obesity, particularly visceral fat accumulation around the colon, has been linked to inflammation that could facilitate cancer development. However, a considerable number of young patients diagnosed with colorectal cancer do not conform to the traditional high-risk profile; many are fit, maintain healthy diets, and do not engage in smoking or excessive drinking. This paradox underscores the complexity of environmental exposures that may play a role in the disease's emergence—a topic currently under extensive research.
The concept of the 'exposome'—the cumulative environmental exposures an individual encounters—provides a valuable framework for understanding the interplay of genetic predisposition and environmental factors that elevate the risk of early-onset cancers. Research efforts are underway to identify specific environmental factors contributing to the rise of colorectal cancer in young populations. Notably, studies have suggested that microplastics can accumulate in the colon, impairing its ability to produce mucus, a protective layer crucial for maintaining colon health.
In addition to environmental risk factors still being identified, several inherited conditions significantly increase the likelihood of developing colorectal cancer at a young age. Around 15-20% of early-onset colorectal cancer cases are attributed to hereditary conditions, primarily Lynch syndrome and familial adenomatous polyposis (FAP). Lynch syndrome results from mutations in genes responsible for DNA repair, increasing the risk of uncontrolled cell growth in the colon. The CDC estimates that one in 279 Americans has Lynch syndrome. FAP leads to the development of numerous polyps in the colon, which, if untreated, almost always result in early-onset cancer.
For individuals with a family history of these conditions, genetic testing and early, frequent screenings (including colonoscopies) are critical for early detection and prevention. A family history of colorectal cancer, especially among first-degree relatives, doubles the overall risk. Consequently, understanding your family history is essential and may prompt early screening, even for those under the current recommended age of 45.
Early diagnosis is vital for treating colorectal cancer, as cancers detected in earlier stages can often be managed effectively with surgery alone. Unfortunately, early-onset colorectal cancer is frequently diagnosed at more advanced stages due to young patients' tendency to overlook symptoms or not yet qualify for standard screenings. The importance of early detection cannot be overstated, as timely intervention significantly enhances treatment success rates.
Recent advancements in screening, such as colonoscopies and at-home stool tests, have led to a decline in colorectal cancer rates among individuals over 65. However, this progress has coincided with a disturbing rise in cases among younger populations who remain below the recommended screening age. A colonoscopy, which involves inserting a long tube with a camera into the anus and through the colon, remains the gold standard for diagnosing colorectal cancer. If polyps are identified during the procedure, they can be removed and tested for cancer.
The American Cancer Society recommends that individuals begin regular colonoscopy screenings at age 45, yet this guideline does not adequately address the increasing number of patients diagnosed in their 20s and 30s. At-home stool tests, such as Cologuard, have gained popularity as they allow individuals to collect stool samples for hidden blood and DNA changes, potential indicators of cancer. However, positive stool tests typically lead to a referral for a colonoscopy for confirmation.
Treating young patients with colorectal cancer necessitates special considerations. Given the prevalence of hereditary conditions among young cancer patients, anyone diagnosed with early-onset colorectal cancer should undergo genetic testing. Identifying genetic syndromes like Lynch syndrome or FAP not only informs the patient's treatment but also has significant implications for family members, potentially preventing subsequent cancers.
For young patients with metastatic disease—where cancer has spread to other areas—aggressive treatment strategies may be necessary, including surgery to remove the primary tumor and any metastases. However, treatment plans must be carefully tailored to each patient's unique needs. Psychological care is also essential, as a cancer diagnosis at a young age can have profound emotional and social implications. Young patients, often primary caregivers for children or aging parents, may struggle with the sudden shift in their roles and responsibilities.
Financial toxicity, referring to the high costs of cancer treatment, is another significant challenge for many young patients who may lack adequate savings and rely on regular income. Social work support is crucial for addressing these financial burdens and helping patients navigate the complexities of their care. Additionally, as certain cancer treatments can impact reproductive and sexual health, it is vital for young EOCRC patients to discuss their family planning goals with healthcare providers and be referred to fertility specialists. Many of these patients are focused on expanding their families, and we aim to ensure they have every opportunity to do so.
The rise of early-onset colorectal cancer represents a significant public health challenge, influenced by intricate interactions between genetic, environmental, and lifestyle factors. To combat the increasing prevalence of this disease among young people, we must deepen our understanding of these influences and implement personalized screening strategies, particularly for those with hereditary risks or family histories.
Enhancing early diagnosis is critical for improving survival rates, necessitating vigilance from both patients and healthcare providers to prevent delays in detection. Treatment approaches must be tailored to the distinct needs of younger patients through multidisciplinary care at expert centers. As research continues to unveil the causes behind colorectal cancer in young individuals, adopting a comprehensive, patient-centered approach will not only enhance outcomes but also mitigate the overall impact of this serious disease.
