HEALTHY INTESTINE

Illustration courtesy of Christoph Burgstedt/Science Photo Library

 

INTESTINE WITH POLYPS

Illustration courtesy of Kateryna Kon/Science Photo Library

BY STEPHANIE STEMMLER

Once considered a disease that primarily affected older adults, colorectal cancer no longer fits that description. Over the past two decades, the number of new cases of colorectal cancer in adults under the age of 50 in the United States and worldwide has increased dramatically. The National Cancer Institute now projects that by 2030 it will be the leading cause of cancer deaths in Americans between the ages of 20 and 49. Oncologists across the country are alarmed by this fairly recent trend—and they want you to take notice, too.

What’s even more alarming is that a large percentage of these newly diagnosed colorectal cases are diagnosed when they are in advanced stages, meaning the disease is tougher to treat or cure.

“It’s really shocking,” says Radhika Smith, MD, Washington University colorectal surgeon. “We are seeing lower rates of colorectal cancer in the older population thanks to screenings and education programs for that age group, but cases in young adults are rising.” Smith, who treats people with colorectal cancer at Siteman Cancer Center, based at Barnes-Jewish Hospital and Washington University School of Medicine, notes that many young adults aren’t aware of the disease’s early symptoms—or tend to discount them because they are young and think cancer won’t happen to them. “We need to change that,” Smith says.

IT’S REALLY SHOCKING. WE ARE SEEING LOWER RATES OF COLORECTAL CANCER IN THE OLDER POPULATION THANKS TO SCREENINGS AND EDUCATION PROGRAMS FOR THAT AGE GROUP, BUT CASES IN YOUNG ADULTS ARE RISING.

Defining the disease

Colorectal cancer is an umbrella term for cancers that start in either the colon (also called the large intestine or large bowel) or the rectum, all part of the body’s digestive system. While more men than women are diagnosed with colorectal cancer and African Americans have a higher risk, the disease cuts across all racial and ethnic groups. It still is diagnosed more often in older adults but that’s changing: A 2021 study published in the Journal of the American Medical Association notes that one in 10 colon cancers and one in four rectal cancers occur in people younger than age 50.

Analyzing the trend

Doctors still don’t know why new cases are rising in young adults. Evidence, however, points to environmental exposures and lifestyle risks, including a diet low in fiber, high in fat and sugar, and high in processed food. Tobacco and alcohol use, and a sedentary lifestyle may be contributing factors.

Problems occurring within a person’s gut microbiome also may help drive this trend—and genetics is another possible factor, though oncologists tend to believe this affects less than one-third of young adult cases. Still, hereditary conditions such as familial adenomatous polyposis (FAP), which causes hundreds of polyps to form in the small and large intestines, and Lynch syndrome, along with inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis, are conditions that do increase the risk of colorectal cancer.

FROM LEFT TO RIGHT: RADHIKA SMITH, MD; HYUN KIM, MD; AND KATRINA PEDERSEN, MD, MS, ARE PART OF SITEMAN CANCER CENTER’S PROGRAM TO TREAT YOUNG ADULTS WITH COLORECTAL CANCER.

What is probable is that young adults—and their physicians—don’t consider the possibility of colorectal cancer when potential symptoms first appear. The disease, then, goes undiagnosed until it can be too late for life-saving treatment. To change this situation, cancer specialists now are actively campaigning for increased self-awareness and better education for young adults and their doctors—and for colorectal cancer screenings when appropriate.

“Health-care professionals were terrible publicists five to eight years ago when we recognized the rising numbers,” admits Katrina Pedersen, MD, MS, Washington University medical oncologist at Siteman. “We have to be more vocal and empower younger individuals to recognize the risks and symptoms.”

Hot spots for increased early-age colorectal cancers are in the Mississippi Delta and Appalachian regions of the United States, which have strong links between the rate of cancers diagnosed and socio-economic issues such as poverty and lack of medical access. Close behind are surrounding states, including Louisiana, Arkansas, Missouri and Oklahoma, as well as Kentucky, Tennessee and Alabama.

Many oncologists are concerned that young adults don’t have the information they need to recognize early warning signs for colon and rectal cancers, which can mimic other non-cancerous conditions, including hemorrhoids, tears in the anus and gastrointestinal problems. But Hyun Kim, MD, Washington University radiation oncologist at Siteman, says, “You should have a low threshold for contacting your physician if you notice unusual symptoms. Often, it won’t be cancer. But get yourself checked.”

HYUN KIM, MD, RADIATION ONCOLOGIST

Kim says everyone should get used to checking their stool before they flush; simply glancing at the toilet paper to check for blood stains is a start. “Be aware; that’s what we’re advocating,” he says. “People need to be self-aware.”

Consider early screening

The medical community now recommends that a person’s first formal colorectal cancer screening should occur at age 45—and regular screenings should continue until age 75.

You may want to be screened earlier than age 45 if any of the following factors are part of your health history:

• A family history of colorectal cancer. If so, you should be screened 10 years earlier than the age of that family member when they were first diagnosed with cancer.
• A son or daughter diagnosed with early-age colon or rectal cancer. If so, your risk increases, and early screening is important.
• You notice, at any age, symptoms that might suggest colorectal cancer. If so, talk with your doctor about screening, even if there’s no family history of the disease.

Screening options

Sigmoidoscopy and colonoscopy. These are the gold-standard tests for colorectal screening; they are performed in an outpatient setting by a doctor. Done while the patient is sedated, colonoscopy involves the insertion of a small scope into the rectum; it is then guided up into the colon to check for polyps or cancerous growths. Polyps, which are found in about 25% of patients, are typically benign, but they are considered precursors to cancer. They can be removed as part of the screening.

A sigmoidoscopy test usually does not require sedation. However, unlike colonoscopy, sigmoidoscopy examines only the lower section of the colon and rectum, so it should be paired with other screening tests to avoid missing cancers that can be located higher in the colon.

The most common complaint about such procedures is the advance prep work, which includes a light diet and only clear liquids the night before the procedure, along with a bowel prep medication (in liquid or pill form) taken to ensure the colon is clean and offers good visibility during the test.

Stool tests. These are easy screenings that can be done at home. A swab is used to obtain a small sample of stool. That sample is then placed in a provided container, which is returned to the doctor’s office or a lab. The samples are checked for the presence of blood in the stool. Advanced stool tests also check for abnormal DNA that may signal the presence of cancer. The drawback with at-home tests is that they don’t detect nor remove polyps, a process that can prevent cancer from starting. And if a stool test returns results showing an abnormality, a colonoscopy is the next step.

Treatment options

Within the last several years, the number of treatment options for colorectal cancers has increased. The type of treatment used is based upon where the cancer is located, how deeply it invades into and through the bowel wall, and whether it has spread to other parts of the body.

For colon cancer, surgery to remove a tumor and surrounding lymph nodes is usually the first option. Such procedures can be minimally invasive, which means smaller incisions and faster recoveries. Robot-assisted minimally invasive surgeries also are available. When needed, chemotherapy before or after surgery may be part of the treatment plan.

For rectal cancers, short-course radiation therapy is a commonly used treatment in Europe but has been slow to be adopted in the United States. Washington University radiation oncologists have been offering and evaluating short-course radiation therapy since the 1970s. Since 2017, short-course radiation combined with nonoperative management (omitting surgery if the tumor goes away completely) has been the standard practice at Siteman for rectal cancer.

In this course of care, Kim says, “instead of 28 to 30 days of radiation, patients receive higher doses of radiation for just five days, followed by chemotherapy and intense monitoring.” He adds: “Outcomes are good, with studies showing that cancer initially goes away in up to 74% of patients treated. Patients are pleased to complete their treatments quickly and return to their lives; many report their bowel function returns to pre-cancer function after treatment is complete.”

Immunotherapy drugs, which unmask tumors hiding from a patient’s own immune system before attacking the cancer cells, also are showing promise for some colorectal cancers. The FDA already has approved several such drugs—and drug combinations—to treat advanced, metastatic colorectal cancer. Many more in clinical trials are looking at immunotherapy combined with other treatment options and as a stand-alone treatment option.

In 2022, a preliminary study published in the New England Journal of Medicine, pertaining to a specific type of rectal cancer, caused a good deal of excitement. In this study at Memorial Sloan Kettering, the first 14 participants in an immunotherapy trial went into complete remission from their rectal cancer, meaning that they did not require any of the usual radiation, chemotherapy or surgery. Larger studies are under way to confirm whether this approach should become a standard of care.

The study, Pedersen notes, included “a small subset of people with Stage 2 and Stage 3 rectal cancer whose disease contained a specific gene mutation and had not spread to other parts of the body.” Nevertheless, she notes, the results of this trial have helped increase the number of clinical trials investigating various immunotherapies for treating earlier stages of colorectal cancer.

Further advancements in minimally invasive surgical treatments have enhanced overall quality of life for patients after surgery by eliminating the need for a permanent colostomy bag, an external bag that is a repository for bowel waste eliminated from the body. Today, the majority of patients undergoing colon or rectal surgery won’t need a permanent ostomy bag.

Tailoring treatment

As the incidence of colorectal cancer continues to rise in young adults, leading cancer centers, including Siteman Cancer Center, have opened specialized, multidisciplinary colorectal cancer programs specifically tailored to improve cancer care and research while addressing the unique needs of young adults with the disease. The programs bring together not only medical oncologists, radiation oncologists and colorectal surgeons, but also reproductive and fertility specialists, genetic counselors and lifestyle medicine experts, as well as survivor care, behavioral support, symptom-focused clinics and social services. These programs meet the needs of younger adults and are well-used resources.

“When we officially opened our program in early 2023, we immediately started to see four to five new patients a week,” says Pedersen. “That’s two to five times the weekly volume that we anticipated, and it highlights the full impact of the rising rates in young adults.”

Pedersen, Kim and Smith, all of whom are part of Siteman’s program for young adults with colorectal cancer, are adamant that all young adults learn more about colorectal cancer and its warning signs. They are actively involved in a growing number of public education and awareness events.

“We want to tell young people that there are multiple resources available, from counseling to cutting-edge treatments and clinical trials, for colon and rectal cancer,” stresses Kim.

Pedersen, Kim and Smith offer a simple message to young adults: “Check your poop. It could save your life.”