Sponsored Insight
By Dr. David H. Johnson, Kootenai Health, Coeur d’Alene, Idaho
In my community gastroenterology practice, it is impossible not to notice trends among my patients – especially alarming and, better yet, solvable trends. I diagnose as many as 10 to 15 patients with colorectal cancer each year. It’s the third most common cancer and the second most common cause of cancer-related deaths in the United States.[1] Lately, I’ve been seeing an increasing number of younger patients with precancerous polyps, advanced precancerous polyps, and even malignant tumors – a trend that makes me curious as a clinician and genuinely concerned as a care provider.
Recently, a 39-year-old female patient with no family history of colorectal polyps or cancer was seen in the emergency department of our local hospital for pelvic pain. Results of a CT scan showed she had a very large ovarian cyst, which thankfully turned out to be benign. However, the radiologist also noted a subtle soft tissue mass in her ascending colon, and she was sent to me for a follow-up colonoscopy. We found a very large and advanced adenomatous, or precancerous, polyp that required surgical resection. Without that incidental CT scan finding, the polyp very likely would have developed into colorectal cancer when the patient was in her 40s – and certainly by the time she turned 50, the historically recommended age for initiating colorectal cancer screening.
I share this story because cases like this one are more common than some might think. Even though this patient is younger than the current recommended age for screening, her experience showcases how vital it is to follow current colorectal cancer screening guidelines, such as the American Cancer Society’s, which now recommend that all people of average risk be screened starting at age 45 rather than 50.
While incidence has dropped overall, colorectal cancer among younger Americans is on the rise
Despite a general decline in the rate of colorectal cancer among older populations, the United States has seen a dramatic increase in colorectal cancer among adults under 50 over the past decade.[2] In 2016 alone, more than 11,000 men and women in their 40s were diagnosed with colorectal cancer.[3] Compounding the concern is that more of these younger adults are diagnosed with an advanced-stage cancer[4] compared to older patients. Advanced-stage colorectal cancer is associated with a far poorer prognosis than early-stage disease.[5] Given this, it’s vital that we shift not only our clinical practices but also our perspective on who is at risk for colorectal cancer.
Research is needed to better understand both the biological and environmental contributions of this increasing incidence of colorectal cancer in younger adults. However, we can’t sit back and wait for answers. We must make a nationwide effort to shift the paradigm and begin to screen the 45-to-49 age group for colorectal cancer – a disease that has been deemed the most preventable type of cancer by many.[6]
Understanding colorectal cancer risk and the need to screen
What exactly does average risk mean? An individual who does not have a personal or family history of colorectal cancer, inflammatory bowel disease, a personal history of precancerous colon polyps, or a hereditary colon cancer syndrome is at average risk. The most important point that I make to my patients is that everyone is at least at average risk, and everyone should be speaking with their healthcare provider about what type of screening is appropriate for them.
Screening tests for colorectal cancer can detect the disease in the early stages when it is not causing symptoms and is most treatable. Some screening tools can also detect precancerous, non-malignant polyps. For this typically slow-progressing cancer, early detection and prevention can save lives: for patients diagnosed with early-stage colorectal cancer (stage I or II), the five-year survival rate is 90% compared with only 14% for patients diagnosed with late-stage disease.[7]
Just as colorectal cancer mortality rates for people older than 50 have declined with increased screening,[8] we can potentially achieve a similar improvement in the younger population by starting screening at age 45. We have to learn from our current screening challenges: as we’ve worked for decades to close the screening gap for those 50 and older, we have the unique opportunity to face this head on with younger patients. Making this behavior change now is key to preventing a déjà vu-like conversation about closing the screening gap among the 45-to-49 age group down the road.
Providing patients with screening options is critical
I believe the best screening test is the screening test that gets done. I’ve noticed that younger patients are information collectors – they want to know more details and to be involved in the decision-making process with their healthcare provider. Giving patients options for screening – so they can choose the test that best suits their lifestyle or personal preference – is critical. Research has shown that providing patients with options improves adherence to screening.[9]
If someone at average risk in the 45-to-49 age group is not ready or willing to undergo an invasive screening test (e.g., colonoscopy or flexible sigmoidoscopy), they can choose a noninvasive stool-based test, such as the fecal immunochemical test (FIT) or a multi-target stool DNA test (mt-sDNA or Cologuard®).
The mt-sDNA is an at-home stool test approved by the FDA for use in adults 45 and older at average risk for colorectal cancer. This test includes a user-navigation program with reminders to complete the test as well as live 24/7 support – a system I have seen my patients benefit from directly.
Both FIT and mt-sDNA complement colonoscopy. If a patient has a positive DNA-based stool test, he or she must undergo a diagnostic colonoscopy, which can often double as not only a tool to detect early-stage cancer, but also a cancer prevention tool if polyps are found and removed. Research I conducted showed that a physician’s knowledge of a patient’s positive at-home, stool DNA test has a beneficial impact on the quality of the colonoscopy that patient receives:[10] Physicians who knew the patient’s test was positive detected more precancerous polyps and advanced tumors than physicians who were not aware of the positive at-home test result.
Everyone age 45 and older at average risk should be screened
While there have been long-term declines in mortality rates for the four leading cancers (lung, colorectal, breast and prostate) since the mid-1990s,[11] progress has slowed over the past decade (2008 to 2017) for cancers that are amenable to early detection through screening, including colorectal cancer.1 That means we must be more diligent than ever about emphasizing the importance of screening for colorectal cancer in patients age 45 and older as recommended by the American Cancer Society guidelines.
I’m confident and hopeful that, by applying the many valuable lessons we’ve learned from screening patients age 50 and older at average risk, we can help the younger generation avoid this highly preventable disease.
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Dr. Johnson has received honoraria related to speaking, consulting fees and/or research grants from Exact Sciences.
[1] American Cancer Society. Key Statistics for Colorectal Cancer. https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html. Accessed January 9, 2020.
[2] Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250-281.
[3] U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on November 2018 submission data (1999-2016): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; www.cdc.gov/cancer/dataviz, Accessed June 2019.
[4] Virostko J, Capasso A, Yankeelov TE, et al. Recent trends in the age at diagnosis of colorectal cancer in the US National Cancer Data Base, 2004-2015. Cancer. 2019;0:1-8.
[5] Colorectal Cancer Facts and Figures 2017-2019. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2017-2019.pdf. Accessed December 18, 2019.
[6] Itzkowitz SH. Incremental advances in excremental cancer detection tests. J Natl Cancer Inst. 2009;101(18)1225-1227.
[7] Colorectal Cancer Facts and Figures 2017-2019. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2017-2019.pdf. Accessed December 18, 2019.
[8] Report: Colon and Rectal Cancer Rates Continue to Drop Among Older Americans. American Cancer Society. https://www.cancer.org/latest-news/report-colon-and-rectal-cancer-rates-continue-to-drop-among-older-americans.html. Accessed January 9, 2020.
[9] Inadomi JM, Vijan S, Janz NK, et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med. 2012;172(7):575-582. doi:10.1001/archinternmed.2012.332.
[10] Johnson DH, Kisiel JB, Burger KN, et al. Multitarget stool DNA test: clinical performance and impact on yield and quality of colonoscopy for colorectal cancer screening. Gastrointest Endosc. 2017 Mar;85(3):657-665.
[11] Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;0:1-24.