Bright and early at 7am every Wednesday our team of cancer experts convenes a meeting of the ‘tumor board’.
Here we discuss the issue at the forefront of the medical community’s mind: Why are so many young people dying of colorectal cancer?
We first caught the trend about a decade ago when we noticed more and more patients were significantly younger than the doctors sitting around the table.
Colorectal cancer, a disease typically associated with people over the age of the 50, was increasingly striking those in their 40s, 30s and even 20s.
Suddenly young people who should be getting ready to graduate college, walk down the aisle, or start families of their own were sitting in our offices, baffled as to how they had got there.
It’s become clear over the last ten years that this trend isn’t just a statistical blip.
Early onset colorectal cancer – when the disease strikes before age 50 – is surging in the US and across the globe, with far-reaching consequences.
While colorectal cancer at any age is a difficult disease, the impact is more extensive when it affects young people in the prime of their life.
Below is everything my team at Cleveland Clinic’s Center for Young-Onset Colorectal Cancer and I know about the disease, what’s behind the rise, and what we think could stop the global epidemic.
What is colorectal cancer?
Dr David Liska is one of the most eminent voices in the fight against the rise of colon cancer
Rates of colorectal cancer in Americans under 50 have risen over the past two decades. This graph shows the latest year for which data is available
Colorectal cancer is the fourth most common cancer in the US and the second-leading cause of cancer deaths.
The American Cancer Society estimates 154,270 Americans will be diagnosed with colon cancer this year, and 52,900 will die.
The disease is also the second most common cause of cancer deaths around the world.
According to Cancer Research UK, 44,063 cases are diagnosed per year, and the nation experiences 16,808 deaths every year.
Studies show that in industrialized countries like the US and UK, early-onset colorectal cancer is increasing by two to four percent every year.
And since the 1990s, cancer statistics have shown that EOCRC (early-onset colorectal cancer) has increased by more than 50 percent, meaning it is the leading cause of cancer death in men and the second-leading cause in women under 50.
Colorectal cancer is most commonly found in the sigmoid colon, the lowest part of the colon just before the rectum.
What are the symptoms?
A survey conducted by the Colorectal Cancer Alliance revealed that young patients with EOCRC often experience changes in bowel habits, such as diarrhea or constipation, unexplained weight loss, fatigue and abdominal pain.
The biggest red flag, however, is blood in the stool, on the toilet paper, or in the toilet bowl.
If blood is bright red, it’s ‘newer’ or came from lower in the digestive tract, such as in the sigmoid colon or rectum.
However, if it’s darker or black, it’s ‘older’ and could have come from higher up in the colon or the stomach.
One of the main reasons colorectal cancer is diagnosed so late or dismissed in young people is these signs could be attributed to more benign and common conditions like hemorrhoids or irritable bowel syndrome.
For example, roughly half of all Americans will have hemorrhoids at least once in their life, and one in 10 will be diagnosed with IBS.
Although bright red rectal bleeding is commonly associated with hemorrhoids, the rising incidence of EOCRC means that any concerning symptoms in younger individuals should not be dismissed without further investigation.
This blood loss can also cause anemia, leading to fatigue.
Why is there a surge of cases in young people?
Lifestyle factors such as smoking, alcohol consumption, diets rich in red and processed meats, sedentary behavior, and obesity, are well-documented risk factors for colorectal cancer.
Last year a study from Cleveland Clinic’s Center for Young-Onset Colorectal Cancer shed some light on why processed meats such as deli ham, hot dogs and burgers can be a problem.
My colleague Dr Suneel Kamath and his team collected plasma samples from 64 patients with colorectal cancer and found young patients had higher levels of compounds called metabolites from red and processed meat in their blood.
We think these metabolites help feed cancer cells and hijack normal cells, causing tumors to grow while healthy cells are deprived of the energy they need to function normally.
This is also thought to be the case for alcohol.
As for obesity, the latest science tells us that carrying more visceral fat around organs like the colon may create inflammation, which makes cancer cells more likely to form.
However, a significant proportion of young patients diagnosed with colorectal cancer do not fit this typical high-risk profile. Many are fit, have healthy diets, and do not exhibit common lifestyle risks like smoking or drinking.
This paradox points to the complexity of environmental exposures contributing to the disease, an active area of research that still comes with many unknowns.
The concept of the ‘exposome’ – the total amount of environmental exposures that a person encounters during their lifetime – has emerged as a valuable framework for how genetic predisposition and the environment raise the risk of early-onset cancers.
Teams like ours at the Cleveland Clinic are now trying to figure out which environmental factors contribute to the rise in colorectal cancer in young people.
Some research has already provided theories.
A review from the University of California San Francisco of more than 3,000 studies found that microplastics can accumulate in the colon and cause it to produce less mucus, a protective layer.
If the colon can’t produce mucus, the intestinal walls can’t protect against contaminants like microplastics and bacteria.
Mucus also lubricates the colon and helps stool pass easily. When stool builds up in the colon, it irritates the colon and inflames the inner lining.
However, much of this territory is still uncharted.
Am I at risk?
Besides environmental risk factors that still need to be identified, there are several known inherited conditions that predispose patients to colorectal cancer at a young age.
In fact, about 15 to 20 percent of early-onset colorectal cases cases are attributed to hereditary conditions – those passed on through families.
The majority of these are related to Lynch syndrome and familial adenomatous polyposis (FAP).
Lynch syndrome is a genetic condition that occurs when genes involved in DNA repair – mismatch repair genes – mutate. This significantly raises the risk of cells in organs like the colon growing out of control.
The CDC estimates one in 279 Americans has Lynch syndrome.
FAP, meanwhile, causes the growth of numerous polyps that almost always lead to early-onset cancer if left untreated.
For people with a family history of these conditions, genetic testing and early and frequent screening, including colonoscopies, are critical in identifying and preventing colon cancer.
In some cases, risk-reducing surgeries, like removing parts or even all of the colon, may be the best prevention.
A family history of colorectal cancer, especially when in a first-degree relative, even without a known hereditary condition, doubles your overall risk, so it’s crucial to know your history.
A known family history of colorectal cancer may prompt genetic testing and potentially life-saving screening colonoscopies, even if you’re younger than 45, the current recommended screening age.
How is colon cancer screened for and diagnosed?
Early diagnosis of colorectal cancer is crucial, as cancers detected in the early stages can often be cured with surgery alone.
Unfortunately, early-onset colorectal cancer is frequently diagnosed at advanced stages because young people are more likely to ignore their symptoms or not be old enough for regular screenings.
This complicates treatment and lowers survival rates. When addressed early, the chances of successful treatment and cure are significantly higher.
The good news in recent decades has been thanks to screening tools like colonoscopies and at-home stool tests, colon cancer rates are down in people over 65.
Alarmingly these important gains were accompanied by a rise in cases and deaths in young people that are still below the age of recommended screening examinations.
A colonoscopy is the gold standard for diagnosing colorectal cancer.
This involves inserting a long tube with a camera on the end into the anus and passing it through the rectum and colon.
If the doctor finds polyps during the exam, they will remove them and test them for cancer.
The American Cancer Society recommends getting a colonoscopy every 10 years starting at age 45, though this guideline fails to capture the growing number of patients in their 20s and 30s.
At-home stool tests like Cologuard have also become increasingly popular, allowing people to take a sample of their stool and send it off to check for hidden blood for DNA changes, which could be a sign of cancer.
However, if you get a positive stool test, you will likely still be referred for a colonoscopy to confirm the diagnosis.
How is colon cancer treated?
Treating young people with colon cancer requires special considerations.
Since hereditary conditions are more commonly found in young patients with cancer, any patient diagnosed with early-onset colon cancer should undergo genetic testing.
Diagnosing genetic conditions like Lynch syndrome or FAP can have significant implications not only for the patient but for their relatives, as it could prevent further cancers in the family.
Young patients with metastatic disease – meaning the cancer has spread to other areas – may benefit from aggressive treatment, including surgery to remove the primary tumor in the colon and also potential metastases in the liver or lung, but this must be balanced with a careful, individualized approach.
Psychological care is also an essential part of treatment, as cancer at a young age can have profound emotional and social impacts.
It can be very difficult for people who are used to being the primary caregivers in their families, taking care of young children and aging parents, to suddenly require care to be given to them.
Financial toxicity, which refers to the high costs associated with cancer treatment, is another challenge faced by many young patients who frequently do not have sufficient savings and are dependent on regular paychecks to make ends meet.
Social work support is crucial in addressing these financial burdens and helping patients navigate the complexities of cancer care.
Additionally, since some cancer treatments can affect reproductive and sexual health, it is critical for EOCRC patients to discuss their plans for childbearing with their cancer provider and be referred to fertility specialists.
Unlike many patients traditionally diagnosed with colon cancer, these patients are focused on expanding their families, and we want to make sure they have every opportunity to do that.
The goal of my team is to optimize the quality of life for cancer survivors and provide ongoing support tailored to their unique needs.
What’s the takeaway?
Early-onset colorectal cancer presents a significant public health challenge, driven by complex interactions between genetic, environmental, and lifestyle factors.
Preventing and reversing the rise of the disease in young people requires a deeper understanding of these influences and the implementation of personalized screening strategies, particularly for individuals with hereditary risks or a family history.
Early diagnosis is crucial to improving survival, and patients and healthcare providers need to be vigilant to prevent delays in detection.
Treatment must be tailored to the unique needs of younger patients through a multidisciplinary approach at expert centers.
As innovative research continues to shed light on the causes of colon cancer in young people, a more comprehensive patient- and population-centered approach will not only improve outcomes but also help reduce the overall impact of this disease.
