Study Results Indicate Increase in Early-Onset Colorectal Cancer


Delayed diagnosis in younger individuals and presentation of advanced disease highlights need for awareness.

The incidence of early-onset colorectal cancer is projected to increase by 2030 and more than double, according to a review article published in The New England Journal of Medicine.

Additionally, there is delayed diagnosis in younger individuals and presentation of advanced disease that poses a need for awareness on early-onset colorectal cancer, according to investigators.

In the review, author Frank A. Sinicrope, MD, detailed the importance of screening patients for the disease by addressing educational needs, overcoming barriers to screening, and increasing adherence to screening.

Earlier diagnosis of colorectal cancer can help reduce mortality, he said.

Patients with early-onset colorectal cancer are presented with advanced-stage disease, and it is associated with increased mortality rates.

Although there are clear benefits to screening for colorectal cancer, among patients aged 50 years or older who are recommended to should get screened, just 68.8% do.

“It is essential that individuals are aware of recent recommendation changes for colorectal cancer [CRC] screening. We know that early screening and intervention can save lives,” David DeRemer, PharmD, BCOP, FCCP, FHOPA, clinical professor at the College of Pharmacy at the University of Florida, said in an interview.

“Despite this fact, approximately 69% of eligible patients in the US undergo screening. The recommendation for those over the age of 50 who have not received a CRC screening modality is to seek one now,” DeRemer said.

“The preferred modality is a colonoscopy, but others such as a flexible sigmoidoscopy, stool-based testing such as fecal immunochemical test (FIT), multitargeted stool DNA, and [computed tomography] colonography are options as well. As many are aware, COVID-19 significantly impacted the screening of several other cancers such as breast, lung, and prostate,” DeRemer said.

“The broader message should be for all patients to consult health care professionals on adhering to recommended guidelines,” he said.

There are multiple options for patients, including colonoscopy, the FIT, a guaiac test, multitarget stool DNA testing, and sigmoidoscopy alone or combined with FIT. Although the most invasive method of screening, colonoscopies remain the standard for screening for colorectal cancer.

It is important to acknowledge that the reason for this could be because of barriers that affect patient access, which could include lack of access to health care providers, lack of knowledge of the benefits of screening, or reluctance to undergo screening. Unsurprisingly, the rate of screening is low among patients who are uninsured, individuals with lower incomes, and those who are minorities.

Previous recommendations indicated that individuals older than aged 50 years should start screening for colorectal cancer.

However, given the rise of early-onset colorectal cancer, the US Preventive Service Task Force has recommended that individuals who aged 45 to 49 years should also begin screening for colorectal cancer, according to the review.

“The incidence of colorectal cancer has been increasing steadily since the late 1980s in industrialized countries. In fact, patients under the age of 50 represent 10% of all new cases of colorectal cancer,” DeRemer said.

“Several organizations, including the American Cancer Society, National Comprehensive Cancer Network, and the US Preventative Task Force, now recommend that average-risk individuals initiate regular screening at the age of 45 rather than 50. Colorectal cancer is most treatable when found earlier, so this earlier detection will save lives,” DeRemer said.

“In addition, colonoscopies can prevent cancer, since precancerous adenomas can be removed during the procedure,” he said.

However, this has been a controversial recommendation, because of the increase in the incidence of early-onset colorectal cancer occurring in individuals younger than aged 45 years, according to Sinicrope.

Therefore, recommending that the screening age be lowered to aged 45 years might not be as effective.

Additionally, increasing the number of individuals who undergo screening could cause more barriers for patients who already have limited access to screening and those who would benefit the most from screening, Sinicrope said.

Another recommended approach is earlier screening for individuals who have a family history of colorectal cancer.

The recommendation is that those who have a first-degree relative with colorectal cancer or an advanced adenoma diagnosis aged 60 years or 2 first-degree relatives with colorectal cancer at any age should undergo screening. They should receive a colonoscopy at aged 40 years or at any age that is 10 years younger than the age of the family member who was diagnosed with colorectal cancer at the earliest.

However, this could create another barrier, because some individuals might not know their family history.

The factor that influences adherence most is a physician’s recommendation, Sinicrope said, adding that a physician should tailor screening recommendations for patients, including with noninvasive, stool-based tests.

Additionally, physicians should obtain and update family history, because it is essential for identifying patients who are at high risk for colorectal cancer, he said.

Sinicrope also noted new approaches that could increase the screening rates, including germline multigene panel testing for early-onset colorectal cancer and universal testing of colorectal cancer for the Lynch syndrome.

Another new screening approach could be the assessment of circulating tumor DNA in blood plasma, which is in clinical trials and has the potential to increase screening rates.

However, access to care still must be addressed, Sinicrope said.

Educational campaigns are needed to help spread awareness of early-onset colorectal cancer and could increase screenings.

Additionally, ongoing prospective studies could examine early-life exposures, Sinicrope said.

Further studies are needed to determine if and how environmental factors can play a role in the risk of cancer, including gut microbial composition and function before neoplastic development.

Data also suggest that there is an overlap with the risk factors for later-onset colorectal cancer, including a Western diet, which can alter gut microbial composition, Sinicrope said.

This could result in dysbiosis and chronic inflammation.

Additionally, a healthier, plant-based diet can produce a more favorable gut microbiome that could help reduce the risk of colorectal cancer.


Sinicrope FA. Increasing incidence of early-onset colorectal cancer. N Eng J Med. 2022;386:1547-1558. doi:10.1056/NEJMra2200869

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