Increasing rate of colorectal cancer in younger patients: a review of colonoscopy findings in patients under 50 at a tertiary institution

Abstract

Background: In Australia, colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer death. It is more common in patients over 50 years, with previous evidence showing patients under 50 years account for only 9% of CRC. However, recent Australian and International studies have shown an increase in CRC incidence in patients under 50 years of age. The main aim of this study was to analyse the incidence of CRC in patients under 50 and to determine if screening would be beneficial in this population. Methods: A retrospective cohort study was performed on all patients under 50 years of age who underwent a colonoscopy, performed by a colorectal surgeon, at the Gold Coast Hospital and Health Service between January 2013 and December 2017. Results: A total of 557 patients were included in the study; 120 (21.5%) colonoscopies had a significant finding (CRC or adenoma with malignant potential). 1.9% of patients were diagnosed with CRC, all were symptomatic at time of diagnosis, the majority were stage 3 or 4. Conclusion: A total of 1.9% of patients under 50 who underwent colonoscopy were diagnosed with CRC, whilst 21.5% of patients had significant findings. These rates are greater than previously quoted figures and data for patients under 50, and provides evidence to support lowering of the CRC faecal occult blood testing screening age.

Should the high prevalence of sessile serrated lesions in patients aged below 50 years influence screening colonoscopy recommendations?

“…Our findings demonstrate that a substantial proportion of patients below the routine average risk screening age of 50 years have potentially premalignant SSLs that may contribute to the burden of CRC long-term. Therefore, while recent studies support earlier initiation of FIT for increasing CRC rates in younger patients, 3 our findings suggest that this may not provide adequate protection for females under 50 years who have considerable rates of SSLs. Our study thus raises the question of whether CRC screening using specifically colonoscopy should be considered for Caucasian women aged < 50 years.…”

“…The data presented demonstrated that although SLs were detected more frequently in older patients, one in six (16.9%) of SLs were detected in patients aged 40-49, which is below the minimum age for many CRC screening programs. These findings challenge the current paradigms of CRC screening programs, particularly when viewed in the context of the new risk classification for SLs (which establish their malignant potential), rising rates of CRC in patients < 50, 3 the fact that fecal immunochemical tests (FIT) are not sensitive for detection of sessile serrated lesions (SSLs), 4 and recent US recommendations lowering the CRC screening age to 45 years. 5 We would like to share our observations from a cross-sectional examination of 2164 patients from a predominantly Caucasian, general colonoscopy population in Perth, Australia, in 2019.…”

Disparate age and sex distribution of sessile serrated lesions and conventional adenomas in an outpatient colonoscopy population–implications for colorectal cancer screening?

“…Significantly, FIT status was not associated with SSL detection, consistent with the fact that SSLs rarely bleed [4,16]. This means that while some studies support earlier initiation of FIT for increasing rates of CRC in average-risk patients < 50 years, such an approach may provide inadequate protection for females < 50 years who may be more susceptible to SSLs [3]. Whether there are specific characteristics that would justify screening with colonoscopy in females < 50 years remains to be explored.…”

“…Reasons for this variability are similar to those regarding sex. A recent Australian study by Kim et al [3] identified rising CRC rates in patients aged < 50 years, particularly in males. Furthermore, another recent paper by Sehgal et al [30] concluded that colonoscopy at ages 45-49 was associated with a considerable decrease in CRC incidence in both males and females.…”

“…As CRC rates continue to rise globally, ongoing efforts are being made to better understand the changing epidemiology, risk factors, prevention, screening, and treatment of CRC. Rising CRC rates in people < 50 years of age is increasingly being observed [3].…”