Meeting the Unmet Needs of Young Adults With Colorectal Cancer

Cathy Eng, MD

Cathy Eng, MD

Historically, colorectal cancer (CRC) has been viewed as a common cancer among elderly patients. The average age at diagnosis of patients with CRC in the United States is 67 years,¹in which a screening colonoscopy remains the gold standard of care for prevention and is recommended for all individuals >50 years of age.^2,3Recent literature has suggested, however, that there will be an unexpected rise in the incidence of CRC, notably of left-sided tumors of the descending colon and rectum, in young adults (<50 years of age) over the next decade.⁴

The recognition of the rising incidence of CRC in young adults was initially reported by Bailey and colleagues.⁴This was a retrospective cohort study of patients with colon or rectal cancer using the Surveillance, Epidemiology, and End Results (SEER) database. The SEER database reports on the incidence, survival, and prevalence of cancer and represents approximately 28% of the United States patient population. Data were reviewed from January 1, 1975, through December 31, 2010 (n = 393,241). The incidence of cancer was predicted for 2020 and 2030 compared with 2010. Despite an expected sharp decline in the diagnosis of colon cancer for individuals >75 years of age, the incidence of colon cancer is expected to dramatically increase by 90% for those between 20 to 34 years of age by the year 2030. Similar findings were noted in left-sided tumors, specifically in rectosigmoid and rectal cancer, with an increase of 124% for young adults aged 20 to 34 years.

Rebecca L. Siegel, MPH, conducted an updated review of the SEER database from 1974 through 2013 (n = 490,305).⁵When compared with individuals born before 1950, those born after 1990 have double the risk of colon cancer and quadruple the risk of rectal cancer. The investigators noted that from the mid-1980s and on, rates of colon cancer rose by 2.4% per year for individuals aged 20 to 29 years and by 1.0% for those 30 to 39 years of age.

Based on my own clinical experience and when speaking to CRC advocacy groups, it is not uncommon to hear that many young adults had reported earlier signs or symptoms but had often ignored their symptoms or attributed their bowel irregularity to hemorrhoids. Other patients reported that despite their symptoms, their primary care provider either did not pursue a full evaluation or misdiagnosed them with hemorrhoids or irritable bowel disease. As a result of the increased recognition of the expected rise in CRC in young adults and with the support of advocacy groups, CRC screening at a younger age is being considered. As of 2018, the American Cancer Society is now recommending CRC screening to start at age 45.6 However, an earlier age of screening remains controversial and is not supported at this time by the United States Preventive Services Task Force or the American Society of Gastroenterology.^3,7

Regardless of screening protocols, the etiology for this unexpected rise of CRC in young adults remains unknown at this time, is likely multifactorial, and continues to be under investigation.

For all patients, cancer treatment can be daunting. For a young adult who is about to embark on an independent life with a new career, a new relationship, or a new home, however, a diagnosis of CRC is especially shocking. Although many hospitals have an adolescent young adult program, it is often associated with a pediatric program. Often, young adults <45 years of age neither fit the description of an adolescent young adult nor fit in with the average age of the elderly CRC population. Furthermore, most hospitals do not have a specific treatment approach for young adult patients and often manage these individuals in a similar fashion to their average age elderly patients.

Despite our best intentions to cure patients, there are both acute and chronic toxicities associated with therapy. The treatment of CRC often requires surgery for curative intent. The consideration of chemotherapy and/or chemoradiation therapy is also often part of the treatment plan. Examples of typical acute toxicities include postoperative discomfort, change in bowel habits, nausea, vomiting, mouth sensitivity, fatigue, and possibly peripheral neuropathy. Of greater concern, however, is the period after completing therapy, as the chronic toxicities may include bowel and urinary dysfunction, sexual dysfunction, lingering neuropathy, etc.

With an expected rise in CRC in young adults over the next decade, health care providers must be educated to recognize these patients&rsquo; unmet needs and the concerns and difficulties they face.

Facets that caregivers should consider for generalized aspects of cancer care in young adults with CRC are listed as follows:

• Reproductive health and sexuality counseling
• Exercise/wellness
• Nutrition
• Wound care/ostomy support services
• Palliative/supportive care
• Spiritual care
• Pain management
• Caregiver support
• Financial counseling
• Integrative medicine
• Genetics and possible referral to a high-risk genetics clinic
• Body image
• Advance care planning
• Age-specific support groups

Hopefully, cancer care providers will increase their efforts to recognize the needs of our young adult patients. Recognition will only optimize the overall patient outcome.

References:

1. Cancer Stats Facts: Colorectal cancer. Surveillance, Epidemiology, and End Results Program website. seer.cancer.gov/statfacts/html/ colorect.html. Accessed October 24, 2019.
2. U.S. Preventive Services Task Force. Archived. Colorectal cancer: screening. https://bit.ly/2JZ9Xvy. Published 2008. Accessed October 24, 2019.
3. Final recommendation statement, colorectal cancer: screening. https://bit.ly/2NUVTUO. Updated June 2016. Accessed October 24, 2019.
4. Bailey CE, Hu CY, You YN, et al. Increasing disparities in the age-related incidences of colon and rectal cancers in the United States, 1975-2010. JAMA Surgery. 2015;150(1):17-22. doi: 10.1001/ jamasurg.2014.1756.
5. Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974—2013. J Natl Cancer Inst. 2017;109(8). doi: 10.1093/jnci/djw322.
6. American Cancer Society updates colorectal cancer screening guidelines. American Cancer Society. cancer.org/latest-news/ american-cancer-society-updates-colorectal-cancer-screening-guideline.html. Published May 30, 2018. Accessed October 24, 2019.
7. Rex DK, Boland R, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. multi-society task force on colorectal cancer. Gastrointest Endosc. 2017;86(1):18-33. doi: 10.1016/j. gie.2017.04.003.