In this episode of PodMD, Colorectal and General Surgeon Dr Christopher Steen will be discussing the topic of colorectal cancer in young people. We discuss what colorectal cancer is, how it presents in younger people, appropriate initial investigations, and more.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Christopher Steen.
Dr Steen is a Melbourne- and Peninsula-based Colorectal and General Surgeon with a special interest in minimally invasive ‘keyhole’ surgery. He specialises in colorectal cancer and screening, haemorrhoids and proctology as well as a variety of general surgical pathologies. Alongside his clinical practice, Dr Steen is committed to advancing healthcare through research and is widely published in renowned surgical journals.
You can read more about Dr Steen on his profile page on our PodMD website.
*Please listen to our disclosure at the end of this podcast
Today, we’ll be discussing the topic of colorectal cancer in young people. Chris, thanks for talking with us on PodMD today.
Chris: Thank you for having me.
Could you please give us a brief overview of colorectal cancer to start us off?
Chris: Yeah, certainly. So colorectal cancer is essentially a cancer of either the colon or the rectum, as its name implies. It is a result of cells of the bowel wall that undergo cell change, which then leads to abnormal cell growth and polyps. And some of these polyps undergo further transformation into cancer. Now, some of this is due to genetics, but there are also other factors at play, such as DNA damage from alterations in gut microbiome.
Why colorectal cancer is important is that it is the 3rd most common cancer worldwide, as well as the second leading cause of death. Here in Australia, we have a high incidence, with approximately 15,000 cases being diagnosed annually, and unfortunately, over 5,000 deaths per year. This year, it is estimated that Australians have a 1 in 78 risk of dying from colorectal cancer by the age of 85. And here in Victoria, we seem to have the highest incidence in the country. And what’s more, it is the deadliest cancer for young Australian adults.
So how does its presentation in younger people differ from the traditional older demographic?
Chris: Well, that’s what’s tricky. It presents in a similar fashion. The common signs or symptoms we look out for include blood in the stool, altered bowel habits, weight loss, abdominal pain or bloating, as well as fatigue. The problem is that these signs or symptoms in presentation can often be missed or dismissed in younger adults. So young adults tend to present with much more advanced stages of cancer where the cancer has already metastasised to lymph nodes or other organs.
Okay, we often think of colorectal cancer as a disease of older adults. So how common is it in younger patients, and are we seeing an increase in incidence?
Chris: Colorectal cancer still mainly occurs in individuals over the age of 50. Only about one in eight individuals diagnosed with colorectal cancer will be under 50. But we know, likely due to our advances in screening and colonoscopy, that colorectal cancer in people over 50 is on the decline, which is great. But worryingly, it is on the rise in individuals under 50.
The risk of being diagnosed before 40 has more than doubled since the year 2000. And those bowel cancer rates have increased by two to three times that for people born in the 90s versus those baby boomers born in the 50s. This seems to be a global phenomenon, but Australia is up there with some of the highest incidence in colorectal cancer being diagnosed in young people. And we’ve recognised this as a health society by recently bringing forward the age of screening from 50 to 45 years of age.
What are the typical signs and symptoms of colorectal cancer in young adults that are most likely to be missed or misattributed?
Chris: It’s the same signs and symptoms that I mentioned earlier that present in older adults, like blood in the stool, altered bowel habits, abdominal pain, et cetera. These symptoms are more likely in a young patient to be attributed to benign pathologies, like hemorrhoids that cause bleeding or irritable bowel syndrome that causes pain or bloating. And these symptoms are more likely to be missed because of a lack of awareness around colorectal cancer by patients, doctors, and society. People think that person is too young to have colorectal or bowel cancer.
But really it’s happening and we hear about it all the time, whether it’s a friend of a friend or some famous actor like the recently deceased Dawson’s Creek actor, James Van der Beek, who’s 48.
Are there particular risk factors that GPs should keep in mind for younger patients?
Chris: Certainly. We know that obesity, sedentary lifestyle, alcohol, smoking and diets Redo the answer. Certainly, we know that obesity, sedentary lifestyle, alcohol, smoking, and diets high in red meat and processed foods and those lacking in fiber are all risk factors. Individuals with a history of colonic polyps or inflammatory bowel disease also have a higher risk.
Importantly, individuals with a genetic predisposition for colorectal cancer, like individuals with Lynch syndrome or familial adenomatous polyposis, FAP for short, are more at risk.
So you mentioned Lynch syndrome and FAP. So how does family history or known hereditary syndromes like this influence a GP’s approach to screening and early investigation?
Chris: That’s a really good question and it’s a really big question. I think if you have a patient who has a family history of one of these syndromes, you’re going to be extra suspicious when it comes to any symptoms they might present with. You would want to take a thorough family history to find out who in the family has the syndrome, if it’s just isolated to one individual or many, and is there any associated cancers that family members have? And at what ages those cancers were diagnosed.
Many of these syndromes are not just associated with colorectal malignancy. For example, Lynch is associated with other cancers like that of endometrial cancer. So you’re going to want to check the up-to-date guidelines around this, and Cancer Council Victoria is a really good place to start. This can guide you to what screening needs to be done and at what ages.
You may also want to reach out to the familiar cancer clinics because they can help with testing. And lastly, it’s good to get help to diagnose and or screen these patients with various specialists, given the many cancers they can cause.
From a colorectal point of view, having someone like a colorectal surgeon to help you with surveillance endoscopy would be my recommendation. Moreover, some of these symptoms, like FAP, can have a very high risk of colorectal cancer, and prophylactic colectomies are actually part of the recommended treatment approach.
In the primary care setting, what initial investigations are appropriate before referring, Chris?
Chris: If these are patients, we are concerned, may have an underlying colorectal pathology, I think blood tests as a baseline are required. So you definitely want to examine a patient’s hemoglobin and iron studies.
Tumor marker serology tends to be reserved for those diagnosed with bowel cancer or for those who we have a high suspicion of having bowel cancer. Or it can even be for those who are just undergoing active surveillance from a previously managed bowel cancer. With respect to fecal-occult blood testing, it’s great for screening and looking for causes of anemia, but obviously it’s not needed if the patient reports blood or melena in their stool.
I think a CT scan is useful, especially in cases where there is unexplained abdominal pain, especially if it’s persistent or if there’s focal tenderness on examination, or even if you can feel a mass. But if the referral is for, say, PR bleeding or anemia, for instance, sometimes a CT scan isn’t always required. But the key is to refer to a specialist who can help you diagnose the underlying pathology. And for most of the symptoms we’ve mentioned, endoscopy is usually the next step.
Perfect. And at what point should a GP escalate to referring the patient to a colorectal specialist, even if initial tests appear inconclusive?
Chris: Well, for me, bleeding from the back passage or in the stool really needs proper investigating. Unless the patient has had a recent colonoscopy which was clear and has a known other pathology like haemorrhoids that could account for the bleeding, I’d be a bit concerned. A positive fecal occult blood test always needs following up.
Iron deficiency is another important condition that requires investigation. And I’ll do a podcast at another date on that. Additionally, though, when there are red flags like unexplained weight loss and or anemia, or there’s a family history of colorectal cancer or even a personal history of colorectal cancer or polyps, then I would escalate my referral.
If this is a young person who has been having symptoms for some time and maybe put off seeing a doctor, or conversely, if they’ve seen a bunch of GPs about this problem, but all the tests appear inconclusive, it’s probably a good idea to escalate your referral and consider endoscopy. Or really, if you’re worried at all or just unsure, I would just encourage you to reach out to a colorectal surgeon as we’re all here to help each other and to help care for our patients.
And how would a referral like this be triaged?
Chris: Well, usually we surgeons like to see these patients pretty quick. PR bleeding, iron deficiency, positive faecal call blood tests or a concerned referral from a colleague would all usually be seen within a few weeks. And this would be triaged as a category one referral in the public system usually.
Can you walk us through potential treatment options and whether their age impacts treatment planning or outcomes?
Chris: So this is another really big question. Treatment of colorectal cancer nowadays has a lot of options. And there seems to be more exciting modalities in the near future, and that’s why referral to a colorectal surgeon and other multidisciplinary specialists like oncologists is critical.
There are many different options, and these are more and more being tailored to each individual’s, sort of a bespoke treatment, if you will.
Not only can this involve surgery, chemotherapy, immunotherapy, or radiation, but the timing of these modalities can vary from patient to patient. And this changes with the age of the patient, the location of the cancer, its stage, and even its genetics.
So when it comes to age, usually most treatment modalities are on the table. As younger people are more robust, and for instance, could handle the side effects of, say, chemotherapy, where you may not offer that modality to, say, a 90-year-old.
With young people, you tend to worry about more advanced cancers, given the higher likelihood of a late diagnosis. So they’re a little less likely to, say, just get away with surgery like a right hemicolectomy. A younger age also brings into question fertility planning. Younger people with genetic or syndrome-based colorectal cancer have a higher risk of other cancers, like say those of gynecological nature, sometimes needing removal of other reproductive organs.
There’s also the risk of treatments, for instance, surgery or radiation that can actually lead to fertility problems in both males and females. So this must be considered.
Age also impacts thoughts around cosmesis. For instance, a younger person may not want to have surgery that results in a stoma. So they may pursue options of trying to treat the cancer fully with, say, chemo radiotherapy in the hopes that the tumour just disappears and they can undergo close surveillance rather than a bowel resection.So really there’s much to consider and we need more than a podcast just to answer this question alone.
And are there particular challenges, clinical or psychosocial, that are more common when treating younger patients with colorectal cancer?
Chris: I’ve alluded to a few of the particular challenges. I think the biggest is dismissing patients’ clinical symptoms as being attributed to some other benign cause. Nowadays, colorectal cancer must always be in the back of your mind. And from a psychosocial point of view, our thoughts that this is an old person’s cancer and our society norms that reinforce these thoughts needs to be challenged.
What practical advice would you give GPs to help them pick up colorectal cancer earlier in younger patients and improve referral pathways?
Chris: I think having a higher index of suspicion than you did when you first completed your training is important. This holds true for all of us. We were all taught that this really isn’t a young person cancer.
But more and more, we’re learning that it’s getting worse, it’s aggressive in this population, and it presents late. We don’t know entirely why, but we all need to start to suspect it as a cause for our patients’ symptoms.
To sum up for us, could you please identify the three key take-home messages from today’s podcast?
Chris: Three take-home messages. I would say colorectal cancer is on the rise in young people.
We must always suspect colorectal cancer might be the diagnosis when you have a patient with red flag symptoms or a personal or family history, even if the patient is young.
And lastly, to reach out to your colleague colorectal specialist if you’re unsure, as we’re always here to help.
Well, thanks again for your time and for the insights you have provided today, Chris, it’s been a pleasure.
Chris: No problem. Thanks for having me.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
