Connections: Youth no longer a safeguard from colorectal cancer | Winter 2020

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From the OHSU Knight Cancer Institute

V. Liana Tsikitis headshot

V. Liana Tsikitis, M.D., M.C.R., M.B.A., FACS, FASCRS

Dr. Tsikitis is the division head of gastrointestinal and general surgery at OHSU. Her research interests include colorectal cancer genetics, examining the etiology of colorectal cancer in young adults (<45 years of age) and improving their outcomes.

As physicians, we must change our lens from viewing colorectal cancer as a disease of the elderly and be suspicious of any changes in bowel habits in patients under 50 as symptoms that require a thorough physical exam.

A clear trend in rising rates of colorectal cancer under 50

Well-documented reviews of national databases show a significant increase in the incidence of colorectal cancer in people younger than 50, with young adults disproportionately affected by rectal cancer. According to the National Cancer Institute, colorectal cancers diagnosed before age 50 have increased by 51% since 1994. Research by the American Cancer Society shows that these younger people are more likely to receive a late-stage diagnosis, which is more challenging to treat.

Screening guidelines and preventive measures

In 2018, the American Cancer Society changed its recommendations for starting colorectal screening in people of average risk from age 50 to age 45. However, the U.S. Preventive Services Task Force guidelines remain 50 years of age.

Since 90% of colorectal cancers occur in people older than 50, these screening guidelines are reasonable but shouldn’t prevent us considering colorectal cancer as a possibility in younger patients. At OHSU, we have operated on patients as young as 19 with colorectal cancer.

Screening is vital as colorectal cancer is largely spontaneous, without family history or other warning signs. By the time there are symptoms (blood in the stool, anemia, narrow stool, changes in bowel habits), the cancer has advanced.

Patients may be slow to report these symptoms, especially young people who may have fewer reasons to check in with their providers regularly. A survey by the Colorectal Cancer Alliance showed that nearly half of young colorectal cancer patients waited an average of six months before talking with a provider about their symptoms.

Getting past taboo topics and fears

Bowel habits can be an embarrassing topic for patients, and they aren’t likely to volunteer for exams. We must work to normalize these conversations and raise awareness at every age that rectal bleeding is worth a phone call to their provider, as are recurrent diarrhea, narrow stools, abdominal cramping and bloating. Then it is up to us to consider colorectal cancer among the other possible diagnoses, no matter the patient’s age. If caught early, colorectal cancer is nearly fully curable.

So, how can we identify signs of a symptomless disease among a younger demographic than guidelines recommend?

  • Ask: Any opportunity to interact with patients is a good time to bring up bowel habits and any changes or issues they may be having.
  • Examine: A digital rectal exam should be part of a full physical.
  • Test: An anoscopy or sigmoidoscopy can be done in the clinic. A colonoscopy is the gold-standard and preventative, but if a patient is unwilling for whatever reasons, a FIT test can be a substitute.

When to refer

  • Patients with a family history of colorectal cancer.
  • Patients with a history of inflammatory bowel disease.
  • Patients with blood in stool.
  • Patients with anemia.
  • Patients with changes in bowel habits.

Contact us

From the latest technology to the newest drugs that are increasing survival, OHSU Knight Cancer Institute, Oregon’s only NCI-designated Cancer Center, offers a full range of options for cancer patients. We are always available to answer questions.

Please call the OHSU Physician Advice and Referral Service at 503‑494‑4567.

To refer a patient, please fax to 503‑346‑6854.