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Young Patient Colon Cancer

Patients Under 50 Years of Age Are at Risk for Colon Cancer and are More Likely to Have Advanced Disease When Diagnosed

Richard L. Whelan, MD, C.C.C.N.Y., Chief Colon and Rectal Surgery at St. Luke’s Roosevelt Hospital

The Colorectal Surgery Service at CCCNY’s Roosevelt Hospital site, under the direction of Dr. Richard L. Whelan, has recently completed a retrospective review of patients under 50 years of age who underwent surgery for colon or rectal cancer during an 15 year period at either St. Luke’s Roosevelt Hospital or a second institution. This study’s results suggest that the chances of a younger patient developing colorectal cancer is increasing and that advanced disease is more likely to be found when compared to patients over 50 with CRC. Further, in some cases there was a delay in diagnosis that may have been due, in part, to a reluctance of primary care physicians to refer patients for colonoscopy or other diagnostic tests.

A total of 174 young patients were treated during the time period examined. Between 2006 and 2011, patients under 50 accounted for 12 % of all colorectal cancer patients treated at the institutions in question. This percentage is notably higher than the previously published rates. Contrary to popular opinion, the vast majority of these patients (91%) did not have a parent, brother or sister who had had a CRC. Thus, most of these patients had no known risk factors for colorectal cancer. The symptom most frequently reported was rectal bleeding. Unfortunately, in some patients there was a delay of 6 months or longer before diagnostic tests were carried out.

It was also noted in this study that patients under 50 were more likely to be diagnosed with an advanced cancer than patients 50 or older. Over 50 % of younger CRC patients had Stage 3 or 4 tumors at the time of diagnosis as opposed to 35 % of patients 50 or older. Why should younger patients have worse disease when diagnosed? There are several possible explanations. One reason may be that the cancers that develop in younger patients tend to be more aggressive. Another explanation is that there is a delay in diagnosis in some cases which allows the cancer to grow and, perhaps, spread to lymph nodes or other sites.

Why should there be a delay in diagnosis in younger patients? There are numerous possible reasons including reluctance on the part of patients to seek medical assistance and lack of medical insurance coverage. Also, many patients and some physicians are under the impression that colonoscopy need not be performed until age 50. Importantly, one reason reported by some patients was that primary care physicians, upon learning of the rectal bleeding, did not immediately refer patients for colonoscopy or other tests that would lead to the diagnosis. Instead, patients were told that the bleeding was most likely from hemorrhoids or other anorectal problem and were treated accordingly. Only when the bleeding persisted or when other symptoms developed was a colonoscopy performed. Some patients were told by some physicians that colonoscopy did not need to be carried out until age 50. Where did the age 50 cut off for colon evaluation come from? Current CRC screening guidelines from most authorities suggest that the first colonoscopy be done at age 50 in patients without a close family history (parents or siblings) of CRC. These guidelines are based on the fact that the great majority of CRC patients are 50 years or older. Most national health systems and insurance companies use these guidelines to determine eligibility for colon screening exams. For these reasons, as well as others, primary care physicians and patients are more likely to minimize or discount symptoms that in older patients would lead to an immediate colonoscopy. As alluded to above, another factor contributing to delay is that, historically, it has been more difficult to get approval from insurance companies for colonoscopy and other diagnostic tests in younger patients. This study’s results suggest that there should be a lower threshold for performing colonoscopy in patients under 50 with symptoms such as rectal bleeding, a change in bowel habits, abdominal or rectal pain.

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