Dr. Lebwohl, who is also an associate professor of medicine and epidemiology at Columbia University Vagelos College of Physicians and Surgeons, spoke with Health Matters on the latest statistics on colorectal cancer, why screening continues to be critical, and what can be done to address the rise in cases in the younger population.
Why is colorectal cancer rising in people younger than 50?
There is a lot we do not know about what is causing this increase and what causes these cases in an individual. For that reason, recommendations about when to screen are based on established colorectal cancer risk factors. These include family history, lifestyle factors, age, and people with underlying conditions. People with a family history, for example, have two to four times the risk of developing the disease, and in the U.S., some proportion of colorectal cancers is attributable to lifestyle factors, such as an unhealthy diet or insufficient physical activity.
Screening for colorectal cancer is recommended to begin at age 45. For people younger than 45, how are screening recommendations determined?
We recommend that someone who has a first-degree relative, such as a parent or sibling, who had early onset colorectal cancer get screened earlier. This would be either 10 years younger than when their relative was diagnosed with cancer or at age 40, whichever comes first. For example, if your relative was diagnosed at 35, you should get screened at 25.
We also want to identify people who have genetic syndromes such as familial adenomatous polyposis, caused by changes in genes that a person inherits from parents, and underlying conditions that also put people at risk. These include inflammatory bowel disease, Crohn’s disease, and ulcerative colitis. In Crohn’s disease, parts of the digestive system get inflamed and have deep sores called ulcers, resulting in belly pain and diarrhea. Ulcerative colitis causes swelling, inflammation, and ulcers in the lining of the large intestine (colon) and causes diarrhea, belly pain, and bleeding from the rectum.
People who have these genetic syndromes and underlying conditions should be screened earlier than 45.
What are the symptoms of colorectal cancer people need to be aware of?
The most common symptoms are blood in the stool or very dark stools, a change in bowel habits, such as having more frequent bowel movements or a feeling that bowels are not emptying completely, having low energy, and belly or rectal pain.
What would you like young people to know about these symptoms, and what to do if they are experiencing them?
Many people could find this subject embarrassing in terms of talking about bowel movements and frightening when thinking about cancer. But it is important to be as open as possible, especially with healthcare providers, about anything that is out of the ordinary. They can help formulate a plan and engage in shared decision-making about the next steps. Sometimes that plan involves further testing and evaluation, including, in some cases, a colonoscopy, which is one way to get checked for colorectal cancer.
How do we stop this rise in cases among younger people?
We should first take heed of the good news, and that is that the incidence of colorectal cancer is falling among people 65 and older, and has remained stable in people ages 50 to 64 years since 2011. We believe that is at least in some part due to screening efforts. This means that if we can contribute to a decline in this cancer in people 64 and over, then we can likely make a dent for the better if we were to screen people younger than 50.
The recommendation to start at age 45, for example, is one that we need to be serious about and talk to patients about. Some people might be resistant to doing something they had been told could have waited until 50 to proceed with. And so it is important for us to share data with patients and share our understanding that by screening younger people, we can likely make a difference.
We also need to do more research on colorectal cancer in people younger than 50. There are several studies being done, including multicenter ones that we are part of here at NewYork-Presbyterian/Columbia University Irving Medical Center. A lot of the fundamental and basic science work involved in tumor biology that is being done in our labs will hopefully lead to discoveries that yield insights into why there is a rise and how to reverse it.