Contributor: An Urgent Call to Action as Colorectal Cancer Rates Skyrocket Among Young People

In 2023, more than 153,000 people were diagnosed with colorectal cancer (CRC). Among them were almost 20,000 children, youth, and adults younger than 50 years of age.

It’s not breaking news that the incidence of CRC has been rising in this atypical population: since the early 2010s, researchers have been noticing a significant uptick in cases—about 3% per year—in individuals younger than 50 years.

But, recent research from the University of Missouri-Kansas City adds a new reason to focus on this worrying trend. Younger and younger patients are being diagnosed, including a growing number of children and teenagers too young to drive, vote, or graduate college.

The new study shows that over the past 2 decades, cases of CRC increased by 500% among children aged 10 to 14 years, more than 330% in teens aged 15 to 19 years, and 185% among young adults aged 20 to 24 years.

While the absolute numbers of patients in these groups still remain low (0.6/100,000 children and 2/100,000 young adults), clinicians are concerned about the rise over time—especially because the reasons behind the increasing numbers remain unclear. Lifestyle and dietary habits likely play a role, and there may be additional genetic components that scientists have not yet uncovered.

Jeffrey Reese | Image credit: Reese Pharma

The lack of concrete evidence behind the trends makes it difficult for clinicians to reliably understand which populations are at elevated risk, which in turn creates challenges for altering recommended screening guidelines to catch cancers as early as possible.

As a result, not only are more younger people being diagnosed with CRC but they are being diagnosed at later stages of the disease when it is more difficult to treat. According to the American Cancer Society, the proportion of regional- or distant-stage cancer has increased from 52% in the mid-2000s to 60% in 2019, which is tied to the 1% increase in annual death rates among those aged younger than 50 years since 2005.

It's becoming increasingly clear that CRC is no longer just a disease for older people to worry about. But the nation’s screening guidelines—and the reimbursement structures behind them— simply aren’t adequately recognizing this new reality for much younger people.

It’s time to reexamine how and when CRC screenings are provided to people younger than the typical CRC age group and develop new strategies for connecting younger people with affordable and accessible screening options, including FIT tests and other stool-based sampling, to combat the rise in cancer among these groups.

The affordability challenge of colonoscopy access for young adults

Currently, the US Preventive Services Task Force recommends that adults of average risk, ages 45 to 75, receive regular screenings via a number of different possible modalities, including colonoscopies every 10 years or a CT colonography or flexible sigmoidoscopy every 5 years.

Most health plans will cover the costs of colonoscopies provided according to the recommended screening schedule for people older than 45 years, thanks to the Affordable Care Act. But it’s a different story for those younger.

Because younger patients fall outside the established recommendation schedule, these colonoscopies are typically classified as “diagnostic” procedures, not “screening” procedures, allowing health plans to bill the patient for the related services. This can put colonoscopies or other imaging tests out of reach financially for many young adults or families, contributing to later diagnoses and potentially worse outcomes.

Prioritizing education and awareness of symptoms

There’s another reason why younger people may not get screened for CRC: they don’t know that they should. CRC symptoms can range from subtle to severe, and younger people may be more likely to blame stress, poor eating habits, or hemorrhoids than think about CRC as a cause of their symptoms, which can further delay access to screenings.

The American Cancer Society urges younger people not to ignore four main symptoms most commonly tied to a cancer diagnosis: abdominal pain, rectal bleeding, diarrhea, and iron deficiency anemia.

In a recent study, having just 1 of these signs before 50 years of age was associated with nearly twice the likelihood of being diagnosed with early-onset CRC, while having 3 or more was tied to a 6-fold probability of being diagnosed with CRC.

Younger people should be encouraged to talk to their doctors about any symptoms that are concerning. They should also make an effort to collect family history data that could influence when they begin screenings, since first-degree and second-degree relatives with CRC, especially those who were diagnosed at earlier ages, significantly raise the risks of developing cancer.

A Call to Action: Reimagining Screenings as CRC Shifts Younger

With so much at stake for young people, the health system needs to take another look at how to accurately and reliably catch cancers in people younger than 45 years while balancing the overall costs and potential risks of significantly expanding the nation’s screening initiatives.

Colonoscopies for everyone starting decades younger than present guidelines would not be practical, nor is it called for among people of average risk. But colonoscopies aren’t the only effective screening methodology.

The US Preventive Services Task Force also endorses the use of high-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every year to provide important data that can then be explored further with additional testing, if necessary.

These tests are low cost, reduce the financial barriers associated with non-routine colonoscopies, are available over the counter, and are easy to complete in the home at the patient’s convenience with less extensive bowel preparation.

They are an important bridge to appropriate clinical care for people who do not yet qualify for regular colonoscopy screenings, with evidence suggesting that using these tests can reduce the likelihood of death from CRC by up to 33%, with notable gains among traditionally underserved racial and ethnic groups. Considering close to 5% of people aged 40-49 years screen positive during a FIT test, this could translate into a large number of lives saved.

As cancer experts take another look at how to educate younger people on the importance of screenings, connect people with screening options, and manage the growing number of young patients presenting with concerning symptoms, FIT tests should become a bigger part of the solution.

There is an opportunity to consider a new set of guidelines for those younger than 45 years of age with certain risk factors that recommend periodic FIT or HSgFOBT tests as a first line screening, followed up by colonoscopy or other appropriate imaging tests as needed.

With growing evidence of the reliability and potential life-saving utility of stool-based testing, integrating these options into clinical guidelines could have a major impact on reversing recent trends and improving outcomes for children, teens, and young adults at risk of developing CRC.