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Although the rates of colorectal cancer (CRC) overall have declined in the United States, the disease has been on the rise in patients younger than 50. This has sparked investigation into the possible reasons for the increase in early-onset CRC, as well as debate about screening individuals in that age group.

In a recent , Nilofer Azad, MD, of Johns Hopkins Sidney Kimmel Comprehensive Cancer Center in Baltimore, and colleagues discussed the epidemiology, prevention, diagnosis, management, and challenges of CRC in younger patients.

In the following interview, Azad elaborated on the discussion.

The rate of colorectal cancer in people younger than 50 has been increasing, although the reasons are unknown. What can you tell us about this trend?

Azad: Over the course of the last 15 or 20 years there has been a very slow increase in the number of patients who are younger who are developing colorectal cancer. There have been a couple of analyses that have looked at that. But it is important to say that it's still a significant minority of patients under the age of 55 who develop colorectal cancer; it's just that it has gone from being extraordinarily rare to now being just somewhat rare.

This is still a disease of people predominantly in their 50s and 60s, but we need to keep a higher index of suspicion now when younger patients present with worrisome symptoms, considering the data that are emerging.

Most guidelines recommend screening average-risk patients at age 50, although some have lowered that to 45. What are your thoughts on screening individuals in their 40s?

Azad: I think the models need to be reworked with the newer incidence data to assess whether it would be appropriate to move guidelines to an earlier age of screening, and what modalities to use. Right now we have strong data that there is an increase in younger people developing colorectal cancer.

The question remains open, however, about whether increasing screening at a younger age would be both cost effective and balance the increased complications of screening versus catching cancer earlier. That balance is what modeling is for -- to figure out whether we're getting more benefit than harm if we change screening guidelines. Right now, without the models being reworked with the most current data, we can't strongly say we need to move the guidelines up, but this absolutely needs to get reassessed.

Why is diagnosis of CRC in younger people so often delayed?

Azad: The common symptoms of colorectal cancer can also occur in a lot of benign conditions. And the younger a person is, the more likely it's going to be assumed that it is one of these other benign conditions. That's why we think there's a delay in some of these patients being diagnosed. People are not keeping a high enough index of suspicion that it could be cancer.

What are some of the challenges for younger patients with early-onset CRC?

Azad: Many of these patients have young families. They are also in the prime of their money-making years and earning potential, so the financial impact of having colorectal cancer can be quite large. So they have both financial stresses and familial stresses. In addition, they are often at an age when they are taking care of older parents, so they've got familial responsibilities on both ends.

There is also the sexual impact of CRC, and that is definitely true in the young. Young patients may have the struggles with body image and sexuality that older patients have as well. There is also the potential impact on fertility and the concerns younger patients may have about that.

Is there anything else you would like oncologists to understand about early-onset CRC?

Azad: What I really want to emphasize is keeping the higher index of suspicion when younger people present with symptoms that, if they were older, would be triggering you to evaluate for CRC. Primary care doctors really need to keep a high index of suspicion.

Read the study abstract here and expert commentary on the clinical implications here.