Colorectal cancer is no longer a condition that predominantly affects older adults. There has been a marked increase among younger individuals. Cases of early-onset colorectal cancer (EOCRC) are rising, and patients frequently present with advanced stages of the disease with more aggressive histological types. To address this situation, updating screening strategies and promoting earlier intervention measures are necessary.
Epidemiology and Trends in EOCRC
EOCRC cases have risen alarmingly over the past three decades. Millennials face double the risk of colorectal cancer compared to previous generations. These cases may involve mucinous and signet-ring cell carcinomas, which are aggressive and diagnosed later due to symptom misattribution. Patients endure prolonged symptom duration before receiving a correct diagnosis and are often initially misdiagnosed with IBS or hemorrhoids.
Risk Factors and Pathogenesis
While hereditary syndromes like Lynch syndrome and APC mutations do contribute to some cases of EOCRC, most patients do not have a known genetic predisposition. Additional factors must be considered, including gut microbiome dysbiosis. Studies suggest dysbiosis may be associated with EOCRC because pathogenic bacteria, such as Fusobacterium nucleatum and Bacteroides fragilis, promote inflammation and carcinogenesis. Environmental exposure to microplastics and industrial pollutants are concerns that, along with diet and lifestyle choices, have been linked to shifts in microbial populations, which may be contributing to DNA damage and tumor initiation.
Clinical Presentation and Challenges in Diagnosis
While we are aware of the alarm features of rectal bleeding and unintentional weight loss, patients often present with deceptively straightforward symptoms of abdominal pain, a change in bowel habits and fatigue. As GI providers, we need to remain vigilant about EOCRC even in these patients with subtle signs. We must continue to advocate for early endoscopic evaluation in younger patients presenting with these symptoms rather than automatically attributing them to benign disorders.
Screening Guidelines: Are They Enough?
Although the U.S. Preventive Services Task Force recommends routine CRC screening starting at age 45, this may be insufficient. What if we could develop a risk-stratified approach that would allow screening to begin earlier for individuals with metabolic risk factors, family history and high-risk lifestyle exposures linked to EOCRC? Machine learning and large language model tools already exist to help us create these types of algorithms to identify at-risk populations. I can already hear the skeptics saying, “Here is another gastroenterologist suggesting more colonoscopies.” While the gold standard for screening at age 45 remains a colonoscopy, younger patients could also consider noninvasive alternatives like stool-based and blood-based screening tests.
The Role of GI Physicians in EOCRC Prevention
Educate patients by reinforcing the importance of early detection and prevention. Know and teach the environmental and lifestyle risk factors. Advocate for policy changes to expand insurance coverage and individualized screening protocols for high-risk younger adults while continuing to support the investigation into microbiome-targeted therapies and environmental risk factors. This will make a difference.
The crisis is real. EOCRC is not an anomaly. We have a responsibility to lead the conversation on prevention and early detection. By recognizing the warning signs and advocating for earlier screenings, we can shape the framework around EOCRC management and the work to reduce the risk of this devastating and largely preventable disease.
I envision and hope for a future where we not only increase screening compliance in our age 45 and older population but also create a viable screening protocol for our at-risk younger patients.
Neil Parikh, MD, is the chief of gastroenterology at Hartford Hospital, the chief innovation officer for Connecticut GI, the chair of the GI Alliance Innovation Committee, and an assistant clinical professor at the University of Connecticut.