Time Stamps

  • 01:45 Colorectal cancer rising in younger adults
  • 06:42 Why screening starts at age 45
  • 08:15 What may be driving early-onset colorectal cancer
  • 13:37 Key takeaways: symptoms, follow-up, and family history

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Show Notes

Pearl 1: Early-onset colorectal cancer changes the threshold for attention – not the definition of screening

  • CRC = historically thought of as a disease of OLDER adults
    • Why? Driven by the relatively SLOW natural progression of adenoma to carcinoma
      • Example: While 50% of patients age >50 years have polyps, only a small fraction will develop into cancers!
  • What about younger adults?
  • Current guidelines for CRC screening:
  • Who should be screened EARLIER than 45 years old?
    • Multifactorial decision considering:
      •  Family history
      • Medical history
      • Genetic risk factors
    • High-risk individuals (i.e., those with family history of colorectal cancer)
      • Screening STARTS 10 years before the first degree relative developed cancer or a high-risk polyp!
        • Other screening algorithms and considerations are present for those with underlying conditions that predispose to CRC development,
          • Example:  IBD and familial polyposis syndromes
            • Typically managed by gastroenterologistsThese
              • But important for the primary care physician to be aware of to ensure no lapses in screening!
    • What questions should you ask younger patients?
  • Frequent and detailed review of symptoms (annually) are a critical tool!
    • BENEFITS of yearly ROS:
      • Screen for red flag symptoms
      • Raises awareness that CRC is not ONLY a disease of older adults
    • Get creative and ask ROS questions that are more descriptive/illustrative to the patient!
      • SAY THIS: “Have you ever had red or tomato sauce-looking stool?”
      • INSTEAD OF THIS: “Do you have blood or mucous in stool?”
    • Red Flag Symptoms:
      • Visible blood in or on stool (hematochezia)
        • ALWAYS warrants further evaluation and diagnostic colonoscopy.
      • Melena is a different bleeding pattern, but also requires evaluation
      • Changes in bowel habits (Common!)
        • ew constipation/diarrhea
        • Farrower stools
        • Feelings of incomplete evacuation
      • Unintentional (or rapid but “intentional) weight loss (Common!)
      • Iron deficiency anemia
        • Should NOT be explained away!
          • People can have more than ONE reason for anemia
            • Ex: CRC +/- menstruation, inflammatory conditions, etc
      • Other vague symptoms
        • “My gut just isn’t right anymore”
        • Intermittent “IBS-like” discomfor,
        • New food intolerance
        • Bloating or vague abdominal discomfort
          • Patients often DO NOT describe this as “abdominal pain” and may deny the presence of abdominal pain on review of symptoms
    • REMEMBER: A plausible benign diagnosis (such as hemorrhoids) does NOT close the loop on red flag symptoms by itself.
      • Document the working diagnosis, treat when appropriate, and set explicit follow-up (e.g., within 30 days) on your working diagnosis, so that patients are not lost to follow-up!

Transcript

Dr. Rachel Issaka: And by 2030, it is estimated that for people, men and women under the age of 50, colorectal cancer will be the number one cause of cancer deaths in that group. And those statistics are very stark, and that’s in large part why the guidelines were updated to include people starting screening at the age of 45.

Dr. Shreya Trivedi: That’s Dr. Rachel Issaka, gastroenterologist from the University of Washington. Welcome to the Core IM Five Pearls podcast, bringing you high-yield, evidence-based pearls. I’m Dr. Shreya Trivedi.

Dr. Stephen Le Breton: And I’m Dr. Stephen Le Breton, internal medicine resident at Beth Israel Deaconess Medical Center.

Dr. Shreya Trivedi: And today we’re talking all about colorectal cancer and screening, and let’s meet our discussions for the day.

Dr. Xavier Llor: My name is Xavier Llor. I’m a gastroenterologist, and 11 years ago I moved to Yale to head the GI Cancer Prevention Program.

Dr. Samir Gupta: I’m Samir Gupta. I’m a gastroenterologist at the VA San Diego Healthcare System and a professor of medicine at UC San Diego.

Dr. Rachel Issaka: My name is Dr. Rachel Issaka. I’m a gastroenterologist and a health services researcher at the Fred Hutchinson Cancer Center and the University of Washington in Seattle.

Dr. Joseph Feuerstein: My name is Joseph Feuerstein. I’m the clinical chief with gastroenterology at Beth Israel.

Dr. Shreya Trivedi: And we originally recorded this as one comprehensive five Pearls episode in colorectal cancer, but there was so much good stuff that we actually decided to divide it into three shorter episodes that we’ll release over the next couple of weeks. And in this first episode, we’re going to unpack why screening now begins at age 45, which symptoms in younger adults should really prompt us to look further. And personally, I had a vested interest in learning why is it that so many people in their 30s are getting diagnosed with colon cancer? And with that, let’s get into the episode.

Dr. Shreya Trivedi: I think a lot of us are taught that colorectal cancer is something that happens later in life. I think the illness script is like someone who’s elderly, weight loss, anemia, maybe a positive fit test, but that mental model is changing.

Dr. Xavier Llor: That’s because of the last 15 years or so, while we’ve seen these very constant decrease in colorectal cancer incidents overall, we’ve seen creeping up this colorectal cancer among the youngest individuals that in general would call them before the age of 50. So the increases have been so rapid at close to 1.5% per year, but less than about 50% of the individuals who develop colorectal cancer before age 50 actually develop it before age 45. So we are not going to be catching those when we start at 45. So what we are really doing is emphasizing also more not to dismiss symptoms that in the past, because individuals were young and the suspicion was very, very low. We’re being a little bit dismissive, blood in the stool or changing bowel habits, persistent abdominal pains, some things that in younger individuals in the past we were being dismissive and I think no longer we are and we’re being much more aggressive in terms of working out this just because of that rise among youngest individuals.

Dr. Shreya Trivedi: That is so humbling and definitely makes me uncomfortable, I think, if I have just counted a younger person’s symptoms in the past and I definitely want to do better.

Dr. Samir Gupta: I think to tie back to what I would tell clinicians, number one, we really have to raise awareness that colon cancer is not just an old person’s disease. So one of the number one complaints, if not the number one complaint or concern that we hear from young-onset colon cancer survivors is that it took way too long for them to get a diagnosis. And they’ll tell stories about how they had hematochesia, change in bowel habit, anemia for years, and that they even brought up potentially exploring a diagnostic colonoscopy, and they were brushed off because the clinician just didn’t think it was possible for them to have colon cancer. So everyone needs to know what the potential red flag signs are of colon cancer. So hematochezia, change in bowel habits, unexplained abdominal pain, iron deficiency anemia. That doesn’t mean that every single one of these patients has to go for a colonoscopy, but I would argue that all benign causes of these symptoms, if you treat them based on a working diagnosis, should resolve or get better within 30 or 45 days. And if they don’t, then we have to bring colon cancer higher on the differential, and they really should be considered for a colonoscopy. So I think that would be my take home message for clinicians is to know the red flag signs and symptoms and for people who they don’t send for a colonoscopy to make sure they close the clinical loop within 30 days to make sure that whatever their working diagnosis was correct and the patient is getting better.

Dr. Stephen Le Breton: So that really hits home. I had a patient in his 30s in clinic recently who had mentioned a diagnosis of IBS from a prior provider that was driven by constipation and mucus in his stool, which had somewhat improved with dietary modifications. But when we dug a little bit deeper, he said he had recently had blood in his stool, but that he hadn’t mentioned it because he had chalked it up to dietary and discretion that this had happened in the past. So we got the colonoscopy. Lo and behold, we found colorectal cancer.

Dr. Shreya Trivedi: And someone in their 30s? 

Dr. Stephen Le Breton: Yeah. And it was kind of unfortunate because it was caught at a little bit of a later stage. And it makes me think about how in cases like these, closing the loop on a diagnosis and making sure that the patient’s symptoms resolve, and if not, pursuing that further diagnostic workup could make a difference with these young patients and catch the colorectal cancer at a point where we can still do surgery.

Dr. Shreya Trivedi: Yeah. Oh, for sure. And then first of all, kudos to you for doing a good job digging and finding that. One of our reviewers, I think, also noted something that she’s had to do in her clinic, which is really be creative with her patients about how she asks these questions, and she’s been able to find a lot more things. Our patients they don’t know sometimes what to look for or the words that we use. And so maybe just being more explicit and saying, “Have you ever seen red? Has it ever looked like ketchup or tomato sauce?” Instead of just saying like, “Oh, is there any blood in your stool” has made her catch things that she wouldn’t have otherwise.

Dr. Stephen Le Breton: Exactly. And rather than just asking about if they have abdominal pain, maybe asking about how they tolerate different foods, if they’ve ever felt that their gut was off, if they ever experience intermittent discomfort, really kind of digging down into the specifics of what they might be feeling.

Dr. Shreya Trivedi: Yeah, I think it goes back to being a good internist and being thoughtful about how questions may be received and being creative. I wanted to loop back to something that Dr. Llor  had said in the beginning of the episode that’s still bugging me. He said that a good percentage of early-onset colon cancer develops even before the age of 45. Wow. And so I’m curious, if so many people are getting colorectal cancer before 45, then why are our screening guidelines only starting at 45?

Dr. Rachel Issaka: And so using a combination of those epidemiological studies as well as modeling information is really what informed the task force to make the recommendation to reduce the age of screening to start at 45. Now, because of the rising incidence of colon cancer in those who are under 50, some ask, “Well, why not go even younger? Why stop at 45?” And that recommendation is really based on a balance of exposing individuals to risk and harm and where they might benefit. And so the task force, when making the recommendation, really kind of uses that as a cut point. At what point are we saving more lives and causing less harm? And right now, based on the data that we have, that number appears to be 45. I think the task force is open to evaluating new information. So should that age move down, then we would have updated recommendations that reflect that, but that’s just not our current state today.

Dr. Shreya Trivedi: The good old balance of benefit versus harm. Okay, fair. And then a part of me is worried, I think, about me, my loved ones. So many of my young friends have kind of gone through unfortunate early-onset colorectal cancer as well. And I’ve got to say, I’m curious what’s driving this. Is there anything we can do to prevent this, and what’s going on here?

Dr. Samir Gupta: There’s the usual suspects and then things that might be new. So, the usual suspects- obesity, tobacco, alcohol, those do appear to play a role in studies specific to early-onset cancer. We’re seeing things come out about sugar-sweetened beverages, more sedentary time as measured by TV watching. There are some data linking ultra-processed foods to increased prevalence of precancerous polyps, so that could be an issue. And I think what’s hard about this is that all of us have patients who are otherwise completely healthy, who have been 35, 38, 40, presenting with colon cancer. So clearly, while these risk factors are probably important, they don’t tell the whole story. And the thing that has been the most understudied and has been environmental factors, so chemicals in the water, in what we’re eating, could be pollution, could be a factor. All these things have not really been well studied, and that’s probably where the money is. I should also mention, I guess, two other things. One is when we see birth cohort trends, the one thought is that early life exposures might be especially important, and we have seen some signals of this. So for example, exposure to bacteria that produce a toxin called colibactin, and that this exposure, the timing of it is more likely than not to have been an early-life exposure. So the story that people have been telling with that is that children may be being exposed to something, whether it’s antibiotics or something else, that is shifting their microbiome that’s more permissive for bacteria that might produce toxins such as this colibactin that is contributing to a higher risk for cancer. So there’s a lot of interesting work going on here, but a lot to discover.

Dr. Shreya Trivedi: I am so sad to hear that last one. Sadly, every time when I was young, I’d have the slightest cough, Mama Trivedi would take me to our family doctor and make me get a Z-Pak, really actually just demand a Z-Pak, unfortunately, and it’s just RIP to my microbiome.

Dr. Stephen Le Breton: Oh man, I know. I had the same experience, and I expect a lot of our viewers also could probably have had that same exact experience. Speaking of family, the thing I found the most humbling preparing for this episode was that we often anchor on family history, but most colorectal cancer is actually sporadic.

Dr. Joseph Feuerstein: So I’d say the scariest part of colorectal cancer screening is that the vast majority of colon cancers that we diagnose are sporadic. Family history is only about a quarter of the cases that we have in general. And most of these cases that we’re seeing actually have no family history at all. And that’s the biggest challenge is because you would never know to start screening earlier in these individuals. Very often there were symptoms, especially in the more advanced cases, and that’s when people are seeing blood in their stool; that, to us nowadays, is a very simple binary decision. Is there blood present? And if there is, we should do a colonoscopy and make sure there is no advanced polyp or cancer already there. Way too often we see people having seen blood in their stool for six months or longer, but most of these are related to just sporadic changes.

Dr. Shreya Trivedi: Yes. And then even more humbling news is that even though family history may be only counting for 25%, it is still 25%. And even that, we are not good at capturing that 25%.

Dr. Samir Gupta: So there have been now three studies that have shown that a very substantial proportion of people who have young-onset colon cancer had a family history that was sufficient where they could have benefited from earlier initiation of colon cancer screening that could have detected or maybe even prevented their colon cancer. So we see both in the data and in clinical practice, we routinely see people where they had a young relative, first degree relative with colon cancer and the history was not elicited or at least it’s not documented as such and the colonoscopy was never recommended or worse, the history was collected, but the guideline-based recommendation was not given to the patient to start colon cancer screening earlier.

Dr. Stephen Le Breton: I think we can all do a better job reassessing family history and cancer history, especially yearly. Just because a patient’s family history was negative last year doesn’t necessarily mean it’s negative this year. Things can change year to year. And I think oftentimes we get caught up because it can often auto-populate in Epic or our notes, and it might not have been updated in years, but we might still think it is.

Dr. Shreya Trivedi: Yeah, I think it’s low-hanging fruit, and depending on how your clinic is set up, patients may or may not fill it out online, so always good to make sure we’re asking about it at least yearly or have some system in place where someone is capturing that yearly. So Steve, I feel like this is a good point to recap. What are you taking away?

Dr. Stephen Le Breton: So my takeaway from Pearl One is that colorectal cancer is no longer just an older person’s disease. Even though the age of screening has moved up to 45 years old, a ton of early-onset colorectal cancer happens earlier than age 45 years old. So it’s important for us to look out for younger patients who have unexplained iron deficiency, unexplained abdominal pain, changes in bowel habits, or blood in their stools.

Dr. Shreya Trivedi: Yeah. And that closed that clinical loop line is still really sticking with me. And I think just that idea of circling back when things are not getting better, and then even on the outset, trying to set expectations with the patient saying, “Hey, there might be a diagnostic colonoscopy in the horizon if things are not getting better.” And that’s just one other layer to make sure these young patients don’t get lost to follow-up.

Dr. Stephen Le Breton: And of course, reassess the family history yearly because for those 25% with family history, that family history can change year to year, and that’s definitely something I want to be better at.

Dr. Shreya Trivedi: Same. And that is a wrap for today’s episode. If you got anything out of this podcast, if it inspired you, our ask us to please send it to one other colleague who might also learn something from this episode too.

Dr. Stephen Le Breton: And a big, big thank you to our discussants, Dr. Samir Gupta, Dr. Rachel Issaka, Dr. Xavier Llor, and Dr. Joseph Feuerstein, as well as our peer reviewer, Dr. Elizabeth Housman.

Dr. Shreya Trivedi: And thank you to Dr. Dexter Noechaku for the graphic, as well as all the other people who made this episode possible. As always, we love hearing feedback. Please email us at hello@coreampodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliate institutions. Thank you and take care.

References