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Although overall colorectal cancer (CRC) rates have been decreasing in the U.S., the incidence of early age-onset CRC diagnosed before age 50 is on the rise. In addition, many higher-risk patients with a family history of early age-onset CRC are not diagnosed until after the recommended age of screening initiation for this group.

These alarming trends have highlighted the need to optimize preventive screening recommendations and assess the potential impact that revised guidelines would have.

To that end, Peter P. Stanich, MD, a gastroenterologist at Ohio State University Wexner Medical Center in Columbus, and colleagues examined data from the statewide Ohio Colorectal Cancer Prevention Initiative (OCCPI) to determine what proportion of early age-onset CRC cases in a prospectively accrued, population-based registry could have been prevented if existing high-risk screening guidelines were followed and if average-risk screening was initiated at age 45, as is now recommended by the .

By the study's estimates, recently published in , 234 (41.3%) of Ohioans diagnosed with sporadic early age-onset CRC would have been diagnosed earlier if screening was initiated at age 45. In high-risk persons, about 50% more cases would have been diagnosed earlier or potentially prevented with earlier screening than if previous age restrictions were in place.

Stanich elaborated on the study in the following interview with the Reading Room.

Why is early age-onset CRC attracting such attention in this country?

Stanich: For two reasons. First, it's out of sync with what we're seeing in older people above the traditional screening age of 50. Despite an overall decrease in CRC incidence, there's an increase in CRC in young people below the traditional screening age. Second, it's because young patients often present with more advanced cancer at the time of diagnosis.

What prompted your group to undertake the OCCPI study at this time?

Stanich: With the recent controversy over the best age to start screening colonoscopy, we felt it would be important to assess the potential impact of starting regular screening at age 45 and following current guidelines for initiation of colonoscopy at age 40 for patients with a family history of colon cancer in a first-degree relative.

Is much known about the reasons for this uptick in younger persons?

Stanich: There are likely multiple reasons and many researchers are trying to identify risk factors that are leading to this, especially ones that can be modified, and hopefully reduce the recent trends.

Does your study have any distinct features compared with other CRC population research?

Stanich: It has the added benefit of including genetic testing results for all patients included. This allowed us to additionally assess the significant potential impact that earlier identification of high-risk genetic syndromes would have.

What was the most significant finding?

Stanich: Our primary finding was that more than 50% of the early age-onset CRC in our cohort could have been diagnosed earlier and 16% could have been potentially prevented if screening was initiated at age 45 and screening guidelines for family history and genetic cancer syndromes were followed.

Our work showed that 13.6% of patients with early age-onset CRC had a family history that should have led to early initiation of screening and would have led to earlier diagnosis and likely prevention in a majority. The recommendation for early screening for those with a family history is long-standing. This study highlights the need for healthcare providers to know these guidelines and make sure their patients are aware of and following them.

What are your best recommendations for effective screening?

Stanich: I would favor a renewed focus on initiating early CRC screening in people with a family history. If we simply improve compliance with this recommendation, that would have a significant impact. I would also favor high vigilance for hereditary cancer syndromes and referral for patients who are at risk. There are some very simple tools involving only a few questions that have been shown to work in busy GI practices to help identify these patients.

For average-risk patients, the optimal age for starting screening is more complicated, but we are hopeful that if this change is widely endorsed, it would be impactful.

Do you see any obstacles to correcting these screening shortfalls?

Stanich: I think the primary barrier to meeting the gap in CRC screening is education of primary care providers and patients about the options available. For example, we need to continue to publicize improvements in bowel prep tolerability and sedation options.

What are you seeing in your own clinical practice?

Stanich: Thankfully, it's still rare to identify CRC in a young person at endoscopy. However, when it occurs, it's devastating for the patient, their family, and the endoscopy team, so it sticks with you for a long time.

In our GI Genetics clinic, we're certainly seeing more young colon cancer patients. This is likely the result of work done over the past several years, including our initial work in the OCCPI, showing the high diagnostic yield of genetic testing in this group.

That has led us to place a specific focus on including genetics referral appointments for these patients and incorporating this recommendation into oncology guidelines. These appointments are often seen by the patients as a chance to be proactive in helping their family members optimize their screening and hopefully avoid CRC. They are often very rewarding and positive.

You can read the abstract of the study here, and about the clinical implications of the study here.