Disclosures: Eng reports serving on advisory boards for Merck and Pfizer and honoraria from Roche.
According to a review article published in the Lancet Oncology.
“This review is one of three articles the Lancet decided to focus on the early-onset colorectal cancer patient population,” Cathy Eng, MD, FACP, FASCO, David H. Johnson endowed chair in the division of surgical and medical oncology and professor of medicine in the department of hematology and oncology at Vanderbilt University Medical Center, said in an interview with Healio.
“The subject is of interest to many of us who treat colorectal cancer, as it is surprising to see a young adult in our clinic diagnosed with sporadic colorectal cancer,” added Eng. “I have been seeing these patients for a second opinion in my office for many years now.”
Eng spoke with Healio about the genesis of the review article, potential underlying causes of sporadic colorectal cancer in young adults, and what oncologists and other clinicians can do to help these patients.
Helio: What prompted this review?
Eng: Greater recognition is now given to early colorectal cancer. We are concerned that the survival of young adults is significantly lower than that of the middle-aged patient, because this younger population has advanced disease. The purpose of these articles is to further promote education and awareness – not only trying to prevent the development of colorectal cancer, but determining how can we optimize the care of younger patients who receive this diagnosis, other than simply treat it surgically or with radiotherapy or chemotherapy.
Helio: What are the potential underlying causes?
Eng: We don’t know the exact etiology, but it’s probably multifactorial. Most of these patients will not be diagnosed with an inherited form of colorectal cancer. I see patients in my clinic who are between 20 and 40 years old, which means they are not of screening age. Most people develop a polyp before it becomes cancerous. The polyp takes between 5 and 10 years to develop into an adenocarcinoma. Being diagnosed with a polyp at such a young age could mean there is an environmental factor at play, and obesity also plays a role. There’s also a lot of interest in how the microbiome plays into this.
We also know that patients with left-sided tumors should do better than those with right-sided tumors. Yet it is interesting because most young adult patients have tumors on the left side. We don’t know why this is happening and we don’t have enough answers, which is why many of us are so interested in the ongoing research and trying to find out more about these patients.
Helio: What does the treatment of these young people look likeuh the patients?
Eng: Patients diagnosed with colon cancer will go directly to resection. For cancers of the rectum, depending on the degree of tumor involvement, radiotherapy is administered. That’s it for the average young patient and it all depends on how many lymph nodes are involved and where the tumor is. A patient with metastatic colon cancer can undergo chemotherapy indefinitely and it is always a difficult subject, especially for younger people who are often starting a crucial aspect of their lives.
Helio: What psychological and quality–of–the impacts of life make colorectal cancer have on younger patients?
Eng: We specifically considered the psychosocial challenges of being diagnosed with colorectal cancer at a younger age and the potential financial toxicity that could result. Even for patients diagnosed with early-stage disease, some chemotherapy can cause neuropathy, which may persist and may be permanent. So we have to be very careful about processing in this context. We also use this treatment in the metastatic setting, and for patients with metastatic disease who cannot have surgery, the duration of most chemotherapies is indefinite. The risk of toxicity in these patients can be quite high and some treatment regimens can cause hair loss. Some patients may also end up with a permanent colostomy, which impacts body image and quality of life. Despite our best efforts, some patients who receive radiation therapy experience radiation toxicities that can significantly impact sexual, urinary, and bowel function.
With the diagnosis alone, patients can sometimes feel hopeless and need social support from others who can relate to what they are going through, so they don’t feel alone. Also, if the patient is young and loses his job and insurance, he may not be able to properly complete his cancer care. They face financial instability and financial stress unimaginable for someone at such a young age.
Helio: What would you advise oncologists for To do for these patients?
Eng: Do your best to communicate with the patient each time they come to your practice. Ask how they are doing and see if you can direct them to the right person or clinic to address their unmet needs. Every oncologist is extremely busy and it’s even harder to do it with COVID, but it’s so important to take the time and make that connection with the patient and get them to open up.
I also hope that with continued outreach, more internal physicians will understand the importance of recognizing early symptoms and referring these patients for testing, even those who appear to be perfectly healthy but have irregular bowel habits, for example. Most patients will tell us in retrospect that they have noticed blood in their stools for several weeks or months. Irregular bowel motility and increased frequency of gas, bloating and night sweats in a young patient are also of concern. Also, it should not be assumed that anemia in a young woman can be attributed to her period. If there is a persistent iron deficiency, I would strongly encourage further workup. By educating others and spreading the word, the hope is that family physicians and internal physicians will recognize that young patients can be diagnosed with colorectal cancer, and if something does not improve after a few weeks, it must be remedied. The ultimate hope is that we can diagnose these patients earlier.
Helio: Do you have anything else you would like to mention?
Eng: This article aims to highlight what is happening in the real world setting. I hope others will recognize that this is a potentially growing problem. We also need to improve our approach and not assume that all colorectal cancer patients are the same, regardless of age. The reality is that our young adult patients have very different personal obstacles in their lives that can be attributed to their diagnosis, and we also need to recognize that they not only want to survive, they want to live. We must help them to live.
For more information:
Cathy Eng, MD, FACP, FASCO, can be reached at Vanderbilt University Medical Center, 2220 Pierce Ave., Nashville, TN 37232; email: [email protected]