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Early-Onset CRC: What Do We Know?

Panelists: Johanna C. Bendell, MD, Sarah Cannon Research Institute; Cathy Eng, MD, FACP, The University of Texas MD Anderson Cancer Center; John L. Marshall, MD, The Ruesch Center for the Cure of GI Cancers ; Michael A. Morse, MD, Duke Cancer Institute; Dale R. Shepard, MD, PhD, FACP, Taussig Cancer Institute, Cleveland Clinic
Published: Wednesday, Mar 14, 2018



Transcript: 

John L. Marshall, MD: Let’s move on to what is really becoming a new observation—young people getting colon cancer. We didn’t sign up for this. I know we’re all seeing this. I’ve got a 17-year-old patient right now. And there are 20-, 30-, 40-year-olds.

Cathy Eng, MD, FACP: A 16-year-old patient?

John L. Marshall, MD: Does anybody have any idea what’s going on?

Cathy Eng, MD, FACP: I think all of us would want to know what’s going on. I think we’re all seeing those patients, just as you’re mentioning. The biology appears to be much more aggressive in quite a few of these patients—more so than in our older patients. They’re not responding to the therapies that we’ve been giving as a standard to all of our other patients.

John L. Marshall, MD: It seems like a different cancer.

Cathy Eng, MD, FACP: Yes, completely.

John L. Marshall, MD: The first topic that always comes out when this emerges is, should we change our screening? Should we move this back from age 45 or 50? What do you think?

Johanna C. Bendell, MD: I’m thinking that the numbers are starting to get there. Maybe we should start screening at age 40? And maybe we need to raise more awareness that when a younger patient presents with gastrointestinal symptoms, we don’t just send them away? Take a peek, early.

John L. Marshall, MD: Yes. Take it seriously. Any thoughts on what’s going on? Are these couch potato, unhealthy people?

Michael A. Morse, MD: Well, apparently not. There’s data that suggest they’re very similar to the older patients. They certainly do not have greater obesity. Their body mass index, for example, is the same between the different age groups. I certainly would think that you would want to look for something environmental or something habit based. It seems like that would be the obvious thing. But until we can collect enough data from a large enough number of people, I just don’t see how we’re going to tease it out.

John L. Marshall, MD: Yes. My observation is that these are really healthy people. I joke that they’re marathon-running, cardboard-eating people.

Cathy Eng, MD, FACP: A lot of them are.

John L. Marshall, MD: I’ve been focused on some work which we’re doing around the microbiome—the bacterial composition. Other than Starbucks and cell phones, what else has changed? Maybe it’s antibiotics? Maybe it’s that we wash our hands too much and don’t eat enough dirt and all of those things with kids today? But we need to figure it out, as Cathy pointed out.

Cathy Eng, MD, FACP: Definitely. That’s one of our research interests at MD Anderson Cancer Center. We’re doing a longitudinal sequential analysis on these patients.

John L. Marshall, MD: We may be able to figure out some science that brings new stuff to the table, that might affect screening, for example. It might tell us which yogurt to eat, or whatever it will be, to prevent the disease. So, it’s really important research.

Cathy Eng, MD, FACP: I think it’s important to mention, and I think we all know, they’re presenting more often with left-sided tumors or rectal tumors. We’re told that left-sided tumors have better survival. But this seems to be a little different in this very unique, young patient population.

John L. Marshall, MD: Peritoneally, as well.

Cathy Eng, MD, FACP: A lot of peritoneal disease, yes.

John L. Marshall, MD: Maybe it’s that they’re young and are affected by it more? But it does seem like it’s worse.

Cathy Eng, MD, FACP: Yes.

John L. Marshall, MD: There’s some evidence that there’s a slight difference in genetic profile. But they’re not fundamentally different tumors, right? They’re not biologically all that different, but kind of clinically behaving? So the main message for us is, how is this affecting your recommendations? When you see one of these 35-year-old patients, does it change what you do, Dale?

Dale R. Shepard, MD, PhD, FACP: Unfortunately, it doesn’t because we don’t have good data. As we’ve suggested, the biology is so different; it has to be. They are mostly left-sided, which we think is better. But they are more aggressive. They don’t seem to respond as well. We just don’t have good information on the biology, to know what to do differently. And so, I think we’re kind of forced into doing what we do with everyone else until we know better.

John L. Marshall, MD: We say that they’re young and can take it. So, is this a situation in which you give 6 months of adjuvant therapy?

Cathy Eng, MD, FACP: I look at everything else, in regard to data, for these patients. But, in regard to metastatic disease, I will be more aggressive than normal on these young patients. Their performance status is usually fairly good. I love to use FOLFOXIRI [fluorouracil, leucovorin, oxaliplatin, and irinotecan] in this setting, on these patients.

John L. Marshall, MD: This is also a patient who’s raising a family and is trying to go to work. So, when we put our foot on the pedal a little harder, it is also more disruptive, right?

Cathy Eng, MD, FACP: I’ve had patients who still function, work, and do everything else. I think it’s really important, when we’re talking with a young patient, that we’re talking about fertility preservation. That’s not discussed enough with patients.

John L. Marshall, MD: We don’t discuss that very much with our patients because they’re usually past those ages. But, yes, it’s becoming an increasing issue with banking—whether it’s for eggs or sperm. Are there any other young patient observations?

Johanna C. Bendell, MD: The other thing that I make sure I do, and I try to do this in all patients, especially the young ones, is get next-generation sequencing for these patients. You need to know as much as you can about their disease, walking into it. If there is something there, you might be able to help treat it. You might find something that’s more genetically linked. That way, you’re better able to take care of them and their families.

Transcript Edited for Clarity 

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Transcript: 

John L. Marshall, MD: Let’s move on to what is really becoming a new observation—young people getting colon cancer. We didn’t sign up for this. I know we’re all seeing this. I’ve got a 17-year-old patient right now. And there are 20-, 30-, 40-year-olds.

Cathy Eng, MD, FACP: A 16-year-old patient?

John L. Marshall, MD: Does anybody have any idea what’s going on?

Cathy Eng, MD, FACP: I think all of us would want to know what’s going on. I think we’re all seeing those patients, just as you’re mentioning. The biology appears to be much more aggressive in quite a few of these patients—more so than in our older patients. They’re not responding to the therapies that we’ve been giving as a standard to all of our other patients.

John L. Marshall, MD: It seems like a different cancer.

Cathy Eng, MD, FACP: Yes, completely.

John L. Marshall, MD: The first topic that always comes out when this emerges is, should we change our screening? Should we move this back from age 45 or 50? What do you think?

Johanna C. Bendell, MD: I’m thinking that the numbers are starting to get there. Maybe we should start screening at age 40? And maybe we need to raise more awareness that when a younger patient presents with gastrointestinal symptoms, we don’t just send them away? Take a peek, early.

John L. Marshall, MD: Yes. Take it seriously. Any thoughts on what’s going on? Are these couch potato, unhealthy people?

Michael A. Morse, MD: Well, apparently not. There’s data that suggest they’re very similar to the older patients. They certainly do not have greater obesity. Their body mass index, for example, is the same between the different age groups. I certainly would think that you would want to look for something environmental or something habit based. It seems like that would be the obvious thing. But until we can collect enough data from a large enough number of people, I just don’t see how we’re going to tease it out.

John L. Marshall, MD: Yes. My observation is that these are really healthy people. I joke that they’re marathon-running, cardboard-eating people.

Cathy Eng, MD, FACP: A lot of them are.

John L. Marshall, MD: I’ve been focused on some work which we’re doing around the microbiome—the bacterial composition. Other than Starbucks and cell phones, what else has changed? Maybe it’s antibiotics? Maybe it’s that we wash our hands too much and don’t eat enough dirt and all of those things with kids today? But we need to figure it out, as Cathy pointed out.

Cathy Eng, MD, FACP: Definitely. That’s one of our research interests at MD Anderson Cancer Center. We’re doing a longitudinal sequential analysis on these patients.

John L. Marshall, MD: We may be able to figure out some science that brings new stuff to the table, that might affect screening, for example. It might tell us which yogurt to eat, or whatever it will be, to prevent the disease. So, it’s really important research.

Cathy Eng, MD, FACP: I think it’s important to mention, and I think we all know, they’re presenting more often with left-sided tumors or rectal tumors. We’re told that left-sided tumors have better survival. But this seems to be a little different in this very unique, young patient population.

John L. Marshall, MD: Peritoneally, as well.

Cathy Eng, MD, FACP: A lot of peritoneal disease, yes.

John L. Marshall, MD: Maybe it’s that they’re young and are affected by it more? But it does seem like it’s worse.

Cathy Eng, MD, FACP: Yes.

John L. Marshall, MD: There’s some evidence that there’s a slight difference in genetic profile. But they’re not fundamentally different tumors, right? They’re not biologically all that different, but kind of clinically behaving? So the main message for us is, how is this affecting your recommendations? When you see one of these 35-year-old patients, does it change what you do, Dale?

Dale R. Shepard, MD, PhD, FACP: Unfortunately, it doesn’t because we don’t have good data. As we’ve suggested, the biology is so different; it has to be. They are mostly left-sided, which we think is better. But they are more aggressive. They don’t seem to respond as well. We just don’t have good information on the biology, to know what to do differently. And so, I think we’re kind of forced into doing what we do with everyone else until we know better.

John L. Marshall, MD: We say that they’re young and can take it. So, is this a situation in which you give 6 months of adjuvant therapy?

Cathy Eng, MD, FACP: I look at everything else, in regard to data, for these patients. But, in regard to metastatic disease, I will be more aggressive than normal on these young patients. Their performance status is usually fairly good. I love to use FOLFOXIRI [fluorouracil, leucovorin, oxaliplatin, and irinotecan] in this setting, on these patients.

John L. Marshall, MD: This is also a patient who’s raising a family and is trying to go to work. So, when we put our foot on the pedal a little harder, it is also more disruptive, right?

Cathy Eng, MD, FACP: I’ve had patients who still function, work, and do everything else. I think it’s really important, when we’re talking with a young patient, that we’re talking about fertility preservation. That’s not discussed enough with patients.

John L. Marshall, MD: We don’t discuss that very much with our patients because they’re usually past those ages. But, yes, it’s becoming an increasing issue with banking—whether it’s for eggs or sperm. Are there any other young patient observations?

Johanna C. Bendell, MD: The other thing that I make sure I do, and I try to do this in all patients, especially the young ones, is get next-generation sequencing for these patients. You need to know as much as you can about their disease, walking into it. If there is something there, you might be able to help treat it. You might find something that’s more genetically linked. That way, you’re better able to take care of them and their families.

Transcript Edited for Clarity 
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