Early Screening for Colorectal Neoplasia and Cancer Is Critical Among Younger Individuals

Steven H. Itzkowitz, MD

Routine colonoscopies and procedures to screen for advanced neoplasia and colorectal cancer (CRC) are paramount for individuals aged 45 to 49 years, said Steven H. Itzkowitz, MD, who added that without early messaging and screening efforts, important disease pathology will not be identified until a patient presents with symptomatic disease.

Findings from a database analysis, which were presented during the 2021 Digestive Disease Week®, demonstrated that a neoplastic finding was identified in 25.4% of procedures in patients aged 30 to 49 years.^1,2 Of these, 6.1% of patients had an advanced neoplasia.

In patients 45 to 49 years, 7.9% had an advanced neoplasia and 0.56% had CRC.

“This degree of pathology is concerning in the sense that it is significant and prevalent enough that if we start screening people between 45 and 49 years, it won’t be fruitless. We will find important pathology,” Itzkowitz said.

Notably, Itzkowitz highlighted that although guidelines are unlikely to change in the next few years, younger individuals may benefit from further lowering the screening age. Additional results of the analysis showed that in individuals aged 40 to 44 years, 6.1% had an advanced neoplasia and 0.50% had CRC.

In May 2021, the United States Preventive Services Task Force (USPSTF) granted a grade B recommendation for CRC screening in adults aged 45 to 49 years.³

In an interview with OncLive^®, Itzkowitz, a professor of medicine and gastroenterology, oncological sciences, and medical education, and the director of the GI Fellowship Program at the Icahn School of Medicine at Mount Sinai, discussed the importance of screening for CRC in younger adults, the results of the database analysis, and strategies for implementing early messaging in the community setting for this population.

OncLive^®: What did this analysis evaluate, and why was it important to conduct a study like this?

Itzkowitz: This research focuses on the prevalence of colorectal neoplasia, both polyps and cancers, in people younger than 50 years. This is a very hot topic now because [recently] the USPSTF came out with their updated recommendations. They gave [screening in individuals 45 to 49 years of age] a grade B recommendation; however, it is still recommended that people start screening at age 45 rather than at age 50. This is a recommendation that was also made 3 years ago by the American Cancer Society.

Now, a lot of the societies seem to be coming into alignment [for recommending screening] starting at age 45.

The problem is that until now, if [an individual] was younger than 50, they weren’t getting colonoscopies until they had symptoms or a family history of colon cancer. We didn’t know what kind of pathology might be lurking in the colons of people younger than 50 in general.

Therefore, we looked at a very large database, which started with close to 3 million colonoscopies. [The database] includes about a quarter of a million people younger than 50 years who have gotten colonoscopies for a host reasons, including symptoms, screening, and family history, to get a larger sample of individuals and get a sense of what one might find now that the screening age is lowered to 45 years.

What was found from the study?

The findings showed that if we look at people aged between 45 and 49, about 7.5% have what we consider a significant polyp. A significant polyp is a large adenomatous polyp, or so-called advanced adenoma, or an advanced sessile serrated polyp, which is another type of polyp that can [progress] to colon cancer.

Already, about 0.58% of people in that age group had a cancer, which is close to what we often see in people older than 50 years.

We found that men had [a higher] rate of polyps and cancers compared with women. That has been shown in every study. It [highlights] the importance of [understanding] family history and early messaging.

How do these findings fit into what was previously known about screening for CRC? What can be taken away from this research?

Other studies have looked at people younger than 50 years with colonoscopy for a variety of indications. Depending upon the study population and the sample size, [the data] have come in at around [7.5%]. Our data are on the higher side, so [that] was a little bit surprising. However, I should also qualify that by saying we included people who had symptoms, such as bleeding and anemia, and family history [of CRC].

Our findings help in that we also looked at people aged 40 to 44 years, and even younger than 40 years. If we look at the pathology findings between ages 40 and 44 years, the numbers are fairly high, suggesting that we need to start having a conversation with people before they are 45 years of age. That is a concept that is being referred to as early messaging.

Until recently, if we looked at people over 50 who were supposed to be getting screened all these years, there is a procrastination effect. The rates of colon cancer have not been going down in people 50 to 54 years of age anywhere near as much as they have been going down in people 55 years of age or older. People who should be coming in at 50 years old have been delaying, so we still see increasing rates of colon cancer between ages 50 and 54.

We are very concerned about this procrastination. If we start screening people at age 45, they will probably procrastinate also, so the idea is to start talking about this when someone is 40 years old. Even if someone comes in at age 40, we are going to find some important pathology. However, we certainly want people to come in by the time they are 45 years of age.

How long do you anticipate it will be before we see the recommended screening age further lowered for individuals below age 45?

That will take some time. It usually takes about 5 to 8 years for insurers, the public, and doctors to embrace new recommendations. I give the USPSTF credit because they had come out with their guidelines before this in 2016.

They don’t usually update their findings all that often, but when the American Cancer Society came out 2 years later with their recommendations to drop the age to 45, it was an incentive to have the USPSTF to start looking again at that same data. That was why they came out just 5 years after the last recommendations [with updated guidance]. We are not going to see the starting age drop to 40 anytime soon. We have to see what we get with individuals between the ages of 45 and 49.

One of the risks of lowering the age is that it is going to enormously increase the volume in endoscopy centers. There is always a concern that we will be scoping relatively healthy 45-to-49-year-olds and take away slots from people over 50 who should be coming in for their screening and in whom we are more likely to find even more rates of [cancerous] pathology. There is a fine balance between a new recommendation opening the doors to more people and handling that.

What is the clinical significance of these findings?

The significance of our findings is that there are real rates of important pathology in people between the ages of 45 and 49 years. We feel [these data] justify lowering the age to 45 years.

These numbers can now be inserted into various models that look at cost-effectiveness and life-years gained. That is the significance.

Our data do show that if one has a family history of colon cancer, [screening] needs to start younger. However, we don’t know how much younger. All along when the screening age was 50, if someone had a family history [of colon cancer], they were supposed to start screening at age 40. We still think that 40 is a useful number for people with a positive family history [of cancer], but we can start to think about: If we are going to start [all screening] at age 45, should we go even 10 years younger than that [for screening in a person with a family history of colon cancer]? That would mean starting at 35 years of age. We don’t know enough about that, so we look forward to more studies that will help us [understand that].

The bottom line is that everybody should be thinking about starting screening at 45 years of age. It doesn’t have to be a colonoscopy. It could be a stool-based test or some other sort of screening at 45 years of age. If there is a family history, [screening should start] at age 40 or at least younger than 45.

Early messaging [is important]. Primary care physicians should be talking to individuals in their 30s or 40s. People are never too young to start screening for CRC.

How can primary care physicians utilize effective early messaging?

I always like to think that it is not great to scare patients into doing things for their health. The public has become aware that the rates of young people with colon cancer are on the rise. It is probably in the back of a lot of minds. We need to make people aware of [the rising incidence of CRC], as well as the fact that most young people under age 50 who get colon cancer don’t have the usual risk factors, such as obesity, sedentary lifestyle, smoking history, or family history. The common risk factors that we see in people over 50 are not necessarily there in people younger than 50, so it is important to make that clear to young people to not wait for symptoms. However, if a young person does have symptoms, such as rectal bleeding, change in bowel movements, or weight loss, they must report that to their doctors to get an early colonoscopy.

Something that we have seen in many studies is that there are long delays in making the diagnosis of colon cancer in a young individual because a lot of physicians and patients don’t believe that they could have a cancer. We have to disavow people of that notion to get people in sooner rather than later for screening.

How will the field prioritize which individuals should undergo a colonoscopy sooner vs later, especially considering most are asymptomatic?

When we talk about screening, we are referring to asymptomatic individuals without a family history [of cancer]. Our numbers, although many of them are derived from colonoscopy procedures that were based on symptoms, again, because people were not coming in for asymptomatic screening, we like to think that these numbers, although a little bit on the high end maybe, could be applied to models that look at what one might expect in average-risk screenings.

All the screening guidelines along the way are geared toward asymptomatic people. When I teach medical students, I ask them what the top 3 symptoms of colon cancer are and they come up with [answers, such as] changes in bowel movements and blood in the stool. I say, “No, the 3 most common symptoms [of colon cancer] are no symptoms, no symptoms, and no symptoms.” Someone can have cancer and not have symptoms, which is why they need to come in for screening.

References

1. AMSURG and Mount Sinai Health System release new research on early-onset colorectal cancer. News release. Mount Sinai. May 24, 2021. Accessed August 10, 2021. https://bit.ly/3ustitb
2. Aditi M, D Parth T, Melissa M, et al. Prevalence of young-onset colorectal neoplasia in a nationally representative colonoscopy registry. Presented at: Digestive Disease Week; May 21-23, 2021; virtual.
3. Colorectal cancer: screening. U.S. Preventive Services Task Force. Published May 18, 2021. Accessed August 11, 2021. https://bit.ly/3xGkVfn.