Treatment for colorectal cancer is not ‘one size fits all’

The incidence of colorectal cancer in younger people is rising globally and there are special considerations to take into account when caring for this patient population says an expert from global health system Cleveland Clinic, speaking during the Colorectal Cancer Awareness Month of March.

For reasons not fully understood, incidence of early-onset colorectal cancer is rising globally at an alarming rate, and researchers have estimated that within the next decade 1 in 10 colon cancers and 1 in 4 rectal cancers will be diagnosed in adults younger than 50 years.

“Screening tests are helping to reduce colon and rectal cancer rates overall, but we are seeing a rising number of cases in younger people. These individuals are often younger than the routine screening age, which varies from country to country, but was recently set at 45 in the U.S.,” says colorectal surgeon David Liska, M.D.

“A colorectal cancer diagnosis can interrupt a young adult’s most productive years. There are considerations that are specific to this age group, and as part of the treatment, it is important to address genetics, fertility, psychosocial aspects, and lifestyle medicine,” says Dr. Liska, who is director of the Center for Young-Onset Colorectal Cancer at Cleveland Clinic.

A common issue among younger patients, says Dr. Liska, is that their diagnosis is delayed and only made after the cancer has advanced because initial symptoms are disregarded or wrongly attributed to hemorrhoids, due to the belief that they were too young to have colorectal cancer.  Potential symptoms include rectal bleeding, blood in the stool, changes in bowel habits such as diarrhea and constipation, unexplained and ongoing abdominal pain, and unintentional weight loss.

“While having symptoms such as rectal bleeding or blood in your stool doesn’t mean you necessarily have colorectal cancer, it is still important to see a doctor straight away because in the event that it is colorectal cancer, the sooner it is caught, the better the treatment outcome will be,” says Dr. Liska.

Genetic testing, fertility and psychological implications

Any person under the age of 50 diagnosed with colorectal cancer should undergo genetic testing to determine if this is a hereditary condition, says Dr. Liska. While the majority of cases are not inherited, hereditary syndromes are more common in young people and there are several important reasons for being tested. In particular, the diagnosis of a hereditary syndrome could determine the best type of treatment, for example, Lynch syndrome, a hereditary colon cancer, responds best to immunotherapy. The risk of developing subsequent cancers is also higher in hereditary conditions which guides surgery and surveillance. Another compelling reason for genetic testing is that the results will determine whether other family members should be tested to assess their risk or undergo specialized screening.

Another consideration specific to younger men and women is that they might be planning to have children, says Dr. Liska. “We need to ensure that whatever treatment we give them doesn’t interfere with this. We will refer them to a fertility specialist at the time of the diagnosis to discuss preserving their fertility.”

The social and psychological implications in younger patients also need to be considered, says Dr. Liska. “While a diagnosis of colorectal cancer is never easy, patients under the age of 50 often have young children at home, and might also be taking care of their older parents. The transition from being the primary care provider to being a person who needs care can be very difficult psychologically and financially. We need to make sure we are offering patients support during their entire treatment journey, including help from social workers or psychologists.

Lifestyle is also an important consideration in younger patients, says Dr. Liska. He recommends patients consult wellness experts to create a plan to modify their diet, exercise and other lifestyle habits. The aim is to support their treatment, to avoid complications related to their cancer or treatment, and to reduce the risk of the cancer returning post-treatment.

Overall, Dr. Liska emphasizes that the quality of treatment received can have a significant impact on outcomes, not just in terms of patients’ survival, but also their quality of life after treatment. “Patients should seek care at a colorectal cancer center of excellence, where a multidisciplinary approach will be followed. This is even more important in rectal cancer, which is a more complicated disease requiring specialized multidisciplinary care,” he advises.

“The multidisciplinary team will be even more extensive in the case of younger individuals due to the special considerations already discussed. In fact, it can become so complex, with so many different specialties, that we have assigned patient coordinators at our Center for Young-Onset Colorectal Cancer to support each patient in navigating through their treatment journey,” he adds.

With an eye on prevention, Dr. Liska urges individuals to go for recommended colorectal cancer screenings, but also to speak openly to their doctor about any symptoms and relevant family history so as to determine their individual optimal timing and frequency of diagnostic tests and screening examinations.