Transcript Related Guidelines

Early-Onset Colorectal Cancer

John L. Marshall, MD · Georgetown University  


September 07, 2023

Editorial Collaboration

Medscape &

Key Takeaways:

  • The number of people diagnosed with colorectal cancer at a young age (in this case, younger than 50 years) is rising steeply.

  • International medical societies, recognizing the distinct differences in colorectal cancer based on whether it is early- or late-onset disease, developed consensus recommendations specifically for the early-onset variety.

  • The many recommendations for early-onset colorectal cancer include taking a thorough family cancer history, conducting germline genetic testing, and addressing reproductive and sexual health function and concerns.

This transcript has been edited for clarity.   

A consensus paper [was recently published].[1] Now, what’s that? A consensus paper [means that] a bunch of people got together and formed a club. They all discussed what they wanted to talk about and they made a recommendation—in this case, if 80% of the people who were invited voted “yes,” [then] that made it into this paper. What was the topic? What to do with young people with colorectal cancer. 

We know that there is this explosion of young people with colorectal cancer all over the world. We call it young if [an individual is] under 50 [years of age]. We see lots of 20-, 30-, and 40-year-olds. The whole [paradigm] has shifted younger, and it’s really disrupted lots of things—in some ways, for the better—because it’s focused a lot of attention, a lot of new research, a lot of: “Are we doing the right thing in colorectal cancer?” 

This consensus group came out with some recommendations that I think are important for us to know, but quite honestly, in my opinion, don’t actually solve the fundamental problem of why this is happening [to patients at such a young age]. This [consensus] group [comprises] gastroenterologists, clinical geneticists, people who are really worried about identifying those patients with familial cancer. 

One of [the group’s] first recommendations is, if a young person comes in with iron deficiency anemia or problems, don’t put it off as a hemorrhoid or something else. Get the patient worked up. I think this awareness is happening through our primary care communities. [People think] young people don’t get colon cancer, but yes, they do. 

[The group’s] second [recommendation concerns] family history. We [need to] take a strong family history in [this younger population]—maybe a better family history than we take in older patients. Most of these people won’t have a family history, by the way (one of my criticisms of this paper). Regardless, you need to take a strong family history. 

[Genetic testing for] inherited cancer is probably important to be doing in almost everybody now. We’re doing MSI [microsatellite instability] testing on everybody, but don’t forget BRCA and other genes. The [consensus group’s] suggestion is that, in everyone who’s under the age of 50 [years], we should be doing germline testing. We’ve got to figure out if we can afford that and [whether it] is really that appropriate. 

MSI testing in everybody: that’s critical. What we’ve come off of, if you’ve noticed, is that, in patients who do have a strong family history and do have Lynch syndrome, for example, we’re not taking out their whole colons as much anymore. I think, in large part, because we know just how much morbidity that causes, but also because we’ve got therapies—if they do, in fact, get cancers—that do work very well for these patients. However, the consideration of, should you be doing more resections, larger colectomies, and other organs if you have an inherited cancer syndrome, is important. 

Good endoscopy [is recommended] in all those patients. Of course, with younger people with colorectal cancer, most of their tumors are in the left rectosigmoid area, so whether you’re giving radiation or surgery or whatnot, fertility and sex life are an important part of lives for certainly everybody, but maybe even more important for the under-50 crowd. 

I like the paper. I like the focus that it’s given, but remember, this is a subset of these young patients who have inherited cancer syndromes. What we really need to figure out is what’s going on with the rest of them. 


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