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Among doctors, colon cancer is mainly known as an age-related disease that only appears around the age of seventy. When young people present to their GP with abdominal complaints, a link with colon cancer is not easily made. Symptoms such as abdominal pain, loss of appetite, blood loss and changes in stool are also consistent with many other diseases, which are also more common in this group.
But since the 1990s, more and more young people have been developing colon cancer. While the proportion of elderly people with colon cancer is decreasing, the number of people under fifty with the condition is rising rapidly, by about 2 percent annually. Because it often takes longer for the correct diagnosis to be made, they are also at greater risk of dying from the disease. The increasing trend can be seen worldwide, especially in high-income Western countries. Researchers warn that the group of young colon cancer patients will double between 2015 and 2030.
Currently, the treatment for young people with colon cancer is the same as for the elderly: surgical removal of the tumors, chemotherapy or immunotherapy, with or without combination with radiotherapy. But since the rising trend came to light about seven years ago, researchers have been unsure about the cause and whether it is a separate condition. How is it possible that people get colon cancer at this age? And should this younger group of patients perhaps also be treated differently?
Western lifestyle
In the Amsterdam Antoni van Leeuwenhoek hospital, doctors notice that the patients who report to the colon cancer center are young and seem to be getting younger. It therefore opened a special clinic for this group last month, says internist-oncologist Karen Bolhuis, who, together with colleagues Monique van Leerdam and Myriam Chalabi, is the initiator of the new clinic.
“Due to the ignorance of colon cancer in young people, the diagnosis is often made later, which unfortunately means that the disease cannot be cured or requires severe treatment that can cause lifelong complaints,” she says. “For young people in their twenties or thirties who are confronted with the diagnosis, this can have a huge impact on their family, career or existing desire to have children.” In addition to the usual colon cancer care, patients and their families therefore receive extra support, allowing them to be referred at an early stage to, for example, a fertility doctor, clinical geneticist or psychologist.
The clinic also serves as a research platform, says Bolhuis. “After the patient’s consent, we ask them about their lifestyle and examine the tumor DNA, the intestinal mucosa and changes in the intestinal bacteria to understand how the disease develops.” Genetic predisposition plays a role in about a fifth of patients, such as in people with Lynch syndrome. But it is precisely in this group that no increase in patients is visible. To explain why more people are diagnosed with colon cancer every year, researchers point to environmental factors such as lifestyle and diet.
It has been established for some time that a high body weight increases the risk of colon cancer. And the Western lifestyle also entails many risks: “Since the 1960s, we have started eating much more red meat and processed food, drinking a lot of sugary drinks and alcohol, and exercising less.” Smokers are at higher risk, and antibiotic use may also play a role because it affects the composition of intestinal bacteria, says Bolhuis.
Aggressive tumor biology
But existing research into the risks is small-scale and only looks at the effect of one or a few factors at a time. “Colon cancer is probably caused by an interaction between lifestyle, intestinal flora and genes. The innovative thing about our research is that we will look at this combination of factors and seek collaboration with foreign research groups from America, among others.”
Researchers talk about it in the professional literature early-onset colorectal cancer, abbreviated to EO-CRC, suggesting that it is distinct from colon cancer in the elderly. But its own abbreviation does not mean that it is actually a separate condition, says Hidde Swartjes. While still completing his master’s degree in medicine, he received his PhD last month at the age of 24 from Radboud University in Nijmegen on colon cancer, and in one of his articles he writes that the disease has few differences in people under fifty compared to the group between 50 and 59. year.
There is no point in expanding the current population survey
When he analyzed the figures of the Dutch Cancer Registry for his dissertation, he saw the well-known annual increase of 1 to 2 percent between 1989 and 2018. But until the introduction of the national population screening for colon cancer in 2014, the number of people between 50 and 59 years old with colon cancer increased at the same rate. “We see a shift in which people are getting colon cancer earlier and earlier, but there is no indication that young patients respond differently to treatment or that survival differs,” says Swartjes. “Based on these data, we therefore conclude that there is no reason to treat colon cancer differently in that group, although I can imagine that younger patients have different care questions and challenges due to their stage of life.”
But according to Bolhuis of the Antoni van Leeuwenhoek, there are indications that colon cancer in young people does have its own characteristics. “We see tumors on the left side of the intestine much more often [waar de endeldarm is] , and publications suggest that tumor biology is more aggressive than in the elderly. It is also related to other mutations.” Research in the new outpatient clinic can show whether these differences also point to other causes, and whether there are better treatment and detection methods.
Unnecessary colonoscopy
Can colon cancer be prevented in young people by lowering the minimum age for population screening? Since 2014, people between the ages of 55 and 75 in the Netherlands have been invited for a stool test once every two years. Reports of colon cancer in the elderly are decreasing; the tumors are discovered and removed at an early stage. In America, the health authority has lowered the recommended age for preventive colon cancer screening to 45 years, and the European Union guideline also recommends starting testing at the age of 50.
In the Netherlands, several researchers and physicians are requesting that testing be started from the age of 50, says Bolhuis. The Health Council came to a similar conclusion in 2022 and recommended conducting a study in which all fifty-year-olds are screened once. Based on the results, it should be determined whether screening from the age of 50 is useful and cost-effective in the Netherlands, but Minister Ernst Kuipers (VWS, D66) decided last year not to follow the research advice.
In any case: an extensive population survey would not be a solution for people under 40, says Swartjes. “Although the incidence is rising, colon cancer is still very rare at this age, meaning that there is little health benefit to be gained.” By testing this group you will find few abnormalities and relatively many false positive results, which means that many people will be subjected to unnecessary visual examinations.
New ways to detect colon cancer are high on the agenda for researchers at the Antoni van Leeuwenhoek, and according to Bolhuis, this also applies to the new outpatient clinic. “If we know what the risk factors for colon cancer in young people are, we can screen much more specifically and develop more reliable screening methods. For example, by looking at the tumor DNA or proteins in the blood or feces. But at this stage that is still in the future.”
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