Early Onset Colorectal Cancer: Screening Options, Prevention & Treatment 

March is Colorectal Cancer Awareness Month, and an increasing number of people below the age of 50 are being diagnosed with colon or rectal cancer. The statistics are alarming: by 2030, the incidence rate of early onset colorectal cancer is expected to double.

Why are more young people being diagnosed with colorectal cancer?

Right now, it’s pretty much speculative.

We’ve noted that there has been a 2% annual increase in the rate that people have been below the age of 50 have been diagnosed with colon and rectal cancer over the last 20 years. And so that incidence is concerning considering that this was typically thought of as a disease that affected patients over the age of 50, more so into their sixth and seventh decades of life.

I’ve seen more young people with colorectal cancer in the last couple of years than I’ve seen in the first 10 to 12 years of my career. I’m seeing patients who have advanced disease in their early twenties—it’s something that I hadn’t imagined when I was a resident.

What are the signs of early onset colorectal cancer?

The symptoms of early-onset colorectal cancer are pretty much the same as in older adults. These include rectal bleeding, anemia, or unintentional weight loss. Sometimes we’re constantly on this diet and feast cycle, but if you’re not actively trying to lose weight and notice the pounds steadily coming off, that’s a concerning sign. Other symptoms include fatigue, abdominal pain, changes in bowel habits, and changes in the caliber of your stool.

For many colon cancers that occur on the right side of the colon—where the stool is more liquid—you may not notice symptoms until the cancer is advanced and nearly causing an obstruction. Early symptoms can be vague, like occasional abdominal pain, but over several months, the discomfort can gradually worsen.

Unfortunately, by the time these symptoms lead to an evaluation, it could be nine months or more, and that’s when a colon cancer diagnosis is often made. In hindsight, those early vague symptoms all pointed to cancer, but it’s hard to recognize them for what they are in the moment. That’s why it’s important to be vigilant and speak up if something feels off. Having a primary care doctor who you can talk to about these concerns is important.

Now, primary care doctors might not love me for saying this, because it could mean every stomachache gets flagged as a potential concern. But research has shown that if you have three or more of these symptoms, it’s serious and needs to be evaluated. That’s not to say that just one or two symptoms aren’t also concerning—but the more symptoms you have, the greater the concern.

The key is to stay aware, listen to your body, and take action when things don’t feel right. I’ve had some relatively young patients who only noticed a feeling of pressure in their pelvis that developed over months, and it ended up being rectal cancer.

Is it possible to have asymptomatic and have early onset colon cancer?

Yes, it is entirely possible to be completely asymptomatic and have colon cancer at almost any age.

What are the screening methods for colorectal cancer?

I’m of the camp of some screening is better than no screening.

Colonoscopy

Colonoscopy is the gold standard because it can prevent colon cancers by removing polyps that can eventually develop into cancer, but the penetrance and availability of the test is not as high as say, giving a stool sample or giving blood.

Stool Studies

There are stool screening tests like Cologuard. My main concern with them is the rate of false negatives and false positives. Some patients with polyps or even cancer can test negative, while others without any issues can test positive. If nothing shows up during a colonoscopy after a positive stool test, it leaves patients wondering where the positive result came from.

At what age should someone start getting a colonoscopy if they don’t have a family history?

We’re trying to capture more of those patients who are developing colon cancer early. The age frame has been moved up for screening purposes and should be encouraged as part of routine health maintenance and screenings. 45 is the new 50 for colonoscopy.

If colorectal cancer does run in your family, when should you start screening?

It depends on which family member it is. If it’s a first-degree family member, then it should be 10 years prior to their diagnosis. To give an example: if someone’s mother developed colon cancer at age of 45 within their first screening, their child’s first colonoscopy should be at age 35.

If a second degree relative, which is like an aunt, an uncle, or a cousin developed colorectal cancer, it doesn’t significantly increase your risk, so the screening guidelines don’t anticipate that you would need to get a colonoscopy earlier than your normal 45 years of age.

Will insurance pay for a younger adult’s colonoscopy?

You can get a colonoscopy if there are concerning symptoms. And in those instances, it’s no longer a screening colonoscopy, it’s a diagnostic colonoscopy, and insurance will likely pay for most of that study but may not pay for all of it. If you have a positive Cologuard, the insurance company is more or less obligated to pay for a diagnostic colonoscopy.

Simply having the symptoms of colorectal cancer and speaking with your primary care doctor (who would refer you to a GI) directly may prompt a study.

What is getting a colonoscopy like?

Some patients are direly afraid of getting a colonoscopy, but the colonoscopy itself is painless. You go to sleep, it’s probably one of the best naps you’ll ever have, and you’ll wake up on the other side, no worse for the wear. You won’t remember anything.

The part that is difficult and a little bit discouraging is the prep process. Luckily there are new formulations that have less volume than the traditional GoLYTELY.

The process seems mystifying, but you simply just stay on a liquid diet the day before, take the bowel prep, and have one night where it’s kind of messy. You stay near the bathroom, and then you’re on the other side of it. Then, the anxiety of not knowing is over.

Lots of people are really scared of the process, and afterwards, they’re like, “Oh, that was easy. That was nothing.” I’m not sure exactly what people envision, but it is not painful. It is uncomfortable beforehand, and then you’re done.

45 is the new 50 for colonoscopy.

Have you seen videos of celebrities getting colonoscopies in order to inspire others?

The one that I saw that was interesting was Will Smith documenting his entire process getting a colonoscopy. He had several polyps, and they weren’t just small little things, and he is one of the most famous, wealthiest people in the world.

We’ve seen lots of celebrities who have been dealing with their own colon cancer diagnoses behind closed doors. Chadwick Bozeman being one of the most famous and another example of someone who was younger than screening guidelines who developed colon cancer and what seemed to be a relatively aggressive form of it.

Watch Our Celebrity Colonoscopy Playlist

Is early onset colorectal cancer typically more aggressive than for someone who is diagnosed later in life?

I have seen it swing both ways. In early onset cancer patients, I’ve seen some very aggressive forms of colon cancer when the patients present with stage four disease, meaning that the disease moved on from just being in the colon and has either moved on to being in the liver or in the lungs.

And I don’t know what it is. I think part of it is these patients have more reserve. Their immune systems may be a little bit more active, but they seem to do well with both chemotherapy and radiation therapy and they tend to come out of it very well.

Most of the stage three colon cancer, meaning that the other areas of the body are not involved, just kind of the lymph nodes or the areas just immediately around the colon cancer are affected. Those patients seem to do well with chemotherapy as well. So, it’s not that this situation is hopeless. I do think that those patients do very well with a combination of therapies.

I’ve also seen the opposite of that where if we neglect the cancer or decide to not proceed with standard care, those cancers evolve in a way that can be relatively unfortunate. This is speaking specifically to those people who don’t believe in the medical establishment’s treatment of colon cancer because they don’t want to take chemotherapy or radiation therapy.

Oddly enough, I was watching a video of a young lady who in her early forties who decided that she was going to partake in holistic medicine alternatives to treat her colon cancer. And unfortunately, and this could have happened I guess with standard therapy, but her disease progressed, and she developed stage four colon cancer, and she was on her heels trying to deal with that diagnosis and the prognosis that comes along with it.

All I can do is offer what I know has been effective and seems to work for the patients that I deal with and then try and discuss patient’s hesitancy about standard of care treatments if it is something that they want to address.

When a young colorectal cancer patient comes in to see you, what initial symptom do they usually describe as the moment they realized, “Something is wrong—I need to go get this checked out”?

It’s called the “Herald Bleed.” It’s one of those things that you can either be freaked out by it, or you can completely disregard it.

It’s one of the more obvious moments—that one episode where the patient had a bunch of rectal bleeding, they didn’t really understand what happened or why it was going on, and then nothing happened after that—they had no further symptoms. I’ve seen that happen.

But when you look at the statistics, there’s nothing more that stands out. Usually, you have the ability to go back and see other symptoms like vague abdominal pain and rectal bleeding, but a lot of times it’s absolutely nothing, which is unfortunate because it’s hard to pinpoint what to do. Is it that every time you have some rectal bleeding, which most people attribute to hemorrhoids, a sign that you should get a colonoscopy? No, but you should probably talk to somebody about that. You should probably tell your primary care doctor and not completely disregard it.

Do young people often think that they just have hemorrhoids when it’s actually something more serious?

It’s legitimately the thing that most people assume it is when there is bleeding present. It is not uncommon for the patients to tell me, “I just thought I had hemorrhoids,” and they may legitimately have hemorrhoids. But can you have hemorrhoids and rectal bleeding due to the hemorrhoids and also have colon cancer? Yes.

Would you recommend if someone thinks that they have bleeding from hemorrhoids to make sure that it is only bleeding from hemorrhoids?

Right.

And if you feel like you’re bleeding from hemorrhoids and you’ve done all the preventative things—you’re drinking adequate amounts of water, not smoking, not drinking, and eating enough fiber in your diet (20 to 30 grams of fiber per day that can be supplemented with Benefiber, Metamucil fiber gummies)—and this is still causing rectal bleeding, talk to somebody.

What dietary and lifestyle changes can lower the risk of early onset colorectal cancer?

I think it’s the same things that we would say for colon cancer in general, and it’s going to sound rote. I wish I could tell you to take a certain medication that will prevent you from getting colon cancer.

The reality is that we’ve noticed that patients who are sedentary and are overweight have a higher risk of developing colon or rectal cancer. Patients who are consuming diets high in processed foods and red meat. Patients who smoke. Patients who consume large amounts of alcohol.

It’s less clear on the red meat exactly why. I think it’s probably related to a diet that does not move efficiently through the GI tract. So, having a higher fiber diet seems to be protective. Being more active and not smoking seems to be protective. But there are patients who are marathon runners who live off of a Mediterranean diet who never touched a cigarette and could still develop colon cancer even in the absence of a family history.

How is treating people with early onset colorectal cancer different?

Fertility Preservation

There is a good segment of the population who do not need radiation therapy. They may just need surgery alone, and that in itself will not affect their fertility or their ability to have children. But chemotherapy and radiation therapy most certainly can.

So whenever I have patients who are still of childbearing age, either male or female, and they’ve come down with a diagnosis where they are going to need chemotherapy or radiation therapy, we encourage those patients to either sperm bank or bank their eggs if it is something that is within their means to do so.

There are certainly resources that can be discussed and even arranged to help those patients out if they want to make sure that that is something that’s possible for them.

Chemotherapy Regimens

If patients do need chemotherapy, the chemotherapy typically used to treat colorectal cancer is not the same type of chemotherapy you would get for other cancers. Typically, this is not the type of chemotherapy that is going to make your hair fall out and cause you to become very ill.

For most colon cancer chemotherapies, the side effects include numbness of the hands and feet, heat and cold intolerance, and changes with their bowel habits. Even then those things tend to fade away once chemotherapy is over. We are intentionally poisoning the portion of the body that is growing out of control, and there are consequences to that. But most of the time for colorectal cancer, it is not as severe as for other cancers such as ovarian, leukemia, lymphoma, etc.

Much respect to our medical oncology colleagues. I think medical oncologists have a very difficult job, are slightly underappreciated, and they deserve their props.

Once the patient gets diagnosed, they go through a very rigorous process of identifying what subcategory cancer it is. Once they do that, they apply the most recent knowledge about that cancer and what it is susceptible to. Then, they specifically tailor the patient’s chemotherapy needs based on their health, what they’ll tolerate, and what is the best thing to help them get the best outcome down the line. I’ll stick with surgery.

Have surgical methods for early onset colorectal cancer advanced in recent years?

Not with early onset per se, but I’ll speak specifically about my practice. When I first started training as a resident in the early 2010s, there was a lot more open surgery happening, and with that, longer recovery times. Patients would be in the hospital for four to 10 days recovering, spending prolonged periods of time without eating, and waiting for bowel movements to happen.

With advancements in technology and medication, we’ve been able to make that process a lot easier. For instance, the majority of patients that I operate on who have colon or rectal cancer will receive minimally invasive robotic surgery. This means that I’m in the room controlling instruments inside the abdominal cavity using a robot.

We’re able to complete the entire surgery inside of the abdominal cavity without having to bring the bowel outside of the abdomen at all. There are also medications now that help make sure the intestines don’t fall asleep. For the most part, my colon cancer patients spend somewhere between one and three days in the hospital after surgery.

I had a patient who was 80+ early last week who came into the hospital on Tuesday and left on Thursday. Several weeks ago, I had a 49-year-old gentleman who left the hospital the day following surgery.

Following an enhanced recovery protocol (ERAS) helps make sure the patient goes home and doesn’t necessarily need to come back. ERAS helps expedite their pain control, return of bowel function, return of bladder function, and their ability to function and ambulate at home.

I always say there are two “C”s that will make people turn off their ears and make me sound like Charlie Brown’s parents—Cancer and Colostomy.

The question I get a lot from patients is, “Is what is going to happen to me going to require an ostomy that is either permanent or temporary?” The answer is that it depends on where the cancer is, but for the most part, the answer is no.

I will say that even though no one wants a colostomy—I don’t want a colostomy or ileostomy— but I would rather have it if it was going to save my life or prevent me from having another issue if entirely possible. That’s the way I frame it. We also are blessed in our local area to have really good ostomy care nurses and support systems that are in place that really help patients longitudinally— from before they get the ostomy to after they get the ostomy—to support their needs.

How can an ostomy improve a young colorectal cancer patient’s quality of life?

When you look at some of the data, the quality of life after surgery for patients who’ve had a low anterior resection—where everything’s been put back together— is about the same as for patients who have a permanent colostomy. The difference is: what are the things that bother them?

There’s some degree of bowel dysfunction that happens after we’ve taken out the rectum and then put everything back together because it’s not the way that we were initially put together, and it doesn’t work exactly the way it used to.

Those changes can be very distressing vs. the more psychological issues that come along with having a permanent colostomy—feelings of being potentially “disfigured” or not the same as you were before.

I think those initial feelings fade away with time, and it’s amazing what people can get used to. Nobody wants to give you a colostomy. It’s something that is done for your benefit so that you can heal, and if it’s potentially reversible, be reversed.

There was a performer on RuPaul’s Drag Race a few seasons ago who performed with an ostomy after surviving stage three colon cancer.

There are tons of social media influencers who are out there living their best lives with their bags, and their stories are amazing. They have them for a variety of reasons. Some because they have Crohn’s disease, and their disease was so bad that they had to have the majority of a portion of their GI tract removed so that they could actually be pain and symptom free. And they’re thankful to have one so that they’re not in constant pain and agony or having to deal with the complications that they had while they did not have the bag.

Sometimes, especially for my younger patients, I’ll pull up my own phone and be like, “hey, look—this young, vibrant person has an ostomy bag. Flip through her pictures, she’s on vacation, she’s swimming, she’s doing all these things. She’s not letting this thing slow her down.” They’re like, “well, I can’t do the things she can do.” I’m like, “well, why not? The only difference is that she’s standing in front of her camera and taking pictures of herself in these exotic locations because she’s figured out how to monetize the situation.”

Watch Some of Dr. Brown’s Favorite Social Influencers With Ostomy Appliances

Do you have any other advice for young people about colorectal cancer?

I know we live in an age where not everybody trusts the medical establishment and maybe even feel like we’re doing this to get money out of people. There may be some bad actors, but the vast majority of us are really looking out for people’s health and do not want to see patients and families torn apart by these diseases.

It’s really hard to see 40-year-old patients with kids who are less than 10 years old being told that they have advanced colorectal cancer when some of the symptoms were really obvious, and if someone had chased it down a little bit , that maybe we wouldn’t be in a situation where we’re altering the trajectory of their entire family. And that’s not to say that that’s the fault of any of those patients. In fact, it’s quite the opposite. We want to help these patients, these people, these families get to a place where they can avoid these things if possible.

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Screening Options for Colon & Rectal Cancers at Singing River

Singing River wants to make it as easy as possible for you to get screened for colon cancer. We have eight medical clinics across the coast where you can establish a primary care provider. You can visit your primary care provider when you’re sick or for regular preventive care like check-ups.

“Some screening is better than no screening”

Call the clinic of your choice or make a first appointment online. During your appointment, tell your doctor or a nurse practitioner that you’re interested in being screened for colon cancer. Read more about the options from your primary care provider below.

Genetic Testing for Hereditary Cancer

At our primary care clinics, anyone with a history of cancer in their family receives a form called the Cancer Risk Assessment. This will help your provider determine what genetic testing you will qualify for. If you are at risk of early onset colorectal cancer, you can be prescribed a genetic test called MyRisk that can tell you if you carry mutations that increase your risk of developing certain diseases. Knowing your genetic risk can help you plan future screening.

Stool Tests

Hemoccult

You can complete an in-office test called a hemoccult test (also known as a fecal occult blood test or FOBT). Your provider will collect a small stool sample, apply it to your test card, and it will detect whether blood is present. Blood being present is an early sign of colorectal cancer, polyps, or other digestive tract conditions like ulcers or hemorrhoids.

Cologuard

After getting a prescription for Cologuard, you’ll receive a test kit sent to your home, complete it, and ship it directly to the lab using a prepaid shipping label. This test also detects blood in the stool, but it also detects DNA mutations and abnormal biomarkers that may be shed by cancer or precancerous polyps.

Colonoscopy

Ask your provider for a referral to a gastroenterologist at Singing River Digestive Health for a colonoscopy—the most accurate screening option that also includes the removal of any pre-cancerous polyps.