Mortality Rates From Early-Onset CRC Have Risen Considerably

PHILADELPHIA — The mortality rate of early-onset colorectal cancer (EO-CRC) has increased considerably across the United States over the past two decades, with the effects most pronounced in those aged 20-44 years, according to a new analysis of the two largest US mortality databases. 

Data from the US Centers for Disease Control and Prevention’s National Center of Health Statistics (NCHS) and the Surveillance, Epidemiology, and End Results (SEER) databases provide yet more evidence of the increasing prevalence of EO-CRC, which is defined as a diagnosis of CRC in patients younger than age 50 years. 

Furthermore, the researchers reported that increased mortality occurred across all patients included in the study (aged 20-54) regardless of tumor stage at diagnosis.

These findings “prompt tailoring further efforts toward raising awareness of colorectal cancer symptoms and keeping a low clinical suspicion in younger patients presenting with anemia, gastrointestinal bleeding, or change in bowel habits,” Yazan Abboud, MD, internal medicine PGY-3, assistant chief resident, and chair of resident research at Rutgers New Jersey Medical School, told Medscape Medical News.

Abboud presented the findings (Abstract P3865) here at the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting. 

Analyzing NCHS and SEER 

Rising rates of EO-CRC had prompted US medical societies to recommend reducing the screening age to 45 years. The US Preventive Services Task Force officially lowered it to this age in 2021.This shift is supported by real-world evidence, which shows that earlier screening leads to a significantly reduced risk for colorectal cancer. However, because colorectal cancer cases are decreasing overall in older adults, there is considerable interest in discovering why young adults are experiencing a paradoxical uptick in EO-CRC, and what impact this is having on associated mortality. 

Abboud and colleagues collected age-adjusted mortality rates for EO-CRC between 2000-2022 from the NCHS database. In addition, stage-specific incidence-based mortality rates between 2004-2020 were obtained from the SEER 22 database. The NCHS database covers approximately 100% of the US population, whereas the SEER 22 database, which is included within the NCHS, covers 42%. 

The researchers divided patients into two cohorts based on age (20-44 years and 45-54 years) and tumor stage at diagnosis (early-stage and late-stage), and compared the annual percentage change (APC) and the average APC between the two groups. They also assessed trends for the entire cohort of patients aged 20-54 years. 

In the NCHS database, there were 147,026 deaths in total across all ages studied resulting from EO-CRC, of which 27% (39,746) occurred in those 20-44 years of age. Although associated mortality rates decreased between 2000-2005 in all ages studied (APC = -1.56), they increased from 2005-2022 (APC = 0.87). 

In the cohort aged 45-54 years, mortality decreased between 2000-2005 and increased thereafter, whereas in the cohort aged 20-44 years mortality increased steadily for the entire follow-up duration of 2000 to 2022 (APC = 0.93). A comparison of the age cohorts confirmed that those aged 20-44 years had a greater increase in mortality (average APC = 0.85; P

In the SEER 22 database, there were 4652 deaths in those with early-stage tumors across all age groups studied (average APC = 12.17). Mortality increased in patients aged 45-54 years (average APC = 11.52) with early-stage tumors, but there were insufficient numbers in those aged 20-44 years to determine this outcome. 

There were 42,120 deaths in those with late-stage tumors across all age groups (average APC = 10.05) in the SEER 22 database. And increased mortality was observed in those with late-stage tumors in both age cohorts: 45-54 years (average APC= 9.58) and 20-44 years (average APC = 11.06).

“When evaluating the SEER database and stratifying the tumors by stage at diagnosis, we demonstrated increasing mortality of early-onset colorectal cancer in both early- and late-stage tumors on average over the study period,” Abboud told Medscape Medical News. 

Identifying At-Risk Patients

Commenting for Medscape Medical News, David A. Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine in Norfolk, said the findings speak to the need for evidence-based means of identifying younger individuals at a higher risk of EO-CRC.

“I suspect many of younger patients with CRC had their cancer detected when it was more advanced due to delayed presentation and diagnostic testing,” said Johnson, who was not involved in the study. 

But it would be interesting to evaluate if the cancers in the cohort aged 20-44 years were more aggressive biologically or if these patients were dismissive of early signs or symptoms, he said. 

Younger patients may dismiss “alarm” features that indicate CRC testing, said Johnson. “In particular, overt bleeding and iron deficiency need a focused evaluation in these younger cohorts.”

“Future research is needed to investigate the role of neoadjuvant chemotherapy in younger patients with early-stage colorectal cancer and evaluate patients’ outcomes,” Abboud added. 

The study had no specific funding. Abboud reported no relevant financial relationships. Johnson reported serving as an advisor to ISOTHRIVE. He is also on the Medscape Gastroenterology editorial board. 

John Watson is a freelance writer in Philadelphia.