Early-onset colorectal cancer: should population screening be brought forward to 45 years of age, by when?

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"apellidos" => "Sebastián Domingo" "email" => array:1 [ 0 => "jjsebastian@salud.aragon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Aparato Digestivo, Hospital Universitario Royo Villanova, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cáncer colorrectal de aparición temprana. ¿Hay que adelantar el cribado poblacional a los 45 años?, ¿para cuándo?" ] ] "textoCompleto" => "Early-onset colorectal cancer: should screening in the population be brought forward to the age of 45 years, and by when?In Spain, population-based screening (PS) for colorectal cancer (CRC) is recommended for people aged 50 or over, with no personal or family history of adenomas or CRC.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>In the European Union, screening for colorectal cancer using the faecal occult blood testing (FOBT) is recommended every two years for the population between 50 and 74 years of age, while in Spain the target population is between 50 and 69 years of age.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>It is likely that the recommendation that CRC PS should be started before the age of 50 will change in the near future, as is beginning to happen in other countries.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Early-onset colorectal cancer (EOCRC), as opposed to late-onset CRC (LOCRC), is defined as cancer that is diagnosed before the age of 50 years,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> which is the current age of onset in most PS programmes, such as in our country.Based on current data, it is estimated that, over the next decade, 1 in 4 rectal cancers and 1 in 10 colon cancers will be diagnosed in people under the age of 50.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Overall, the incidence of EOCRC has increased by 51% from the mid-1990s to the present day, especially for rectal cancer, while the incidence of LOCRC has been falling in recent years.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Currently, approximately 10% of new CRC diagnoses are made in people under the age of 50 and three out of four patients with EOCRC have no family history of the disease.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>According to the CRC Observatory of the Spanish Association Against Cancer (AECC), 40,203 new cases were diagnosed in Spain in 2023, of which 1,089 (2.7%) were in the 45–49 age group, compared to 5,426 (13.5%) in the 50–59 age group and 10,311 (25.6%) in the 60–69 age group. The percentage of CRC detected before the age of 50 remained at around 3% during the year.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a>Is EOCRC the same as LOCRC, but with an early onset? Apparently not, as they have different clinicopathological features and a different prognosis.In terms of location, it appears mainly in the rectum in 25–50% of cases, compared to 20% in LOCRC; it is usually diagnosed in the symptomatic phase, manifesting itself in the form of rectal bleeding, iron deficiency anaemia or unexplained weight loss, which are diagnosed later and in more advanced stages, with a higher rate of lymph node and distant metastases, despite which survival rates are usually higher. Histologically, these tumours are more aggressive than LOCRC, are more often poorly differentiated and, although the vast majority are sporadic, up to a quarter of cases are associated with some hereditary syndromes that predispose to cancer.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6,10–12</a>The earliest possible evaluation of symptoms suggestive of organicity, even in patients under 50 years of age, without underestimating them simply because they are young, is of paramount importance, and GPs should be informed and made aware of this, giving them priority in endoscopy units.To all this must be added the psychosocial and occupational impact of this entity on patients who are young and, theoretically, should still have a long life ahead of them, but with a poor quality of life due to the treatments and tests they will be subjected to.A variable percentage of cases, between 6.3% and 30.4% depending on the study, have a family history of CRC and would therefore in some cases be eligible for screening, which would allow early detection and/or prevention of the tumour.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>It is unclear what factors may be contributing to the upward trend in this type of tumour. Environmental and lifestyle factors such as diet (red meat and processed foods), smoking and alcohol consumption alone do not explain the observed trends. Possible risk factors include obesity, sedentary lifestyle, hyperlipidaemia, male sex, Caucasian race, infections, antibiotics and changes in the gut microbiome.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>On the other hand, protective factors should be emphasised in the prevention of EOCRC. In this respect, it is recommended to reduce the consumption of red meat, processed meat and meat that has been overcooked or exposed to direct fire, and to follow a low-fat diet to avoid obesity. A diet rich in fibre (wholegrain, wholemeal products), fruit and vegetables, fish and poultry, and milk and other dairy products is also recommended.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Without going into further detail about EOCRC, it seems clear that we need to get ahead of the curve by improving our understanding of best clinical practice for detecting and managing CRC in young adults, as has been done in the US for some time.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Given that approximately 25% of all patients with EOCRC have a family history of CRC,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> it will be important to intensify and improve the identification of familial CRC by correctly documenting the family history of our CRC patients, insisting on knowing the exact age of onset of the tumour in the index case and, if applicable, the number and family lineage of other cases that have occurred in the family. It is strongly recommended that a family tree be established to obtain a more precise idea of the incidence of CRC in each family and that the direct relatives of those affected be referred for high-risk and genetic counselling to investigate the possibility of the presence of a hereditary genetic mutation. Once this has been done, follow-up colonoscopy intervals to detect possible adenomas should be strictly adhered to.Predictably, a good approach to EOCRC is to extend population screening from age 45 years, supported by studies such as that of Kolb et al.,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> which concluded that the CRC rate in individuals aged 45–49 years was similar to that observed in those aged 50–59 years, suggesting that extending screening to this younger population could have a similar impact on reducing the risk of colorectal cancer; however, this is a complex issue with additional considerations that need to be addressed.Mathematical-statistical simulation models used in the US to predict the optimal age for starting and completing screening show that the benefits of PS from age 45 outweigh the risks and costs. These models recommend a colonoscopy every 10 years, an annual faecal occult blood test (FOBT), a proctosigmoidoscopy every five years or a CT-colonoscopy every five years, from age 45–75 years.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Taking into account the new evidence, some of which has been referred to in this editorial, we should consider whether it is feasible in our country (and other European countries where screening is systematic and supported by public health systems, with limited resources and oversaturated endoscopy units) to lower the starting age of population screening and to cope with the demand for colonoscopies that would eventually be generated, in a context in which population screening between 50 and 69 years of age can hardly be assumed, and having to adapt to our limited endoscopic capacity, as stated by Dr. Puente Gutiérrez, from the Hospital de Andújar (Jaén)19 and any of us who work in a Spanish public health system involved in CRC PS.According to estimates by the CRC Working Group of the Andalusian Society of Gastrointestinal Pathology, lowering the starting age for screening to 45 years would mean an increase in this need of up to 30% of the eligible population,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> which makes it very difficult to address in our setting.Despite all this, when attempts have been made to bring together and contrast all the evidence for and against bringing forward population screening to age 45, the prevailing view seems to be that early screening would save lives, and starting at age 45 may be a sound option.Last but not least, there is the challenge of community participation in screening programmes, which should be as high as possible to achieve significant reductions in CRC incidence and mortality. Unfortunately, participation generally leaves much to be desired. For example, in Aragon, the Autonomous Community where I work, more than 60% of the population invited for screening do not show up for the initial consultation, which means that opportunities are lost to diagnose polyps and colorectal cancer in the asymptomatic phase, in the very early stages, when the survival rate is around 100%, a figure that can drop to half when the disease is more advanced and symptomatic.According to the study on CRC screening programmes in 2023 by the Spanish Association Against Cancer,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> among people who did not have a FOBT, the reasons were: lack of symptoms or not being in good health (39.6%), not having received the official invitation to participate in the screening programme (39.9%), forgetfulness or laziness (28.6%), barriers related to the desire to stay away from medical centres in the context of a pandemic (24.9%), and perceived saturation of the health care system (22.1%).In this regard, health authorities, both regional and national, should launch more information and awareness campaigns to encourage the screened population to participate in this programme, which still has much to be done and implemented.To conclude this editorial, as we are in the midst of the artificial intelligence frenzy, and out of curiosity, this is what one of the most advanced chatbots (GPT-4) answers when asked on the subject:Bringing forward population-based colorectal cancer screening to age 45 in Spain could be a critical intervention because:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1Increasing incidence in young people: In recent years there has been an increase in the incidence of colon cancer in people under the age of 50. Earlier screening at 45 years of age would allow early detection of the disease in this at-risk population.</li><li class="elsevierStyleListItem" id="lsti0010">2Improved survival rates: Early detection of colon cancer is associated with higher survival rates. Earlier screening could mean earlier diagnosis and therefore better outcomes for patients.</li><li class="elsevierStyleListItem" id="lsti0015">3Long-term cost savings: Detecting colon cancer at earlier stages can not only save lives but can also reduce the costs associated with more aggressive treatments at later stages of the disease.</li><li class="elsevierStyleListItem" id="lsti0020">4Public health benefits: Implementing earlier population screening could have a positive impact on public health by reducing the burden of disease and improving the quality of life of the population.</li></ul>For these reasons, bringing forward the age of screening for colorectal cancer in Spain to 45 years could be an effective and beneficial preventive measure for the health of the population".Ethical considerationsNo patient data appear in the article and no patient records have been consulted.FundingThe manuscript has not received any funding.Conflict of interestThere is no conflict of interest." 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