Early Onset Colorectal Cancer: Trends, Treatment, and Fertility Preservation

Rising Incidence of Early Onset Colorectal Cancer (EOCRC)

• 📈 Colorectal cancer (CRC) is the third leading cause of cancer death, and while overall incidence is declining, early onset colorectal cancer (EOCRC) in patients under 50 is increasing globally.
• ⚠️ The ideology behind this rise is unknown, but potential factors include diet, alcohol, obesity, gut microbiome, activity levels, and environmental influences.
• 🎯 EOCRC predominantly manifests as left-sided or rectal tumors, often presenting at advanced stages, partly due to delayed diagnosis in those not meeting current screening criteria.

Screening Recommendations and Diagnostic Modalities

• 📅 The US Preventive Services Task Force (USPSTF) and American Cancer Society recommend colorectal cancer screening starting at age 45 for average-risk individuals.
• 🩺 Screening methods include direct visualization (colonoscopy, sigmoidoscopy, CT colonography) and stool-based tests (FIT-DNA/ColoGuard), with colonoscopy being the gold standard for detecting both cancers and adenomas.
• 🧬 Patients with a family history of CRC or personal history of IBD, FAP, or Lynch syndrome require earlier and more frequent screening.

Treatment Approaches for EOCRC

• 🏥 Treatment for EOCRC involves a multidisciplinary team approach, including medical oncologists, radiation oncologists, and colorectal surgeons.
• 💡 For locally advanced rectal cancer, total neoadjuvant therapy (TNT), involving chemotherapy and chemoradiation before surgery, is becoming standard, aiming to improve response and organ preservation.
• 🔬 The OPRA study demonstrated the safety and efficacy of a watch-and-wait approach after TNT for patients achieving a clinical complete response, allowing for rectum preservation.
• 🧬 Mismatch repair (MMR) deficient tumors show remarkable response to immunotherapy, with studies showing high rates of clinical complete response, potentially omitting chemotherapy, chemoradiation, and surgery.

Genetic Factors and Disparities

• 🧬 A higher prevalence of MMR-deficient tumors is observed in younger patients, often linked to hereditary predisposition syndromes like Lynch syndrome.
• 🌍 Minority populations, including Black, Hispanic/Latino, American Indian, and Alaskan Natives, face higher risks for CRC development and mortality, often due to disparities in care, access to healthcare, and socioeconomic status.
• 🏘️ Geographic disparities exist within the US, with higher incidence rates noted in regions like Appalachia, the southern US, and the Midwest.

Fertility Preservation and Survivorship

• 🤰 Young patients, especially women, face significant concerns regarding fertility and sexual health due to cancer treatments like pelvic radiation and chemotherapy.
• 🥚 Fertility preservation options include gamete/embryo cryopreservation, hormone suppression, ovarian transposition, and uterine transposition, though access and cost remain barriers.
• 🤝 Establishing young onset centers is crucial for providing comprehensive, multidisciplinary care, including psychosocial support, genetic counseling, and coordinated survivorship services.
• 🌟 Creating a community for young CRC patients through conferences and support groups empowers them and reduces feelings of isolation.