In general terms, before the age of 50, people do not perceive themselves to be at risk of developing colon or rectal cancer. But early-onset colorectal cancer (CRC) (that is, before that age) is increasingly common. And for the first time a study carried out in the country showed that in the last 25 years
mortality rates in young adults
in Argentina increased.
This is the first report on this topic in Latin America that, added to others from the United States, Canada, Europe, China and Australia, "allows us to definitively conclude that the increase in early-onset CRC
is a global phenomenon
," highlights Marina Antelo, physician. gastroenterologist, researcher at Conicet, with an executing unit at the ISCo of UNLa, and field work in the Oncology Section of the Udaondo Gastroenterology Hospital.
As a result of this situation, in 2021, the United States Preventive Services Task Force lowered
the recommended age to begin colorectal cancer screening in the general population
from 50 to 45 years .
Is it time to do the same in Argentina? For Antelo - who spoke with
Clarín
on the eve of
Colon Cancer Day
, which is commemorated on March 31 -, it should be discussed.
Meanwhile, he emphasized "the urgent need to educate the general population and the medical community about the warning symptoms of CRC and the importance of knowing the
family history of cancer, in order to identify people under 50 years of age who
should be studied before the age
indicated by our guidelines.
Colorectal cancer in young people
Mortality rates from colorectal cancer between 1997 and 2020 in people between 20 and 54 years old
increased constantly
and experienced a percentage variation of 25%, warn the results of the work presented at the last Argentine Congress of Gastroenterology and Digestive Endoscopy in Mar del Silver 2023.
"When we analyze the global mortality rates of CRC in the last 24 years, including men and women, we are talking about 16 deaths per 100 thousand inhabitants. But when broken down by age groups, that rate changes a lot," commented Antelo, regarding the work he led, in which Mariano Golubicki collaborated, and which is his Master's thesis in Management, Epidemiology and Health Policies at the ISCo, directed by Marcio Alazraqui.
"In those under 54 years of age, we went from 3.16 deaths per 100 thousand inhabitants in 1997 to 3.95," said the researcher.
When evaluating data by decade and by sex, the greatest increase in colorectal cancer mortality rates was observed
between ages 30 and 39
. And it was greater in women than in men (the percentage variation was 75% and 63%, respectively).
Among the largest, at least when talking about rates, the data was more encouraging. In individuals aged 55 to 74 years (who are covered by the screening recommendation) a very slight decrease in mortality rates was observed, close to 2%. In those over 75,
a more pronounced reduction of 17%
was observed .
A hasty reading of these data would lead one to be too pessimistic with the current situation of early-onset cancer and more optimistic in relation to the elderly. But it would be wrong, or not entirely correct.
"When comparing the mortality rates, even though they increased in young people,
in those over 50 or 54 they are still very high
. While in those under that age we speak of between 3 and 4 deaths per 100 thousand inhabitants, at 55 There are 46; and in those over 75, from 128 to 154 deaths," Antelo said.
"One way to analyze the impact that a disease has on the population is to see the deaths it generates and also how that evolved over time: just because it has decreased in older people does not mean that it is already there. We still have a lot of work to do because
it continues "Many people are dying from preventable cancer
. The fact that it has increased in young people does not mean that we should only focus on them, because the numbers are still very low," he added.
Should the age at which controls begin be lowered?
This question also does not allow a simple answer. In 2022, the National CRC Prevention and Early Detection Program of the National Cancer Institute published a clinical practice guideline in which it suggested
not lowering the age of initiation
of controls to 45 years in an average-risk population (that is, without a history , nor symptoms).
Antelo - who was a reviewer of this guide - believes that "the ideal age to start CRC screening in our country must be discussed again." However, he admits that it is a "very complex" debate, because "it would require many more resources, cost-effectiveness and access studies, it would generate more disparity and it
would also leave out all those under 45 years of age
, who are those who are saw the biggest increases."
With symptoms, there is no need to wait. Photo Shutterstock.
Despite this, the increase in mortality rates in young people (which are most likely correlated with an increase in incidence) "underscores the urgent need to detect the disease in early stages."
The objective, he maintains, should be set on "generating more cost-effective personalized strategies to identify those under 50 who should be studied before the age indicated by our guidelines."
Colon cancer: prevent and detect
Colorectal cancer is one of the easiest to prevent: it is estimated that 9 out of 10 could be avoided, because in most cases it is preceded by a precursor lesion (the adenomatous polyp) that, detected and removed in time (at through tests such as colonoscopy), it does not become a tumor.
Even if it has progressed to cancer, detected at an early stage, the chances of cure are greater than 90%, and the treatments are less invasive.
The problem is that young people have no indication to undergo controls, unless they have a family history, hereditary syndromes or present symptoms. Therefore, according to specialists, the emphasis should be placed on these key factors.
Family background
"One in four young people with CRC had a family history of colorectal cancer or high-risk adenoma that would have indicated the need for a colonoscopy before the age at which they developed the cancer. Thus, that cancer would probably have been prevented or would not have died from that cause," Antelo said.
"We must know
how to question and advise
patients better. People who undergo colonoscopies and polyps or tumors are detected, we must inform them in such a way that it is clear that this information must reach first-degree relatives (children and siblings)" , he emphasized.
In these cases, it is advised that they begin to be
monitored 10 years before
the age at which the family member received the diagnosis (for example: if the father became ill at 40, the son should begin to be monitored at 30), the doctor
explained
Clarín
. gastroenterologist at the German Hospital Lisandro Pereyra, one of the creators of the ChequeáTuColon tool (in which individual risk can be calculated online).
People with hereditary syndromes associated with a high risk of colorectal cancer should also be studied first.
"The study of this syndrome is recommended to begin with the person who had cancer in the family and it is detected by a blood test, which is a genetic test. Once the syndrome is identified,
healthy relatives are checked 'in cascade
' and those Carriers begin their colonoscopy controls at very early ages (around 20-25 years old)", explains Luisina Bruno, head of Oncogenetics and member of the Digestive Area of the Alexander Fleming Institute (IAF).
Red flag symptoms
"The United States lowered the age to 45 years, but cancer can also occur earlier. The person may be young, but if they have symptoms or history they must be evaluated," said Pereyra.
And he stressed: "Although the age of onset is not lowered in countries like ours and many others, it is key to be attentive to trying to improve the detection of early symptoms in those who already have them. The message is: everyone come to 50, but anyone who has the slightest symptom
has to consult at any age
, there is no need to wait," he stressed.
The list of symptoms includes: changes in evacuation habits (going from constipation to diarrhea or vice versa), proctorrhagia (bleeding from the tail), blood mixed with fecal matter, prolonged belly pain without improvement with treatment, anemia (low red blood cells), lack of appetite, pale or yellowing of the skin and mucous membranes, weight loss without apparent cause, diarrhea lasting more than a month, extreme fatigue.
"The red flag symptoms that have the greatest positive predictive value are
proctorrhagia and iron deficiency anemia
," said Antelo.
"Obviously," he added, "we cannot perform a colonoscopy on every individual who has abdominal pain, because we would have to perform a colonoscopy on many people. Yes, for now, those who have proctorrhagia or iron deficiency anemia have an indication for a colonoscopy, even if they are young and not have a family history."
Meanwhile, "those who have diarrhea or abdominal pain that does not improve with treatment and adequate nutrition and/or in case of weight loss without apparent explanation, an endoscopic study should also be considered."
Why is colon cancer increasing in young people?
"If we look at the incidence and mortality curves, for example in the United States, we can clearly see differences in groups disaggregated by age. In the group of people over 50 years of age, incidence and mortality are decreasing. The inverse relationship is can be seen in people under 50 years of age, who are considered young adults, in whom the incidence and mortality show an
increasing trend
," said Juan Manuel O'Connor, head of the Gastrointestinal Tumors area at the IAF.
"It is estimated that between 30 and 40% of cancer cases in young people have a first-degree family history of CRC, or high-risk adenomas, or hereditary syndromes, but
more than half of the cases have nothing that justifies
that this tumor has appeared," said Antelo.
"There are a lot of hypotheses,"
he said, "and they are related to changes in lifestyle from early childhood, with alteration of the microbiota and with chronic inflammation at much earlier ages that cause cancer instead of appearing at ages. 65, appear at 45".
"Only now are important studies or analyzes of cohorts beginning to come out that associate it with increased antibiotic use during childhood and adolescence, as well as greater consumption at an early age of ultra-processed foods and increased alcohol consumption in young people." ", he exemplified.
"Cohort studies conducted mainly in the United States found that those born since 1990 have twice the risk of developing colon cancer and four times the risk of developing rectal cancer compared to those born, for example, in 1960. It is a disease in which
we must all be very alert
," concluded Antelo.
***
🡆
Agenda
.
On Thursday, April 4, from 11 a.m. to 7 p.m., LALCEC, in collaboration with Merck, will install a giant inflatable colon in the Plaza Dr. Bernardo Houssay in the City of Buenos Aires (2100 Córdoba Avenue). You can tour the interior of the facility for free and LALCEC staff will share information about the importance of prevention and early detection of CRC.
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