Rising colorectal cancer in young adults: A warning for all! Let us adopt a healthy lifestyle and colorectal cancer screening : Indian Journal of Cancer

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Rising colorectal cancer in young adults

A warning for all! Let us adopt a healthy lifestyle and colorectal cancer screening

Patel, Amol; Hande, Vivek

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Indian Journal of Cancer 59(3):p 307-309, Jul–Sep 2022. | DOI: 10.4103/ijc.ijc_948_22
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Colorectal cancer (CRC) is one of the most common malignancies across the world. It is the fourth most common cancer among men in India as per the Global Cancer Observatory (GLOBOCAN) data 2020.[1] There is a consistent rise in the incidence of colon cancer across all Indian cancer registries, ranging from 20% to 124% per year.[2] Though the overall estimated numbers are low, for a population of over 1.3 billion, the absolute numbers are alarming. To add to this, the median age across multiple series is 50 years, which is less as compared to the western patient population.[3456] A large database from a tertiary care hospital from southern India showed that rectum (42%) was the most common site, followed by rectosigmoid (21%), colon (20%), and anorectum (13%).[3] Majority of these cases present in advanced stages, further making the outcomes worse. This combination of delayed presentation and poor prognosis is not acceptable in a cancer which is largely preventable and has established and effective screening methods. CRCs have high cure rates if diagnosed and treated in early stages. In the USA, due to the adoption of screening, the incidence and mortality is reduced in elderly population. However, a worrisome epidemiological change is witnessed. Incidence of colon cancer among the younger population (age <50 years) has increased by 63% from 1988 to 2015 in the USA,[7] and there has been a parallel increase in mortality in this age group.

Rising incidence is largely due to change in diet patterns (western diet: enriched in red meat, processed sugars, refined grains, high sugar containing drinks), lack of physical exercises, obesity, and smoking. Hereditary non-polyposis colon cancer (Lynch syndrome) contributes to <5% in the western world. Its prevalence in India is 10%–15%, higher than the western world. These figures are based on smaller studies and may not be a true representation.[8] Literature on rare hereditary CRCs like familial adenomatous polyposis, MUTYH-associated polyposis, juvenile polyposis, Cowden syndrome, Li–Fraumeni syndrome, and Peutz–Jeghers syndrome is limited. Multi-institutional collaborative work is needed to look for the genetic link in the Indian population. The relative risk of colon cancer for overweight (body mass index [BMI] 25–29.9) individuals is 1.2–1.5 and for obese (BMI >30) individuals, it is 1.5–1.8 as per experts from the International Agency for Research on Cancer.[9] The World Cancer Research Fund/American Institute of Cancer Research has laid down recommendations for reducing cancer incidence.[10] Adherence to these recommendations had led to a 30% reduction in CRC in the European population.[11] Alcohol consumption of more than 30 g/d is another risk factor for CRC. Early age of initiation and consumption of large quantities of alcohol are characteristics found in growing Indian alcohol consumers.[12] Data on the risk factors of rectal cancer is not robust. With this societal change in adopting food habits and lifestyle patterns of the western world, incidence of CRC is going to increase in India. We feel that health awareness and screening are the best approaches to reduce the burden of this disease.

Health education and awareness: A study was conducted in medical students and interns on the awareness of colon cancer and its prevention. Only 35% of participants had information on colon cancer prevention and how to control it.[13] If this is the situation among medicos, the level of awareness among the general population would be further low. Symptoms of CRC are shared by other benign conditions like hemorrhoids, fissure in ano, inflammatory bowel disease, and irritable bowel disease. Lack of knowledge of colon cancer leads to further delay in diagnosis and initiation of treatment. Advertising on television is presently only focused on oral and lung cancer. Basic information on colon cancer will certainly help in educating the masses on adopting healthy lifestyles and the screening methods.

Screening methods: Almost all CRCs develop from adenoma–carcinoma sequence. Screening with colonoscopy is an attractive strategy for early detection of colon cancer, wherein the polyps are removed, which otherwise take 10–15 years to develop into carcinoma.[14] Polyps can be adenomatous, hyperplastic, and inflammatory or hamartomatous. Not all adenomas develop into cancer. Adenomatous polyps of >10 mm are at the highest risk for cancer transformation. Colonoscopy is a safe and well-established method of colon screening. It has proven survival benefits; however, it remains underutilized even in western population. Screening with flexible sigmoidoscopy also reduces the incidence of colon cancer and reduces mortality.[151617] In a retrospective analysis from South India, 246 patients underwent screening by colonoscopy and 12.19% were diagnosed with polyps. In the age group of 40–50 years, 8.7% of patients had adenomas and one in six people aged >40 years had a polyp.[18]

Guaiac-based fecal occult blood test (FOBT) is a low-cost, easily available screening test which has been extensively studied and proved to be beneficial in reducing CRC mortality (16% reduction in relative risk).[19] The low sensitivity and false-positive results are a major challenge. Fecal immunochemical test (FIT) detects the human globin and has better sensitivity than guaiac-based test. It has advantage of one-time testing and requires no dietary restrictions, unlike FOBT.[20] FIT has limited availability and its higher cost makes it an underutilized method of colon cancer screening in India.

Computed tomography (CT) colonography is an emerging noninvasive alternative to colonoscopy with a sensitivity and specificity of >90% for detection of polyps >10 mm.[20] Radiation exposure data is not available, and colonoscopy is needed for polyp removal post-detection. Multiple screening tests like multitarget stool DNA test, FIT-DNA tests, and blood-based SEPT9 DNA test (US Food and Drug Administration [US FDA] approved in 2016) are not available in India. There is an immense opportunity to develop a cost-effective, logistically feasible blood-based test for colon cancer screening in India.

There are no formal screening guidelines on CRC in India. Indian Council of Medical Research, Indian Society of Medical and Pediatric Oncology, and Indian Cancer Society may come forward and formulate the guidelines which would certainly help the Indian community. There is also a need for a mass campaign to raise awareness on the rising incidence of colon cancer in younger people. Reducing the risk factors and adoption of a healthy lifestyle will reduce the cancer burden and safeguard our working force. Though the access to treatment is improving, there are still many miles to reach to the grassroot level in India. Awareness of the rising incidence of CRC must be a national agenda.

In the end, as we follow the western pattern of diet and adopt a similar lifestyle, the expected burden of CRC in the coming three decades is huge. The impact would affect the present younger generation, who are not aware of this trend of rise in CRC which typically affects them. Along with adopting a healthy lifestyle, yearly FOBT and 10-yearly screening with colonoscopy or sigmoidoscopy should be considered, starting at the age of 40 years, in India by average-risk individuals. The shared symptoms with other benign conditions warrant use of best medical practices inclusive of comprehensive history taking, with a special attention to persistent rectal bleeding, a thorough clinical examination, and timely referral to specialist for evaluation and colonoscopy.

Time to screen, colon cancer is preventable!


1. WHO GLOBOCAN. 2020 India fact sheets. Available from: https://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf. [Last accessed on 2022 Aug 12].
2. Mathew Thomas V, Baby B, Wang K, Lei F, Chen Q, Huang B, et al Trends in colorectal cancer incidence in India JCO. 2020;38(15 Suppl):e16084
3. Patil PS, Saklani A, Gambhire P, Mehta S, Engineer R, De'Souza A, et al Colorectal cancer in India: An audit from a tertiary center in a low prevalence area Indian J Surg Oncol. 2017;8:484–90
4. Noronha J, deSouza A, Patil P, Mehta S, Engineer R, Ostwal V, et al Management of colon cancer at a tertiary referral center in India - Patterns of presentation, treatment, and survival outcomes Indian J Cancer. 2019;56:297–301
5. Sud R, Viswanath S, Mujeeb V, Jaiswal P, Gupta S. Is the disease profile in metastatic colorectal cancer still driven by the mutational parameters as before? A tertiary care center study from India in 2020 Clin Cancer Investig J. 2021;10:142–7
6. Deo SVS, Kumar S, Bhoriwal S, Shukla NK, Sharma A, Thulkar S, et al Colorectal cancers in low- and middle-income countries—demographic pattern and clinical profile of 970 patients treated at a tertiary care cancer center in India JCO Global Oncol. 2021:1110–5
7. Sinicrope FA. Increasing incidence of early-onset colorectal cancer N Engl J Med. 2022;386:1547–58
8. Maharaj R, Shukla PJ, Sakpal SV, Naraynsingh V, Dan D, Hariharan S. The impact of hereditary colorectal cancer on the Indian population Indian J Cancer. 2014;51:538.
9. Lauby-Secretan B, Scoccianti C, Loomis D, Grosse Y, Bianchini F, Straif K. Body fatness and cancer — viewpoint of the IARC working group N Engl J Med. 2016;375:794–8
10. World Cancer Research Fund/American Institute for Cancer Research. . Continuous Update Project Expert Report 2018 Diet, nutrition, physical activity and colorectal cancer. Available from: dietandcancerreport.org.
11. Turati F, Bravi F, Di Maso M, Bosetti C, Polesel J, Serraino D, et al Adherence to the World Cancer Research Fund/American Institute for Cancer Research recommendations and colorectal cancer risk Eur J Cancer. 2017;85:86–94
12. Prasad R. Alcohol use on the rise in India Lancet. 2009;373:17–8
13. Kulkarni V, Darshan BB, Unnikrishnan B, Cheng KC, Hui GC, Theng AY, et al Colorectal cancer: How familiar are our future doctors with the cancer of tomorrow? Biomed Res Int. 2018;2018:e7462101.
14. Helsingen LM, Kalager M. Colorectal cancer screening — approach, evidence, and future directions NEJM Evidence. 2022;1:EVIDra2100035
15. Lin OS, Kozarek RA, Cha JM. Impact of sigmoidoscopy and colonoscopy on colorectal cancer incidence and mortality: An evidence-based review of published prospective and retrospective studies Intestinal Res. 2014;12:268–74
16. Holme Ø, Løberg M, Kalager M, Bretthauer M, Hernán MA, Aas E, et al Effect of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality: A randomized clinical trial JAMA. 2014;312:606–15
17. Schoen RE, Pinsky PF, Weissfeld JL, Yokochi LA, Church T, Laiyemo AO, et al Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy N Engl J Med. 2012;366:2345–57
18. Jayadevan R S AT, Sabu S, Venugopalan RP. Prevalence of colorectal polyps: A retrospective study to determine the cut-off age for screening J Gastroenterol Pancreatol Liver Disord. 2016:31–5
19. Hewitson P, Glasziou P, Watson E, Towler B, Irwig L. Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): An update Am J Gastroenterol. 2008;103:1541–9
20. Provenzale D, Gupta S, Ahnen DJ, Markowitz AJ, Chung DC, Mayer RJ, et al NCCN guidelines insights: Colorectal cancer screening, version 1.2018 J Natl Compr Cancer Netw. 2018;16:939–49
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