Research Original Investigation
US Age-Related Incidence of Colon and Rectal Cancers
4. Pignone M, Rich M, Teutsch SM, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2002;137(2):132-141.
cancers are increasing in young adults. Am Surg. 2003;69(10):866-872.
5. US Preventive Services Task Force. Screening for colorectal cancer: recommendation and rationale. Ann Intern Med. 2002;137(2):129-131.
11. Johnson RH, Chien FL, Bleyer A. Incidence of breast cancer with distant involvement among women in the United States, 1976 to 2009. JAMA. 2013;309(8):800-805.
6. Stryker SJ, Wolff BG, Culp CE, Libbe SD, Ilstrup DM, MacCarty RL. Natural history of untreated colonic polyps. Gastroenterology. 1987;93(5): 1009-1013. 7. Winawer SJ, Zauber AG, Ho MN, et al; The National Polyp Study Workgroup. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med. 1993;329(27):1977-1981. 8. Siegel RL, Jemal A, Ward EM. Increase in incidence of colorectal cancer among young men and women in the United States. Cancer Epidemiol Biomarkers Prev. 2009;18(6):1695-1698. 9. O’Connell JB, Maggard MA, Liu JH, Etzioni DA, Livingston EH, Ko CY. Rates of colon and rectal
10. You YN, Xing Y, Feig BW, Chang GJ, Cormier JN. Young-onset colorectal cancer: is it time to pay attention? Arch Intern Med. 2012;172(3):287-289.
12. Citations for SEER databases and SEER*Stat Software. Surveillance, Epidemiology, and End Results Program website. http://www.seer.cancer.gov /data/citation.html). Accessed July 11, 2013. 13. Aleksandrova K, Pischon T, Buijsse B, et al. Adult weight change and risk of colorectal cancer in the European Prospective Investigation into Cancer and Nutrition. Eur J Cancer. 2013;49(16):3526-3536.
15. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004;291(23): 2847-2850. 16. Slattery ML, Edwards S, Curtin K, et al. Physical activity and colorectal cancer. Am J Epidemiol. 2003;158(3):214-224. 17. Thune I, Lund E. Physical activity and risk of colorectal cancer in men and women. Br J Cancer. 1996;73(9):1134-1140. 18. Slattery ML, Boucher KM, Caan BJ, Potter JD, Ma KN. Eating patterns and risk of colon cancer. Am J Epidemiol. 1998;148(1):4-16.
14. Bassett JK, Severi G, English DR, et al. Body size, weight change, and risk of colon cancer. Cancer Epidemiol Biomarkers Prev. 2010;19(11): 2978-2986.
Invited Commentary
Screening Young Adults for Nonhereditary Colorectal Cancer Kiran K. Turaga, MD, MPH
The public health burden of colorectal cancer is a significant challenge, with more than 50 000 deaths annually in the United States. Widespread adoption of the US Preventative Task Force Guidelines for mandatory screening for colon cancer, along with improvement in access to advanced fiber optic techRelated article page 17 nology and training of physicians, among other factors, are some of the reasons why the overall incidence of colorectal cancer has been decreasing in the United States and in other developed nations. Randomized trials and epidemiological studies have demonstrated significant decreases in the incidence and mortality from colorectal cancer with the use of colonoscopy (and flexible sigmoidoscopy), with the reduction of risk persistent even at 15 years after a negative colonoscopy finding.1,2 In the setting of these congratulatory reports of a successful public health screening program, this report from Bailey et al3 is rather unsettling. The authors examined the incidence of colorectal cancer in 9 Surveillance, Epidemiology, and End Results registries from 1975 to 2010 and describe a rather alarming trend of an increase in the incidences of colon and rectal cancers in young adults, especially in the 20- to-34-yearold age group. This incidence was pervasive regardless of stage of disease, although not as dramatic in patients aged 35 to 49 years. Their data suggest an overall decrease in the ageadjusted incidence of colorectal cancer, which could be attributed predominantly to the decrease in the incidence of all stages of cancer in the older population, although limitations in the use of all the registries could contribute to lack of generalizability.3 22
Temporal trends in incidence are rather difficult for clinicians to interpret given the changing technology and understanding/detection of disease. While it is possible that this increase in the incidence of cancer in young adults could be owing to increased detection from frequent use of colonoscopies in symptomatic young adults or to sophisticated pathological techniques/imaging, the simultaneous temporal decrease in the incidence of cancer in those older than 50 years is intriguing. One might argue that perhaps the risk reduction (or decrease in incidence) in this age group would have been higher had these temporal trends not been a factor. Nevertheless, assuming that this increasing incidence of colorectal cancer in young adults is a real phenomenon, it begs the question of why this is occurring and what one should do about it. The authors suggested the Western diet and lifestyle might be some of the contributing factors for this trend. Tumors occurring in younger patients are frequently different in their expression of microsatellite instability, BRAF, KRAS, or in the CpG island methylator phenotype and are more frequently mucinous and aggressive.2 Further epidemiological investigation into causality is critical to reduction in the nonhereditary cancer incidence in younger adults. While it is attractive to suggest that all adults should obtain a colonoscopy, especially given the possible durability of cancer risk reduction, it is important to note that the absolute incidence of colorectal cancer in the young adults (aged 20-34 years) is 1% of the total colorectal cancer burden and similarly fairly low in the 35- to 49-year-old age group (6.8%). Hence,
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US Age-Related Incidence of Colon and Rectal Cancers
Original Investigation Research
widespread application of colonoscopic screening might add significant cost and risk without societal benefit. However, this report should stimulate opportunities for development of better risk-prediction tools that might help us identify these ARTICLE INFORMATION Author Affiliation: Medical College of Wisconsin, Surgery, Milwaukee. Corresponding Author: Kiran K. Turaga, MD, MPH, Medical College of Wisconsin, Surgery, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (kturaga @mcw.edu). Published Online: November 5, 2014. doi:10.1001/jamasurg.2014.1765.
jamasurgery.com
individuals early and initiate better screening/prevention strategies. The use of stool DNA, genomic profiling, and mathematical modeling might all be tools in the armamentarium of the oncologist in the near future.
Conflict of Interest Disclosures: Dr Turaga serves as a consultant for Castle Biosciences and Ethicon. REFERENCES 1. Nishihara R, Ogino S, Chan AT. Colorectal-cancer incidence and mortality after screening. N Engl J Med. 2013;369(24):2355.
mortality with screening flexible sigmoidoscopy. N Engl J Med. 2012;366(25):2345-2357. 3. Bailey CE, Hu C-Y, You YN, et al. Increasing disparities in the age-related incidences of colon and rectal cancers in the United States, 1975-2010 [published online November 5, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014.1756.
2. Schoen RE, Pinsky PF, Weissfeld JL, et al; PLCO Project Team. Colorectal-cancer incidence and
JAMA Surgery January 2015 Volume 150, Number 1
Copyright 2014 American Medical Association. All rights reserved.
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23
US Age-Related Incidence of Colon and Rectal Cancers
4. Pignone M, Rich M, Teutsch SM, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2002;137(2):132-141.
cancers are increasing in young adults. Am Surg. 2003;69(10):866-872.
5. US Preventive Services Task Force. Screening for colorectal cancer: recommendation and rationale. Ann Intern Med. 2002;137(2):129-131.
11. Johnson RH, Chien FL, Bleyer A. Incidence of breast cancer with distant involvement among women in the United States, 1976 to 2009. JAMA. 2013;309(8):800-805.
6. Stryker SJ, Wolff BG, Culp CE, Libbe SD, Ilstrup DM, MacCarty RL. Natural history of untreated colonic polyps. Gastroenterology. 1987;93(5): 1009-1013. 7. Winawer SJ, Zauber AG, Ho MN, et al; The National Polyp Study Workgroup. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med. 1993;329(27):1977-1981. 8. Siegel RL, Jemal A, Ward EM. Increase in incidence of colorectal cancer among young men and women in the United States. Cancer Epidemiol Biomarkers Prev. 2009;18(6):1695-1698. 9. O’Connell JB, Maggard MA, Liu JH, Etzioni DA, Livingston EH, Ko CY. Rates of colon and rectal
10. You YN, Xing Y, Feig BW, Chang GJ, Cormier JN. Young-onset colorectal cancer: is it time to pay attention? Arch Intern Med. 2012;172(3):287-289.
12. Citations for SEER databases and SEER*Stat Software. Surveillance, Epidemiology, and End Results Program website. http://www.seer.cancer.gov /data/citation.html). Accessed July 11, 2013. 13. Aleksandrova K, Pischon T, Buijsse B, et al. Adult weight change and risk of colorectal cancer in the European Prospective Investigation into Cancer and Nutrition. Eur J Cancer. 2013;49(16):3526-3536.
15. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004;291(23): 2847-2850. 16. Slattery ML, Edwards S, Curtin K, et al. Physical activity and colorectal cancer. Am J Epidemiol. 2003;158(3):214-224. 17. Thune I, Lund E. Physical activity and risk of colorectal cancer in men and women. Br J Cancer. 1996;73(9):1134-1140. 18. Slattery ML, Boucher KM, Caan BJ, Potter JD, Ma KN. Eating patterns and risk of colon cancer. Am J Epidemiol. 1998;148(1):4-16.
14. Bassett JK, Severi G, English DR, et al. Body size, weight change, and risk of colon cancer. Cancer Epidemiol Biomarkers Prev. 2010;19(11): 2978-2986.
Invited Commentary
Screening Young Adults for Nonhereditary Colorectal Cancer Kiran K. Turaga, MD, MPH
The public health burden of colorectal cancer is a significant challenge, with more than 50 000 deaths annually in the United States. Widespread adoption of the US Preventative Task Force Guidelines for mandatory screening for colon cancer, along with improvement in access to advanced fiber optic techRelated article page 17 nology and training of physicians, among other factors, are some of the reasons why the overall incidence of colorectal cancer has been decreasing in the United States and in other developed nations. Randomized trials and epidemiological studies have demonstrated significant decreases in the incidence and mortality from colorectal cancer with the use of colonoscopy (and flexible sigmoidoscopy), with the reduction of risk persistent even at 15 years after a negative colonoscopy finding.1,2 In the setting of these congratulatory reports of a successful public health screening program, this report from Bailey et al3 is rather unsettling. The authors examined the incidence of colorectal cancer in 9 Surveillance, Epidemiology, and End Results registries from 1975 to 2010 and describe a rather alarming trend of an increase in the incidences of colon and rectal cancers in young adults, especially in the 20- to-34-yearold age group. This incidence was pervasive regardless of stage of disease, although not as dramatic in patients aged 35 to 49 years. Their data suggest an overall decrease in the ageadjusted incidence of colorectal cancer, which could be attributed predominantly to the decrease in the incidence of all stages of cancer in the older population, although limitations in the use of all the registries could contribute to lack of generalizability.3 22
Temporal trends in incidence are rather difficult for clinicians to interpret given the changing technology and understanding/detection of disease. While it is possible that this increase in the incidence of cancer in young adults could be owing to increased detection from frequent use of colonoscopies in symptomatic young adults or to sophisticated pathological techniques/imaging, the simultaneous temporal decrease in the incidence of cancer in those older than 50 years is intriguing. One might argue that perhaps the risk reduction (or decrease in incidence) in this age group would have been higher had these temporal trends not been a factor. Nevertheless, assuming that this increasing incidence of colorectal cancer in young adults is a real phenomenon, it begs the question of why this is occurring and what one should do about it. The authors suggested the Western diet and lifestyle might be some of the contributing factors for this trend. Tumors occurring in younger patients are frequently different in their expression of microsatellite instability, BRAF, KRAS, or in the CpG island methylator phenotype and are more frequently mucinous and aggressive.2 Further epidemiological investigation into causality is critical to reduction in the nonhereditary cancer incidence in younger adults. While it is attractive to suggest that all adults should obtain a colonoscopy, especially given the possible durability of cancer risk reduction, it is important to note that the absolute incidence of colorectal cancer in the young adults (aged 20-34 years) is 1% of the total colorectal cancer burden and similarly fairly low in the 35- to 49-year-old age group (6.8%). Hence,
JAMA Surgery January 2015 Volume 150, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/05/2015
jamasurgery.com
US Age-Related Incidence of Colon and Rectal Cancers
Original Investigation Research
widespread application of colonoscopic screening might add significant cost and risk without societal benefit. However, this report should stimulate opportunities for development of better risk-prediction tools that might help us identify these ARTICLE INFORMATION Author Affiliation: Medical College of Wisconsin, Surgery, Milwaukee. Corresponding Author: Kiran K. Turaga, MD, MPH, Medical College of Wisconsin, Surgery, 9200 W Wisconsin Ave, Milwaukee, WI 53226 (kturaga @mcw.edu). Published Online: November 5, 2014. doi:10.1001/jamasurg.2014.1765.
jamasurgery.com
individuals early and initiate better screening/prevention strategies. The use of stool DNA, genomic profiling, and mathematical modeling might all be tools in the armamentarium of the oncologist in the near future.
Conflict of Interest Disclosures: Dr Turaga serves as a consultant for Castle Biosciences and Ethicon. REFERENCES 1. Nishihara R, Ogino S, Chan AT. Colorectal-cancer incidence and mortality after screening. N Engl J Med. 2013;369(24):2355.
mortality with screening flexible sigmoidoscopy. N Engl J Med. 2012;366(25):2345-2357. 3. Bailey CE, Hu C-Y, You YN, et al. Increasing disparities in the age-related incidences of colon and rectal cancers in the United States, 1975-2010 [published online November 5, 2014]. JAMA Surg. doi:10.1001/jamasurg.2014.1756.
2. Schoen RE, Pinsky PF, Weissfeld JL, et al; PLCO Project Team. Colorectal-cancer incidence and
JAMA Surgery January 2015 Volume 150, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/05/2015
23
