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Bowel cancer incidence rates up 266% among 15–24-year-olds


Anastasia Tsirtsakis


30/05/2023 4:34:40 PM

Research has found age bias as a perceived barrier to getting a diagnosis for the deadly cancer – but a GP expert says there are other factors.

A young woman in a hospital bed looking outside.
People born in 1990 onwards have double the risk of colon cancer as those born in 1950.

The global incidence of bowel cancer in younger people has been rising since the 1980s, with a 266% increase in incidence rates among adolescents and young adults over the past three decades.
 
This means that one in 10 new bowel cancer cases occur in people under the age of 50.
 
But when it comes to getting a timely diagnosis, recent research published in BMJ Open has revealed that age is proving to be a barrier, with young people reporting that they face an age bias.
 
Chief Investigator on the study, Dr Klay Lamprell, a Research Fellow from the Australian Institute of Health Innovation at Macquarie University, said this appears to be the experience not just in Australia, but around the world.
 
‘Because they are young, they are overlooked for bowel cancer,’ she said.

‘The research found younger people may spend between three months and five years seeing multiple doctors before diagnosis – they may make 10 or more visits to GPs.

‘Even when younger people experience blood in their poo or rectal bleeding, GPs may not immediately refer them to specialists for further testing.’
 
Further research, published in BMC Primary Care and led by Dr Lamprell, backs these findings.
 
The study, which involved 273 people diagnosed with early onset bowel cancer from Australia, New Zealand and the UK, found patients perceived that GPs’ low suspicion of cancer due to them being aged under 50 contributed to a delay in diagnosis.
 
They also reported that their GP seemed unaware of early-onset bowel cancer and that they were not offered screening, even when ‘red flag’ symptoms were present. Inadequate information continuity within general practices and across primary, non-GP specialist and tertiary levels of care were also perceived among patients as having contributed to diagnostic delay.
 
Patients likewise reported tensions with GPs over the patient-centredness of care, describing discord related to symptom seriousness and lack of shared decision-making.
 
In addition to a delay in obtaining a referral for further investigation, study participants also noted lengthy wait times for non-urgent colonoscopies as a contributor to a delayed diagnosis.
 
As a result, the trajectory to obtaining a diagnosis can be up to 60% longer for people with early-onset bowel cancer compared to those who develop the disease later in life. 
 
A consequence of this is that they are also more likely to be diagnosed with stages III or IV of the disease, when it is more difficult to treat and likely to require more aggressive treatment, which can result in significant challenges that have a greater impact on quality of life.
 
Dr Lambprell said there is a clear need for greater education and awareness about early onset bowel cancer among doctors.
 
‘Our research concludes that with the rising global incidence of bowel cancer in people aged under 50, there is a mounting imperative for GPs to receive more information and clinical guidance on early-onset bowel cancer diagnosis,’ she said.
 
While Associate Professor Joel Rhee, Chair of RACGP Specific Interests Cancer and Palliative Care, acknowledges that the rise in prevalence among young people is concerning, he notes that it remains at approximately 1.6 cases per 100,000 people, which is ‘still exceedingly rare’ and therefore difficult to diagnose. 
 
‘Of course, from the point of view of young people with colorectal cancer, or the point of view of specialised cancer services that treat patients with colorectal cancer, these figures provide little comfort,’ he told newsGP.
 
‘But from the perspective of the GP, it is challenging to identify a young person with colorectal cancer from thousands of others who may present with gastrointestinal symptoms but do not have cancer.’
 
Adding to the difficulty, Associate Professor Rhee said, is that there is no easy way to diagnose colorectal cancer other than a colonoscopy – a procedure that carries a risk of one in 1000 of bowel perforation, possible sedation, and bowel preparation.
 
‘And, importantly, for the overstretched healthcare system, significant healthcare resources,’ he said.
 
The studies, led by Dr Lamprell, are the first to investigate the perspectives of patients with early-onset bowel cancer regarding ways to improve experiences of care in Australia, New Zealand, and the UK.
 
Based on current trends, people born in 1990 onwards have double the risk of colon cancer, and quadruple the risk of rectal cancer, compared to people born in 1950.
 
According to Bowel Cancer Australia, patients under 50 have an increased risk of developing bowel cancer when they experience one or more of the following symptoms between three months and two years prior to diagnosis: 

  • Abdominal pain
  • Rectal bleeding
  • Diarrhoea
  • Iron deficiency anaemia
However, Associate Professor Rhee highlights that gastrointestinal symptoms such as changes in bowel habit and abdominal pain are ‘very common in the young adult population’ and that in the vast majority of cases ‘are not due to cancer’.
 
‘Conditions such as irritable bowel syndrome are many magnitudes more common than colorectal cancer and can present with abdominal pain and changes in bowel habit,’ he said.
 
‘Haemorrhoids and anal fissures are much more common causes of rectal bleeding in younger people than colorectal cancer.’
 
When it comes to assessing patient risk, Associate Professor Rhee said taking a careful history, examination, judicious use of investigations and follow-up ‘remain the order of the day’.
 
‘I think the take-home message for GPs is the importance of considering colorectal cancer as part of their differential diagnoses and not ruling it out, especially in people with a family history, people who have symptoms that are not responding to conservative measures, or people who have a combination of concerning symptoms and signs,’ he said.
 
Australians are eligible to take part in the National Bowel Cancer Screening Program from the age of 50. However, advocates say it should be reduced to 45.
 
This step was taken by the American College of Gastroenterology in 2021, when it updated its clinical guidelines recommending screening start at 45 for people of average risk in a bid to reduce the incidence of, and death from, bowel cancer.

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A.Prof Christopher David Hogan   31/05/2023 1:09:51 PM

This is not simple
We cannot nor should not provide colonoscopies for all people with functional gastrointestinal disorders.
Rather they should be screened according to GESA / RACGP protocols at IBS4GPS.com then we can better identify those at high risk of severe disease and urgent colonoscopy. And provide effective care for those with IBS.