young-Onset Colorectal Cancer: - PowerPoint Presentation

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2. young-Onset Colorectal Cancer: the nurse’s perspectiveNatasha PinheiroNurse PractitionerMemorial Sloan Kettering Cancer CenterNY, USA2

3. Introduction3

4. Incidence rate ratio by birth cohort in the United States1Age-standardised incidence rate during 2008-2012 for colorectal cancer among adults ages 20-49 years2Incidences of young-onset CRC are increasing worldwide4CRC, colorectal cancer1. Stoffel EM, Murphy CC. Gastroenterology. 2020;158:341–53; 2. Siegel RL, et al. Gut. 2019;68:2179–85Korea (5 registries)AustraliaUSA, SEER (9 registries)Slovakia*Japan (4 registries)New ZealandNetherlandsCanada†NorwayCroatiaSloveniaIrelandBrazil, GoianiaItaly (8 registries)IsraelCyprusSpain (9 registries)Germany (2 registries)Kuwait: Kuwaiti‡SwedenBulgariaDenmarkUnited KingdomFrance (9 registries)Switzerland (6 registries)Iceland‡Philippines, ManilaColombia, Cali‡China (5 registries)MaltaTurkey (2 registries)Poland, KielceAustriaBahrain, Bahraini‡EstoniaLithuaniaThailand (4 registries)Costa Rica¶Ecuador, Quito‡Chile, Valdivia‡Uganda, Kampala‡India, ChennaiRate per 100,000Birth cohort19901980197019601950194019301.001.251.501.752.002.252.502.753.00Incidence rate ratioRate for Finland unavailable.*Rate based on data during 2008-2010.†Excludes Nunavut, Quebec, and Yukon. ‡Excluded from trend analysis due to insufficient number of annual cases. ¶Rate based on data during 2008-2011.Shading indicates trend in incidence rates based on 10- year average annual per cent changeStatistically significant increaseStatistically significant decreaseStable or insufficient number of cases for trend analysis (‡)

5. Studies in women have linked lifestyle and dietary factors to increased risk of young-onset CRC:Childhood intake of sugar sweetened beverages2Lower vitamin D intake3Sedentary lifestyle4Obesity5young-onset CRC: What is the aetiology?5CRC, colorectal cancer; CVD, cardiovascular disease; T2DM, type 2 diabetes mellitus1. Singh RK, et al. J Transl Med. 2017;15:73; 2. Hur J, et al. Gut. 2021;70:2330–2336; 3. Kim H, et al. Gastroenterology. 2021;161:1208–1217.e9; 4. Nguyen LH, et al. JNCI Cancer Spectrum. 2018;2pky073; 5. Liu P, et al. JAMA Oncol. 2019;5:37–441. Dietary intakeProtein, fat,carbs, polyphenols,pre/probiotics2. Alteredgut bacteriaChanges inBifidobacteria,Lactobacilli,Akkermansia,etc.3. Biologic effectsAlters host metabolism,immune systemproductionof pro- and anti-inflammatorymetabolites4. Host diseaseCVD, T2DM,Obesity, Metabolicsyndrome,Autoimmune diseaseDietary intake has numerous effects on human health, including increasing risk of young-onset CRC1–3

6. young and average onset CRCAre they different diseases?6

7. Most CRC cases are sporadic, regardless of age7CRC, colorectal cancer1. Stoffel EM, Murphy CC. Gastroenterology. 2020;158:341-53Age <35 yearsAge <50 yearsAge >50 yearsLynch syndromeOther variantPolyposis syndromesNonePrevalence of pathogenic variants by age at CRC diagnosis

8. Higher prevalence of rectal bleeding and abdominal pain in YO CRC8Presenting symptoms are similar regardless of age of onsetAO, average onset; CRC, colorectal cancer; YO, young onset; GI, gastrointestinalCercek A, et al. J Natl Cancer Inst. 2021;113:1683-92Frequency of symptoms (%)

9. 82%79%62%Higher incidence of left sided tumours in YO CRC No significant clinical or histological differencesYoung onset less likely to be diagnosed early9Clinical characteristics are similar regardless of age of onsetGenderFemaleMalePercent of patients100%75%50%25%0%YO 14-35YO 36-49AO 50+RaceWhiteBlack or African AmericanFar-East Asian or IndianOther Not availableYO 14-35YO 36-49AO 50+YO 14-35YO 36-49AO 50+BMIUnderweightNormalOverweightObese Not availableYO 14-35YO 36-49AO 50+Smoking statusNeverEver Not availableStage at diagnosisStage IStage IIStage IIIStage IVYO 14-35YO 36-49AO 50+Tumour gradeWell-differentiatedWell-to-moderately-differentiatedModerately-differentiatedModerately-to-poorly-differentiatedPoorly-differentiated Not availableYO 14-35YO 36-49AO 50+Young onsetages 36-49Average onsetHepaticflexureAscendingcolonCecumRectumRectosigmoidSigmoidDescendingcolonTransverseSplenicflexureAverage onsetHepaticflexureAscendingcolonCecumRectumRectosigmoidSigmoidDescendingcolonTransverseSplenicflexureHepaticflexureYoung onsetages 14-35AscendingcolonCecumRectumRectosigmoidSigmoidDescendingcolonTransverseSplenicflexureAO, average onset; CRC, colorectal cancer; YO, young onsetCercek A, et al. J Natl Cancer Inst. 2021;113:1683-92

10. 10Delayed diagnosis of young-onset CRC likely contributes to late-stage diseaseCRC, colorectal cancerColorectal Cancer Alliance 2018 Young-Onset Colorectal Cancer Survey Report. Available from: https://www.ccalliance.org/about/never-too-young/survey/2018-young-onset-colorectal-cancer-survey-report (accessed 11 Feb 2022)41% waited > 6 months beforeseeking medical attention67% saw two or more physiciansprior to diagnosis71% diagnosed withstage III/IV disease<3 months6-12months3-6 months12+ months1 physician3 physicians2 physicians>4 physicians0IIIIIIIV

11. Treat by stage not by age11Aggressive treatment regimens based solely on the age at diagnosis are not warranted2 5-year relative survival (%)Relative survival by age at diagnosis11. Siegel RL, et al. CA Cancer J Clin. 2020;70:145-64; 2. Cercek A, et al. J Natl Cancer Inst. 2021;113:1683-92

12. outcomes are similar REGARDLESS OF AGE OF ONSET12AO, average onset; CRC, colorectal cancer; YO, young onsetCercek A, et al. J Natl Cancer Inst. 2021;113:1683-92Survival (%)100%75%50%25%0%YO ages 14-35YO ages 36-49AO ages 50+AO ages 50+YO ages 36-49YO ages 14-35Not availableNo responseAny responseBest response to first-linetreatment at time of metastasis100%75%50%25%0%01224364860728496108120Months from metastasisLog-rank test p value = 0.31% of cases at risk5745294173202301491038563534245434820912073463424191210111865733181174221First-line response (% )

13. young-onset CRCThe individuals are the difference13

14. People with young-onset CRC are a DIFFERENT population 1485%experienced anxiety or depression during or after treatment.55%sought treatment for anxiety or depression.80%had children under the age of 18 when diagnosed.64%said a medical professional did not talk to them about fertility preservation during diagnosis or treatment.61%did not have a health care proxy or medical directive in place, which lets another person legally make health care decisions in the event the patient is unable.62%experienced financial difficulties.64%took a leave of absence or quit a job or schooling because of their diagnosis.Quality of life3People with YO CRC:Needs and challenges1,2CRC, colorectal cancer; YO, young onset1. Adapted from Memorial Sloan Kettering Cancer Center internal data, courtesy of Hadley Maya, LMSW; 2. Mendelsohn R, et al. Oncologist. 2021;26:625-29; 3. Colorectal Cancer Alliance 2018 Young-Onset Colorectal Cancer Survey Report. Available from: https://www.ccalliance.org/about/never-too-young/survey/2018-young-onset-colorectal-cancer-survey-report (accessed 11 Feb 2022)

15. Unique population, unique support: social work, psychology, and psychiatry 15CRC, colorectal cancer; GI, gastrointestinalAdapted from Memorial Sloan Kettering Cancer Center internal data, courtesy of Hadley Maya, LMSW IsolationFrom healthy peersFrom the general population of people with CRCMost ≥50 years of ageFrom researchMost young-onset CRC research is in adolescent and young adult populations 40-50 year-olds excluded Unique dilemmas for people with young-onset CRCStigmaCRC has a unique and damaging stigmaBowel movementsDigestive/GI symptomsOstomy bags Impact on body image, sexual functioning and intimacyFamily systemMany patients are in relationships and caring for childrenMany patients are caring for their ageing parentsLife stageMost are juggling various rolesMarriage/partnershipsCaring responsibilitiesCareer developmentEducationPremature confrontation with mortality

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