Colon cancer is the third most common cancer in the United States, and the second most lethal. There has been a lot of progress in reducing deaths from colorectal cancer (CRC), both in improved treatment and through early and effective screening. When colon cancer is diagnosed at younger ages, however, it generally has a poorer long term outcome, particularly in the hereditary types. Thus, earlier than normal screening procedures have to be the rule.
Most everyone is now familiar with the American Cancer Society guidelines for early detection of CRC. Beginning at age 50, men and women considered to be at average risk are recommended to have a flexible sigmoidoscopy every 5 years and a colonoscopy every 10 years. A rectal digital examination with every physical exam by the doctor on a yearly basis is also advocated. These are not easy or comfortable exams, but they have made a big difference in the early detection and treatment of colon cancer.
How about people under the age of 50? More than 10 percent of CRC cases and almost 20 percent of rectal caners are now diagnosed in younger individuals, and the incidence and mortality are increasing right alongside. Why is this happening? Researchers are postulating that one cause is a higher obesity rate and a concurrent higher rate of diabetes, both found to be significant in increasing CRC risk. But another and maybe key reason is the absence of screening at younger ages. Without a protocol of necessary recommended testing, people over 50 are having cancers and pre-cancers found earlier and removed at completely curable stages. Cancers in younger age groups are allowed to grow unchecked so that when they are found it is at a much more advanced stage.
Both inherited and sporadic cases of CRC arise from adenomatous polyps. It’s a slow process and may take five years for a polyp to transform into a significant cancer. When screening is early on in the process, the growths are removed in precancerous stages. When allowed to develop on their own, they can become large and deadly. Villous adenomas are the most common of these, with up to 50 percent having foci of cancer.
Of biggest concern are the early appearing and hereditary forms of colorectal cancer. The growths themselves lack the characteristics of normal tissue (anaplastic) and grow more quickly, as well as spread or metastasize to other organs. Major syndromes are familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer, or Lynch syndrome. In FAP, polyps develop in the teenage years and a cancer diagnosis may occur before the age of 40. The risk of extraintestinal cancers is also increased. These cancers may have already spread beyond and through the colon when a diagnosis is made. Telling symptoms, such as rectal bleeding, blood in a bowel movement, abdominal pain and change in character of stools may already be a later presenting sign in these cases.
The key to successful treatment of colon cancer at younger ages is to take a good history and screen earlier in high risk individuals. A family history of colon cancer before the age of 60 or in two or more first degree relatives at any age indicate a candidate for early screening. Those who either have a diagnosis of FAP or Lynch syndrome, or who have inflammatory bowel disease (such as ulcerative colitis or Crohn’s) must be screened earlier, either at 40 years of age or 10 years earlier than the youngest age at CRC diagnosis for any first degree relative. These cancers caught early are very amenable to successful treatment, and time is of the essence.
Most people who have cured colon cancer or cancer treated with complete removal at early stages in a polyp will get standard insurance. Those cases in which there was metastasis, an aggressive type of cancer noted at the time of treatment, or an invasion of cancer through the wall of the colon may have a postpone time, followed by a diminishing flat extra until cure is likely. Familial syndromes are usually treated with the more drastic step of complete removal of the colon and/or rectum, and even then may be declined if risk for recurrence or of another extraintestinal cancer is too high.
Robert Goldstone, MD, FACE, FLMI
Goldstone, board certified internist and endocrinologist, is vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1990. Goldstone can be reached by telephone at 949-420-8390. Email: firstname.lastname@example.org.