Why Are Colorectal Cancer Patients Getting Younger?

 Colorectal cancer has been upending the lives of younger people at disturbing rates in recent years, becoming the second most common type of cancer in people under age 50 in the U.S. today. By 2030, deaths are expected to double, and the disease is predicted to jump to the leading cause of cancer death in 20- to 49-year-olds. On this episode, we talk about epidemiological factors behind the rise in cases, the age groups affected, symptoms people should be paying attention to, preventative screening options, and where the research is going to try to reverse this alarming trend. Our guest is Swati Patel, MD, associate professor of medicine at the University of Colorado School of Medicine and director of the Gastrointestinal Cancer Risk and Prevention Center. 

Transcript

Chris Casey:

Hello. I'm pleased to say that it's a most welcome, sunny and relatively warm day here in Aurora, Colorado, today. And I'm joined once again in our on-campus studio by Dr. Tom Flaig, vice chancellor for research at the University of Colorado Anschutz Medical Campus. Tom, does this late February warming trend have you anticipating the arrival of spring perhaps?

Tom Flaig:

Downright balmy. It's one of those things where you get dressed up for the day and by midday, you don't need the things you've worn to work, like a coat and hat.

Chris Casey:

Isn't that nice?

Tom Flaig:

As a Minnesotan, I'm always prepared for the weather and sometimes overprepared.

Chris Casey:

It's nice when you can shed. I agree.

Tom Flaig:

Hear, hear.

Chris Casey:

So anyway, when we're talking transitions in meteorological phenomena, we notice that March is just around the corner, which is colorectal cancer awareness month. And just by chance then, today we'll be talking about the increasing numbers of younger patients who are being diagnosed with late-stage colorectal cancer. We'll discuss what's driving this trend, the age groups being affected, symptoms people should be paying attention to, the preventative screening options available, and where the research is going to try to reverse this alarming trend.

So, welcome to another episode of Health Science Radio where we take to the airwaves with scientists and clinicians at CU Anschutz to discuss the many ways they are innovating and advancing healthcare. My name is Chris Casey and I'm the director of digital storytelling at our Office of Communications. Without further ado, our guest today is Dr. Swati Patel, associate professor of medicine at the University of Colorado School of Medicine and director of the Gastrointestinal Cancer Risk and Prevention Center, where she cares for patients at high risk for cancer.

Dr. Patel is also a staff physician at the Rocky Mountain Regional Veterans Affairs Medical Center. Swati's research focuses on improving identification and care of patients at increased risk of gastrointestinal cancer based on family history and genetics, as well as optimizing colonoscopy training and quality. The overarching goal of Swati's research is to decrease the burden of cancer in society. That's pretty cool.

Tom Flaig:

That is a great goal, a very important goal.

Chris Casey:

I agree. So, would you like to just take us away?

Tom Flaig:

I will take us away. Looking forward to the topic today. This is one that I think I'm hearing about a lot in the media, from friends and family asking questions about this. It's a very timely topic. So, as we're thinking about early onset cancers, it might be helpful as we kick things off here for you to just define that and talk about the trends we're seeing epidemiologically.

Swati Patel:

Absolutely. First of all, thank you for having me. This is a really, really important topic for us to talk about. Nearly everyone, our friends or family members have someone that they're connected to who has been affected by colon or rectal cancer. So, this is a topic that touches us all. We know, thankfully, that over the last few decades, the rates of colon cancer and the deaths from colon cancer in the United States have steadily decreased. That's a really optimistic story and a success story likely from increased use of colon cancer screening in the general population.

Unfortunately, when we break up the incidence rates, the rates at how frequently patients are diagnosed with cancer by age groups, when we look at individuals under the age of 50, every age group has actually seen a significant increase in the rates of being diagnosed with colon cancer. So, this is really, really alarming. Likely, the groups over the age of 50 have shown stable or decreasing rates because of screening. However, in those that historically aren't eligible for screening, we've seen rising rates in a disease, colon or rectal cancer, that we typically think of as a cancer of old people.

Tom Flaig:

As we think about this trend line then as we see colon cancer as the most common cancer, the second most common cancer in people over the age of 50 and this increasing incidence in younger population, those less than 50, is early onset rectal cancer more deadly than being diagnosed with this type of cancer at an older age? And if so, why is that?

Swati Patel:

That's a good question. Some people say, well, maybe you're just diagnosing more colon cancer in young people because we have more access to things like colonoscopy. And so, patients who have symptoms just have more access to that than maybe they did decades ago. That's unfortunately not the case because when we look at individuals diagnosed under the age of 50, they're more likely to be diagnosed with more aggressive disease. Meaning when you look under the microscope, they have concerning features like signet ring cells, mucinous histology, or poor or no differentiation, which are all bad markers of disease. And they're more likely to be diagnosed with more advanced disease, regional disease, metastatic disease. So, it's not just an issue of whether these patients are getting more colonoscopies and we're finding more colon cancer than we previously did. And so, unfortunately what we are observing is that cancer in the young appears to be more aggressive than cancer in older adults.

And what's interesting is that it seems to have different features than the cancer that we've historically seen in those over the age of 50. One of the most interesting observations is that young patients are more likely to have cancer in the left side of the colon, particularly in the rectum compared to individuals diagnosed over the age of 50. And they also appear to have different molecular profiles. And so, not to go into too much detail, but a colleague of ours, Chris Lieu, has done a lot of work in characterizing colon cancers in young individuals versus older individuals, and they appear to have a different type of tumor in some ways, a different molecular signature than patients diagnosed at older ages. So, more advanced disease, diagnosed at later stages, and appear to have left-sided disease and a slightly different tumor profile than those diagnosed at older ages.

Tom Flaig:

That's really interesting. The colon cancers called it because of where it forms, right, in the colon or the rectum. But I think what you're saying then is we get more molecular and diagnostic ways of evaluating the biology of these tumors, they do appear to be different and with some aggressive features.

Swati Patel:

Yeah. And it's concerning. And so, it just poses the question, is this a different disease than what we've typically been accustomed to taking care of over the last several decades?

Tom Flaig:

Messages about screening for colorectal cancer, any cancer, they're challenging sometimes to get that message out there. And sometimes we as professionals will change those and modify screening, and just an observation I've made from practice, it's challenging when we make those changes to adopt them and get them disseminated out. So, what have been the recommendations for colorectal screening and how are those changing right now?

Swati Patel:

It's a really great question. So, in 1991, Medicare essentially approved colon cancer screening as a service. And so, we've had colon cancer screening for 50-year-old and older since 1991 in the United States, and that's been the long-standing recommendation. At the time, that age cutoff was sort of a somewhat arbitrary decision, but based on the fact that more than 90% of colon cancer diagnoses were occurring in those over the age of 50, and so our health system essentially decided that that's the cutoff at which we should offer colon cancer screening. With this changing epidemiology that we're talking about, in fact, as of 2023, 16% of all rectal cancers were diagnosed in those under the age of 50. 12% of all colon cancers were diagnosed in those under the age of 50, so far exceeding the thresholds for when we decided that 50-year-old age mark back in 1991.

And so, based on these epidemiologic observations, based on data showing that when we do offer screening in those under the age of 50, we essentially find the same rates of cancer and advanced polyps in 45- to 49-year-olds as we do in 50- to 54-year-olds. There was essentially multi-society consensus over the last few years to decrease the age to start screening from 50 to 45. So, the American Cancer Society (ACS) was out front on this back in 2018, and they put out their recommendation with a lot of controversy and there was a lot of discussion, but based on the modeling studies that informed the ACS recommendations, essentially every other major society in the United States followed suit with detailed evidence reviews, including the National Comprehensive Cancer Network, the United States Multi Society Task Force, the American College of Gastroenterology and then finally the United States Preventative Services Task Force. And all societies essentially came to a consensus that we should be offering colon cancer screening to everyone once they turned 45.

Tom Flaig:

One more question about the screening then. We talked about potentially some biological differences between early onset cancer and later onset. Should the type of screening being performed be the same in those under 50 as those over 50?

Swati Patel:

That's a really great question. I think the answer to that question is, we don't quite know yet whether there should be an adapted approach to screening in younger individuals compared to those over the age of 50. And so, based on not having that specific data, we have recommended, the United States Multi Society Task Force and these other societies I mentioned, to offer the menu of screening options that we offer everyone. And the message really is that the best screening test is the one that gets done.

Tom Flaig:

Yeah.

Swati Patel:

So, I think you bring up a really important point. We're talking about expanding screening to a huge segment of our population, 45 to 49, and we have to think about the practical ways to complete screening in that population. But at present, our approach is to offer any tests that a system or patient is willing to complete.

Chris Casey:

Yeah, you see on TV all the time now, these ads for the, what I guess are called stool-based home tests, which seemed to really be gaining in popularity. I mean, you can't really watch an evening's worth of news without seeing those types of ads. At least I can't.

Tom Flaig:

I'm with you there.

Chris Casey:

And so, these are gaining in popularity. Is there any studies into how the accuracy of those kits compares to, say, a colonoscopy?

Swati Patel:

It's a really good question. We kind of divide screening tests into stool-based tests and structural tests. So, the stool-based tests are the tests that you talked about, that we get marketed to. There's a really funny SNL skit on this.

Tom Flaig:

Yes, I saw that.

Swati Patel:

If you caught that a few years ago.

Tom Flaig:

Yeah.

Swati Patel:

But it also includes fecal immunochemical testing, which is essentially a measurement of microscopic blood in the stool. Those tests are designed to essentially screen for colon cancer or rectal cancer because they take advantage of anything that a tumor might shed into the stool and essentially test for that. So, that might be microscopic blood in the case of the multi-targeted stool DNA test that you're talking about, DNA markers that a tumor might shed. It's not specific for cancer because anything that could cause bleeding could trigger those tests to be positive. But if it's abnormal, the other piece that's really important is that it requires a colonoscopy to investigate why it's abnormal. To look in the colon, find out whether there's a cancer there, if there's not a cancer, find out whether there's precancerous polyps and make sure there's not something serious that caused that test to be positive.

Colonoscopy, on the other hand, is in this category of structural tests, which essentially provide us the ability to visualize the entire colon, and in the case of colonoscopy, take tissue samples or remove things or biopsy things while we're there. So, that's a one-step test. These other tests, these stool-based tests are two-step tests, meaning you do the first line of testing. If it's abnormal, then it requires a colonoscopy. There's really, at present, no head-to-head comparison of which test is the best test at detecting cancer. There are multiple studies underway, but with that being said, that's why we essentially offer a menu of options to choose a test that is the best fit for a patient in terms of their priorities, whether they want something that can be done at home and mailed in versus whether they want to do the colonoscopy tests, which can find precancerous polyps and get them removed.

Nonetheless, that's a customized conversation that patients can have with their doctors to decide which test is best for them. But it's important for patients to know that they're designed to do slightly different things. The stool-based tests can screen for cancer, the structural tests not only screen for cancer, but can also find precancerous polyps and remove them. So, it's a cancer screening test and a cancer prevention test.

Tom Flaig:

I don't know if they've looked at this, as they've moved the age for screening to a lower to the 45 realm, what's been the uptake of screening in that group compared to the traditional more than 50? How quickly is this being adapted and adopted?

Swati Patel:

Yeah, it's a little disappointing, to be honest with you. Even in those over the age of 50, the National Colorectal Cancer Roundtable set this aspirational goal that by 2018, 80% of Americans would be up-to-date on colon cancer screening. We missed that mark. I will proudly say as a VA doctor, the VA met that mark.

Tom Flaig:

Wow, that's wonderful.

Swati Patel:

As a system, as did Kaiser. Congratulations to them as well.

Tom Flaig:

Great.

Swati Patel:

But as a society, we didn't quite meet that mark, and that was really for 50 plus year olds. When we look at screening rates by age group, only 50% of those 50 to 54 are up-to-date on screening. When we look at recent data on 45 to 49 year olds, it's probably in the 25 to 30%. So, we have a long ways to go in really getting the message out there, as you said, in emphasizing the importance of screening. And that's got to have a multimodal approach, just like we're doing today, talking about it on a podcast. I think it's important to break through that preconceived notion that colon cancer is a disease of old people. It unfortunately can potentially affect any one of us. So, it's important to know what the screening options are, when to consider screening, and then other reasons to potentially get your colon checked out.

Chris Casey:

There's a lot of talk about the gut microbiome these days and as to be kind of the source of any number of diseases, and I can't help but wonder has there been any advances in learning what the gut microbiome is doing, or how it's contributing possibly to these rising rates of colorectal cancer?

Swati Patel:

Yeah, it's a really interesting question. As we talked about this increasing rate of colon cancer in younger individuals appears to be different than what we've historically seen in older adults. And so, it's kind of brought a lot of people to the table to try to understand why, why this is happening. The short answer is we don't know why the rates are going up in young individuals, but what we do know is that it's likely because of what we call a birth cohort effect. And so, what that means is that there are probably generational exposures that are contributing to that increased risk. So, it's not a period cohort effect. For example, emergence of colonoscopy and increased use of colonoscopy, that's sort of something that happens over a certain period of time that affects cancer diagnoses during that period. This is actually generational level risk factors that probably contribute to the increasing rates of colon cancer. And so, what could those generational factors be? Well, we get some clues in looking at what's happening around the world. So, rates are actually going up around the world, but predominantly in Westernized countries.

And in fact, countries that are more recently Westernizing, like Taiwan and India, the rates that we started to see go up in the seventies and eighties, they're now the nineties, 2000s starting to see those same slopes. So, there's some sense that it's probably a combination of what Westernization sort of exposes us to. Makes us scratch our heads a lot, right? Because there's so many advances in things that we credit to Westernization, that might modulate things like the gut microbiome. So, increased cesarean section deliveries, introduction of antibiotics in childhood, introduction of antibiotics within the food chain, increased kind of consumption of processed foods. There's not probably a single one of these that's the exact cause of this rise, but it's probably a combination of just our changes in lifestyle and our exposures as a generation. And so, the 20- to 29-year-olds now are seeing the sharpest rise in their rates of colon cancer.

And as these 20- to 29-year-olds will be 30 to 39 in a decade and then 40 to 49 in two decades, they're going to carry this risk with them. So, even though the absolute numbers in those young patients is low now, they will carry this risk with them as they age as part of this birth cohort effect. And whether it's because of changes in the gut microbiome that over the longer term confer increased risk, or a variety of different hypotheses around secondary bile acids in the colon and their carcinogenic effect, pro-inflammatory states within the colon, this is going to become an increasing public health issue if we don't needle down as to why this is happening and how we can intercept it.

Chris Casey:

Yeah. It's also interesting what you were saying, Swati, about what the younger folks, you're seeing it localized more on the left side or toward the rectal area. Is there any percentages of what the percentage of these younger folks who are diagnosed with colorectal cancer are in that rectal area? And is it true that rectal cases are rising faster in younger people than older people?

Swati Patel:

Yeah. So, probably about, for all the cancer cases diagnosed in those under the age of 50, about 35% are rectal cancer. That's a much higher proportion than those over the age of 50. And in terms of your second question of, is that rate increasing faster? It appears to be, and the question is whether the tumor biology is different, and maybe next year you invite Chris Lieu and ask him about what he's learning about that. Some of it's hard to tease out in terms of the age of the patient, location of the tumor and whether it's a virtue of just being a rectal tumor, versus modulation of the age at which they were diagnosed. But nonetheless, this does appear to be unique. And so, whether that's microbiome mediated or a variety of other hypotheses around just increased sedentary lifestyle in a different milieu in the rectum than perhaps decades ago when we were up and about significantly more, it does start to make us wonder what's unique about this rectal location that we can kind of hone into.

Tom Flaig:

One thing that strikes me as we're trying to motivate and inform 45- to 49-year-olds about the importance of screening and so forth, one question you might hear is, what can an individual do with this understanding and awareness to try to prevent this, or what dietary changes? Because I think what's clear is the trend is clear. We're seeing as epidemiologic changes, the exact cause is being elucidated through a variety of things. But is there any advice you'd give to people that want to have a healthy colorectal lifestyle or something they can do in their own lives to modify the risk potentially?

Swati Patel:

Absolutely. I think what you're getting at is what in your diet and lifestyle can you do? And I have patients, friends and family ask me all the time, "Which supplement should I take? Should I have..." I'll talk about that. But honestly, probably the most practically useful things that all of us can do is, number one, the moment you meet your doctor, you're never too young, you're never too old, talk about your family history. If you don't know your family history, that's your homework. Go figure it out. Most people are pretty aware that having a family history of colon cancer increases risk, and we, based on guidelines, actually recommend screening those individuals earlier and more aggressively.

I think the piece of the family history that's oftentimes missing, and oftentimes our responsibility as GI doctors, is a family history of advanced colon polyps. So, we know that colon cancer develops from polyps that grow over time and turn into cancer. Patients with really big polyps, OK, so not cancer yet, but knocking on the door to becoming cancer, we feel great when we take those out and we feel like we've saved a patient from suffering from cancer. What we know is that data shows that patients with the first-degree family member with an advanced polyp have the same risk of getting colon cancer as if that first-degree family member had colon cancer.

So, as GI doctors, we don't do a great job of communicating that to our patients. We pat ourselves on the back about taking out a large polyp preventing a cancer. We tell the patient to come back in three years, they usually come back. But we've done studies that show that less than 40% of those patients even know that that polyp they had removed was pre-cancerous. Less than 40% know that that confers increased risk to their siblings, their kids. So, the first thing, go talk to your family about not just anyone diagnosed with colon cancer, but what their colonoscopy results were. I know this is uncomfortable conversation for some, but it's really important, and if there's any question about whether polyps were removed and whether they're the advanced kind or not, to take screenshots, take photos to show those to your doctor to find out because patients with a family history of advanced polyps qualify for screening earlier and more frequently.

The second thing is, make sure you monitor yourself and notify your doctor if you have any symptoms. And the symptoms that we know can increase finding a colon cancer are bleeding that's unexplained and iron deficiency anemia, being the two predominant ones. So, recent studies have shown that patients with iron deficiency anemia or hematochezia, or bright red blood in the stool, have a tenfold increased risk of having early onset colon cancer than patients matched for every other factor without those symptoms. So, if you have those symptoms, please don't delay getting attention for them. We all want to be optimistic that it's from something benign like hemorrhoids, but 1 in 100 patients will have a serious finding like cancer. So, to seek medical attention if those symptoms are present and get those checked out. And then, as you said, be prepared to be screened at age 45, to not start thinking about it at 45, but to start thinking about it at 40, 42, and plan for what type of test you want to do when you do kind of reach that threshold of 45.

In terms of those other things, we know that diets heavy in red meats, processed meats increase risk of colon cancer. Smoking increases risk, excess alcohol intake increases risk of colon cancer. We know that's the case with multiple other cancers. Diets increased in fiber are protective, daily physical activity is protective, lean body mass or low BMI is protective. So really, the bottom line is what's going to be good for your overall health and your heart? Blood pressure risk, stroke risk, orthopedic issues is also going to be protective for your colon. For those patients who say, "I can't consider depriving myself of a hot dog at the ballgame," that's okay. It's really all these things in moderation. And so, if you're going to pick two habits on each end, please don't smoke. Please try to incorporate some physical activity, even if it's light walking on a daily basis.

Tom Flaig:

One of the interesting things, so again, I'm an oncologist, deal with prostate cancer and so forth. People ask, "How can I prevent this? How can I..." It comes back to a healthy lifestyle in such a nice way, in so many ways, right? It's doing some reasonable exercise, it's watching your diet in reasonable ways and staying active, and it sounds like that holds true here as well. I'd also say, I think you made a really thoughtful and important point about the history. So, again, it's somebody that's asking people about their family history regularly, I can't think of the last time someone said, "I have a family history of high-risk polyps." I've had people tell me frequently, "Oh, colorectal cancer in my relative or prostate cancer in my relative." But just to validate what you're saying, I can't think of a time someone said, "High-risk polyps," because that's not conveyed, right?

Swati Patel:

Yeah.

Tom Flaig:

It's conveyed that aunt so-and-so or uncle so-and-so had colorectal cancer. It's a really important educational thing I think you're saying there.

Chris Casey:

And I'm wondering, with the genetic side, Swati, is there any way to do testing of somebody who's genetically at risk for colorectal cancer? And if so, what are those tests?

Swati Patel:

Yeah. So, there's a really important study published in 2017 by the Ohio State Group, where they essentially, across 51 hospitals in Ohio, so as you can get, offered multi-gene panel germline genetic testing to all patients diagnosed with colorectal cancer under the age of 50. And so, they found that 16% of those patients had some germline pathogenic variant, a problem-causing mutation in a gene that's associated with cancer risk. And so, it was that sentinel paper and then multiple that essentially validated those results that followed, that essentially flipped the NCCN to recommend that all patients under the age of 50 who are diagnosed with colorectal cancer should be offered genetic testing because we find something in 16-ish percent. So, for those individuals in that study, that was regardless of family history, regardless of tumor characteristics, and that really fed that recommendation by the NCCN. So, if there's a family member who's been diagnosed with early age onset colon cancer, they should have had hereditary risk assessment and multi-gene panel germline genetic testing.

But the flip side of that is that when they tested all these people, they only found something genetic in 16%. So, that means that 84% had no identified hereditary predisposition. They may have had a family history of colon cancer or colon polyps, but no genetic variant. The things that people should think about in wondering whether maybe there's something genetic going on in the family, there's lots of kind of detailed complicated criteria. But to me, it's a gut check of the following red flags.

If there's multiple cancers on one side of the family, particularly if those cancers are occurring at a young age, which we kind of, again, arbitrarily identify as less than age 50, and particularly if any individual within the family has been diagnosed with multiple cancers. So, for example, an aunt who had a colon cancer, survived that, and then years later had a uterine cancer. That really is just terrible luck in most individuals, but what we can unfortunately see in patients that have genetic syndromes. And so, if you have a family history of multiple cancers on one side of the family, particularly if any of early age onset or multiplicity of cancers within an individual, should talk to your doctor about whether that might be associated with a hereditary syndrome.

Chris Casey:

And so, the stages of a diagnosis, can you talk about the survival outlook for somebody diagnosed with colorectal cancer stage one versus stage four, and does it vary based on where the cancer is found?

Swati Patel:

It's a great question. We do tend to approach kind of treatment of cancer in the rectum differently than treatment of cancer in the colon. But in general, in both locations, if we identify cancer at an early stage, stage one where it's just localized to the colon or rectal tissue, survival's outstanding. We have the ability to completely remove that cancer, and although that patient requires surveillance afterwards with colonoscopies and tests, the survival and the likelihood of that cancer recurring is very, very favorable for the patient. Unfortunately, as patients progress through stages, they have to not only contend with lower survival, but all the morbidity that goes with the advanced stage disease. And so, these are young individuals that oftentimes are very active in their lives and their professions, caregivers, breadwinners for their families, maybe taking care of older generations and younger generations who are taken away from life, family and work to get things like surgery, chemotherapy, radiation treatment, and not to mention all the kind of medical toxicities and even financial toxicities associated with that.

And so, I think when we talk about the consequences of this late stage disease in younger people, it's not just that they're less likely to survive, which we know, the numbers show that and that's very awful, but it's this other additional burden that even in those that do make it through, it is an unacceptable cost to our patients. And interestingly, modeling studies show that the burden on patients diagnosed and the burden to society in terms of quantified by life years gained, for those diagnosed between the ages of 45 to 49 essentially is the same as those diagnosed 65 to 69, even though the absolute number of cases is much, much higher in the 65 to 69 year olds. And it's because of this issue that 45 to 49 year olds are really driving a lot of what we do, right? And driving, if you think about your own family and where the 40 to 49 year olds what they're doing, they're at the prime of everything.

Tom Flaig:

As we think about this topic of early onset cancer, what are the biggest research questions out there and the pursuits? You've mentioned some work being done here in campus in characterizing some of these tumors, but what are the major research topics right now?

Swati Patel:

Yeah, multiple fold. I think there's a lot of work being done in trying to understand the etiology to this rise. And so, cohort type studies that investigate a lot of the detailed factors that we've talked about, diet, lifestyle, activity levels, habits, medications, prior medical history, and how those risk factors can contribute to disease. And then biologically, understanding if there truly is a difference, and helping kind of unveil those differences and understand whether those are markers that can help us figure out targets for prevention and intervention, but also potential targets for more personalized or customized treatment. Because right now, we treat colon cancer in young individuals the same as we treat colon cancer in older individuals. And we don't do that because we know it's just as good, we do that because we don't have information otherwise. And so, that's some of the work that our colleague, Chris Lieu, is working on.

From my side of things, on the early detection and prevention side, there's a lot of attention being put towards this approach to screening. Right now, we've expanded screening to 45 to 49 year olds, and studies looking at risk adapted approaches. So, can we put additional variables into the mix that help us really understand which 45 year olds are at higher risk compared to the others, and focus our screening efforts, or at least our intense colonoscopy screening efforts on that population? How to implement these things on a population-based level to improve adherence. And then, ultimately, understanding whether we follow patients differently that are diagnosed with polyps and cancer at a younger age versus what we do at an older age. So, really, a lot of work across the spectrum. But I think one thing that I'll kind of close with in this area of research is that, it's not just a matter of young onset versus older onset, it's a birth cohort effect.

So, it's cohort level risk factors, and us young folks are aging. And so, the research that we're doing is not just restricted to understanding colon cancer in the young, that's where we're seeing these rises right now. But all the work that we do now and continue to do will pay dividends in terms of the cancer risk as our generation's age. And so, I think that 50-year-old threshold is a very convenient marker for us to kind of just observe trends, but there's nothing biologically magical about that cutoff. And what we do to understand what's happening in 20 to 29 year olds now will help us understand our 30 to 39 year olds in 5 or 10 years and so on. So, I think it's really important work and for folks that say, "Well, even though the rates are increasing, it's not that many numbers." Well, it's not that many numbers right now, but it really significantly impacts our society for the patients that do have to deal with this, and understanding this phenomenon will be really important to curb the trends as individuals age.

Tom Flaig:

It's a very important area of study, and I think as you point out, understand the biology and what biologic differences might be seen here could have all kinds of ramifications for care.

Swati Patel:

Yeah.

Chris Casey:

Yeah, and I believe, well, I believe, Tom, you mentioned earlier that colorectal cancer is the second most common cancer in people under the age of 50 now in the US. But I believe, as you said, Swati, it'll become the number one cancer in people under age 50 by 2030, which is five years away. Is that, that's still the trend, correct?

Swati Patel:

Yeah. If trends continue as they have been, by 2030, colon cancer will be the leading cause of cancer-related death in those under the age of 50.

Chris Casey:

Wow. Well, it's alarming to hear the trend lines where they are, but it's heartening to hear the awesome research that you and your colleagues are doing here. So, that's terrific to get some insights into those. So, thank you for sharing your expertise with us today, Swati. Appreciate it.

Swati Patel:

Of course. Really happy to be here and really happy you're covering this issue, especially with Colon Cancer Awareness Month right around the corner.

Chris Casey:

Thank you.

Tom Flaig:

Thank you.