doi:10.1111/codi.12648
Original article
No increase in colorectal cancer in patients under 50 years of age: a Victorian experience from the last decade C. S. Sia*, E. Paul†, R. J. Wale*, A. C. Lynch‡§, A. G. Heriot‡§ and S. K. Warrier*‡§¶ *Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia, †Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia, ‡Department of Surgery, Peter MacCallum Cancer Center, Melbourne, Victoria, Australia, §Gastrointestinal Cancer Committee, Victorian Cancer Council, Melbourne, Victoria, Australia and ¶Department of Surgery, Epworth Healthcare, Melbourne, Victoria, Australia Received 3 August 2013; accepted 16 February 2014; Accepted Article online 26 April 2014
Abstract Aim The study aimed to assess whether there has been an increase in the incidence of colorectal cancer (CRC) among young patients in Victoria and whether such cancers are more advanced at presentation. Method The Victorian Cancer registry database was searched for patients, 18–50 years of age, diagnosed with CRC [young colorectal cancer (YCRC)] between 2000 and 2010. Average annual percentage changes and incidence rate ratios (IRRs) were calculated to characterize trends in CRC rates over time and to make comparisons with patients over 50 years of age with CRC [late colorectal cancer (LCRC)]. Results Of 37432 CRCs registered during the study period, 2635 (7%) were in YCRC patients (annual increase in incidence = 1.7%; 95% CI: 0.5–2.9), compared with 34797 (93%) in LCRC patients (annual increase in incidence = 1.3%; 95% CI: 0.9–1.6). A small, nonsignificant increase in the incidence of YCRC over time was observed [IRR = 1.004 (95% CI: 0.992– 1.016) for YCRC vs 0.989 (95% CI: 0.986–0.992) for LCRC]. Rectal cancer was more common in YCRC patients than in LCRC patients (42% vs 34%, respectively; P < 0.0001). The cancer would have been seen
Introduction After nonmelanocytic skin cancer, colorectal cancer (CRC) is the cancer most commonly reported to Australian registries. Despite a reduction in the incidence of CRC, attributed to screening programmes, the incidence of CRC in the USA in those under 50 years of age has shown an increase [1], especially in the 40–44 years’ age group [2]. Corresponding to: Satish Warrier, FRACS, Department of Colorectal Surgery, Alfred Health, Commercial Road, Prahan, Melbourne, Victoria 44195, Australia. E-mail: [email protected]
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on flexible sigmoidoscopy in 63% of YCRC patients compared with 53.6% of LCRC patients (P < 0.0001). YCRC patients were more likely to have node-positive disease (49.3% YCRC patients vs 40% LCRC patients; P < 0.0001), especially those with colonic cancer (52.7% YCRC patients vs 41.2% LCRC patients; P < 0.0001). Conclusion There has been an increase in incident cases of YCRC. A small, nonsignificant increase in the incidence of YCRC over time was observed. Young patients are more likely to have rectal cancer and to be node positive. Keywords Young CRC, hereditary CRC, early-onset CRC What does this paper add to the literature? This paper shows that young patients (18–50 years of age) with colorectal carcinoma are diagnosed at more advanced stages than are older patients. The number of cases of young patients with colorectal carcinoma reported to the registry is increasing. Although the majority of these can be detected with flexible sigmoidoscopy, such testing would miss up to a third of cases.
Young colorectal cancer (YCRC) (i.e. that occurring in subjects under 50 years of age) may pose diagnostic difficulty. Symptoms may be attributed to benign pathology, which may result in diagnostic delay. Surveillance Epidemiology and End Results (SEER) data from the USA indicate that younger patients may present at a later stage compared with older patients [3]. This suggests that increasing community and patient awareness of symptoms, combined with reducing the threshold for referral by primary care physicians for endoscopy, could be useful. The primary aim of the study was to report and compare trends in the incidence of CRC among
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 690–695
C. S. Sia et al.
Young CRC in Victoria
young and old age cohorts in the state of Victoria over the last 10 years. We also sought to compare the site of diagnosis and nodal status of tumours using prospectively collected data from a large, State-based registry.
Method The Victorian Cancer registry database was searched for patients with a diagnosis of CRC (ICD codes C180-C209) between 2000 and 2010. All CRCs in the state of Victoria are reported to this cancer registry and death rates are linked to our State-based death registry. The number of CRCs reported is therefore reliable. Victoria is the most densely populated state in Australia, with the second-highest population, having a catchment of 5 603 100 people [4]. Patients under 18 years of age were excluded from the study. The atrisk population was derived from an Australian demographics statistics report released by the Australian Bureau of Statistics and was used to calculate incidence rates [5]. Patients were divided into those younger (YCRC) and older [late-onset colorectal cancer (LRCR)] than 50 years of age, with 50 years being used as the cutoff, as recommended by the modified Bethesda criteria for immunohistochemical or microsatellite testing for Lynch Syndrome [6]. The age of 50 is also an approximate age of onset for menopause [7]. Average annual percentage changes were calculated to charac-
terize trends in CRC rates over time (Joinpoint Regression Program, version 3.5.4., National Cancer Institute, Bethesda, Maryland, USA). Data extracted included that for the site of the tumour, nodal status, survival, patient age and year of diagnosis. Nodal status was only available from 2007. Rates for metachronous and synchronous cancer were calculated from 2000 to 2005. Categorical data were given using counts and percentages. Comparisons of proportions between groups were made using Pearson’s chi-square test for equal proportions. Incidence rate ratios (IRRs) and 95% CI were estimated using population data from the Australian Bureau of Statistics. This data factored in the increasing at-risk population over the 10-year study period. We used Poisson regression analysis to compare IRRs between young and old cohorts. A P value of
Original article
No increase in colorectal cancer in patients under 50 years of age: a Victorian experience from the last decade C. S. Sia*, E. Paul†, R. J. Wale*, A. C. Lynch‡§, A. G. Heriot‡§ and S. K. Warrier*‡§¶ *Department of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia, †Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia, ‡Department of Surgery, Peter MacCallum Cancer Center, Melbourne, Victoria, Australia, §Gastrointestinal Cancer Committee, Victorian Cancer Council, Melbourne, Victoria, Australia and ¶Department of Surgery, Epworth Healthcare, Melbourne, Victoria, Australia Received 3 August 2013; accepted 16 February 2014; Accepted Article online 26 April 2014
Abstract Aim The study aimed to assess whether there has been an increase in the incidence of colorectal cancer (CRC) among young patients in Victoria and whether such cancers are more advanced at presentation. Method The Victorian Cancer registry database was searched for patients, 18–50 years of age, diagnosed with CRC [young colorectal cancer (YCRC)] between 2000 and 2010. Average annual percentage changes and incidence rate ratios (IRRs) were calculated to characterize trends in CRC rates over time and to make comparisons with patients over 50 years of age with CRC [late colorectal cancer (LCRC)]. Results Of 37432 CRCs registered during the study period, 2635 (7%) were in YCRC patients (annual increase in incidence = 1.7%; 95% CI: 0.5–2.9), compared with 34797 (93%) in LCRC patients (annual increase in incidence = 1.3%; 95% CI: 0.9–1.6). A small, nonsignificant increase in the incidence of YCRC over time was observed [IRR = 1.004 (95% CI: 0.992– 1.016) for YCRC vs 0.989 (95% CI: 0.986–0.992) for LCRC]. Rectal cancer was more common in YCRC patients than in LCRC patients (42% vs 34%, respectively; P < 0.0001). The cancer would have been seen
Introduction After nonmelanocytic skin cancer, colorectal cancer (CRC) is the cancer most commonly reported to Australian registries. Despite a reduction in the incidence of CRC, attributed to screening programmes, the incidence of CRC in the USA in those under 50 years of age has shown an increase [1], especially in the 40–44 years’ age group [2]. Corresponding to: Satish Warrier, FRACS, Department of Colorectal Surgery, Alfred Health, Commercial Road, Prahan, Melbourne, Victoria 44195, Australia. E-mail: [email protected]
690
on flexible sigmoidoscopy in 63% of YCRC patients compared with 53.6% of LCRC patients (P < 0.0001). YCRC patients were more likely to have node-positive disease (49.3% YCRC patients vs 40% LCRC patients; P < 0.0001), especially those with colonic cancer (52.7% YCRC patients vs 41.2% LCRC patients; P < 0.0001). Conclusion There has been an increase in incident cases of YCRC. A small, nonsignificant increase in the incidence of YCRC over time was observed. Young patients are more likely to have rectal cancer and to be node positive. Keywords Young CRC, hereditary CRC, early-onset CRC What does this paper add to the literature? This paper shows that young patients (18–50 years of age) with colorectal carcinoma are diagnosed at more advanced stages than are older patients. The number of cases of young patients with colorectal carcinoma reported to the registry is increasing. Although the majority of these can be detected with flexible sigmoidoscopy, such testing would miss up to a third of cases.
Young colorectal cancer (YCRC) (i.e. that occurring in subjects under 50 years of age) may pose diagnostic difficulty. Symptoms may be attributed to benign pathology, which may result in diagnostic delay. Surveillance Epidemiology and End Results (SEER) data from the USA indicate that younger patients may present at a later stage compared with older patients [3]. This suggests that increasing community and patient awareness of symptoms, combined with reducing the threshold for referral by primary care physicians for endoscopy, could be useful. The primary aim of the study was to report and compare trends in the incidence of CRC among
Colorectal Disease ª 2014 The Association of Coloproctology of Great Britain and Ireland. 16, 690–695
C. S. Sia et al.
Young CRC in Victoria
young and old age cohorts in the state of Victoria over the last 10 years. We also sought to compare the site of diagnosis and nodal status of tumours using prospectively collected data from a large, State-based registry.
Method The Victorian Cancer registry database was searched for patients with a diagnosis of CRC (ICD codes C180-C209) between 2000 and 2010. All CRCs in the state of Victoria are reported to this cancer registry and death rates are linked to our State-based death registry. The number of CRCs reported is therefore reliable. Victoria is the most densely populated state in Australia, with the second-highest population, having a catchment of 5 603 100 people [4]. Patients under 18 years of age were excluded from the study. The atrisk population was derived from an Australian demographics statistics report released by the Australian Bureau of Statistics and was used to calculate incidence rates [5]. Patients were divided into those younger (YCRC) and older [late-onset colorectal cancer (LRCR)] than 50 years of age, with 50 years being used as the cutoff, as recommended by the modified Bethesda criteria for immunohistochemical or microsatellite testing for Lynch Syndrome [6]. The age of 50 is also an approximate age of onset for menopause [7]. Average annual percentage changes were calculated to charac-
terize trends in CRC rates over time (Joinpoint Regression Program, version 3.5.4., National Cancer Institute, Bethesda, Maryland, USA). Data extracted included that for the site of the tumour, nodal status, survival, patient age and year of diagnosis. Nodal status was only available from 2007. Rates for metachronous and synchronous cancer were calculated from 2000 to 2005. Categorical data were given using counts and percentages. Comparisons of proportions between groups were made using Pearson’s chi-square test for equal proportions. Incidence rate ratios (IRRs) and 95% CI were estimated using population data from the Australian Bureau of Statistics. This data factored in the increasing at-risk population over the 10-year study period. We used Poisson regression analysis to compare IRRs between young and old cohorts. A P value of
