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ACS analysis finds early onset colorectal cancer rising in many high-income countries

​Steep inclines often in sharp contrast to rapid declines in older adults

A new American Cancer Society study finds that colorectal cancer (CRC) incidence is increasing exclusively in young adults in nine high-income countries spanning three continents. The study, appearing in the journal Gut, finds the rising rates are in contrast to stable or declining trends in older adults, suggesting that changes in early-life exposures are increasing CRC risk.

Colorectal cancer is the third most commonly diagnosed cancer worldwide, with an estimated 1.8 million new cases in 2018. In general, CRC incidence is rising in low- and middle-income countries but beginning to stabilize or decline in high-income countries, especially those that have implemented screening. However, studies of cancer registry data indicate that favorable overall trends in the United States and Canada are masking an increase in young-onset CRC.

To learn more about contemporary patterns of early onset CRC on a global scale, investigators led by Rebecca Siegel, MPH, analyzed long-term population-based data on CRC occurrence in adults under 50 versus those 50 and older for 43 countries covering six continents using high-quality cancer incidence data from population-based cancer registries.

Of the 36 countries with sufficient numbers of cases to analyze trends, CRC incidence among adults under 50 was stable over the past 10 years in 14 countries, decreased in three (Italy, Austria, and Lithuania), and increased in 19. In nine of those 19, the rise in early-onset CRC was in contrast to trends in those 50 and older, which were either dropping (Australia, New Zealand, Canada, Germany, and United States) or stable (Denmark, Slovenia, Sweden, and United Kingdom). In all but one of these countries with long-term data, the uptick in early-onset CRC began in the mid-1990s.

In addition, in three countries (Cyprus, Netherlands, and Norway) where incidence rose in both younger and older age groups, the increase in young adults was twice as steep as that in older adults and also began in the mid-1990s. Early-onset CRC incidence increased most rapidly – by 4.2% per year – in South Korea, where the rate is already highest among all countries analyzed.

Declining incidence in older adults in many countries is partly attributed to CRC screening, which typically emerged over the past two decades and begins between the ages of 50 and 60 years. However, Austria and Italy, two of only three countries where early-onset CRC incidence is declining, have been screening adults beginning at age 40 and 45 years, respectively, since the early 1980s. In both Austria and Italy, declines in CRC under age 50 were confined to ages 40-49 years.

“These patterns potentially signal changes in early-age exposures conducive to large bowel carcinogenesis and highlight an urgent need for research to explore the potentially unique etiology of young-onset CRC,” said Rebecca. “Although the absolute risk of CRC in adults younger than 50 years is low relative to older adults, disease trends in young age groups are a key indicator of recent changes in risk factor exposures and often foreshadow the future cancer burden.”

The authors note that while further studies will elucidate potential causes for the increase, clinicians have an opportunity to help mitigate premature morbidity and mortality from CRC with active documentation of familial cancer history; timely follow-up of symptoms, regardless of patient age; and screening when appropriate.

  • Our new chief medical and scientific officer says he's excited to get started

    ​He will assume his duties on Oct. 21 and will relocate from Arizona to Atlanta

    William G. Cance, MD, our new chief medical and scientific officer, said on Tuesday that he's looking forward to many things, but top of the list is "working with such an amazing organization and a team of 1.5 million volunteers to more rapidly take advances in cancer treatment and cancer prevention to the patients."

    The oncologist said: "We are at a great time in cancer therapy with the advent of precision medicine, precision treatment, precision prevention, and using science and predictive markers to guide our approaches to preventing cancer and to treating cancer. I also believe that we are at a crossroads of being able to fund such initiatives because of the dearth of federal research dollars, the high costs of health care, and the lack of creative focus on our one competitor - cancer. I hope to make a difference in those areas." 

    In the August 15 media release announcing his appointment, Dr. Cance noted that the ACS name "has been synonymous with progress and hope." He said his goal is to "help this historic organization achieve its mission to further reduce the burden of cancer nationwide and globally."

    Dr. Cance will lead the integration of our Research and Cancer Control departments, unifying our intramural and extramural research, prevention and early detection programs, patient and caregiver support, program and service strategies, global cancer control, and health systems.

    Rich Wender, MD, our chief cancer control officer, met Dr. Cance in Atlanta during the oncologist's initial interview. He described our new chief medical and scientific officer as “engaging and enthusiastic.”

    “He’ll be a wonderful spokesperson for ACS and our work. He could not have been more excited about coming to lead our mission activities,” Rich said. He added: "He has a good understanding of the special opportunities and challenges that come with this job - the need to have an entrepreneurial mindset and to link how we drive towards our mission goals and how we fund the work. He is willing to take thoughtful risks – definitely an attribute we need."

    Dr. Cance brings to the American Cancer Society an impressive breadth and depth of experience as an executive leader, practicing surgical oncologist, researcher, and entrepreneur, skills that will help us pursue our 2035 challenge goal to reduce cancer mortality by 40 percent.

    Since 2016, Dr. Cance has been at the University of Arizona, serving as deputy director and presently as interim director of the Arizona Cancer Center in Phoenix. He is highly regarded as a leader who established a culture of collaboration that advanced cancer care and treatment. He has been a professor in the departments of interdisciplinary oncology, pharmacology and toxicology, and surgery for the University of Arizona Colleges of Medicine and Pharmacy in Phoenix. 

    Dr. Cance, who goes by "Bill," has an active surgical oncology practice, and he is principal investigator for a 25-year National Cancer Institute grant focused on focal adhesion kinase, a protein involved in cancer metastasis. He holds eight patents and has been involved in several entrepreneurial projects to bring his research advancements to market, much in the same way our BrightEdge impact fund seeks to do.

    Prior to joining the University of Arizona, Dr. Cance held leadership positions at Roswell Park Cancer Institute, the University of Florida, and the University of North Carolina. He earned undergraduate and medical degrees from Duke University, and he completed a residency in general surgery at Barnes-Jewish Hospital/Washington University School of Medicine and a fellowship in surgical oncology at Memorial Sloan Kettering Cancer Center. 

    In his announcement email to all staff last Thursday, CEO Gary Reedy gave a special acknowledgement to Len Lichtenfeld, MD, for his leadership and the excellent job he has done as interim chief medical and scientific officer since November 2018. Gary also thanked the volunteers and staff who assisted in the interviewing process. 

    If you would like to share this news with others, here is a link to the press release on cancer.org.

    PHOTO: Pictured with Dr. Cance in the smaller image is his wife, Jenn. It was taken during a trip to the Grand Canyon.


  • Cancer survivors in high deductible health plans more likely to have delayed care

    ​A new study from American Cancer Society investigators finds cancer survivors in high deductible health plans were more likely to report delaying or foregoing care. The study appears in the Journal of Oncology Practice. Below is a short recap of the study from lead author Zhiyuan "Jason" Zheng, PhD, principal scientist, health services research.

    Question Asked:

    How do high-deductible health plan (HDHP) enrollment and health savings account (HSA) status affect cancer survivorship, access to care, and health care utilization?

    Summary Answer:

    HDHP enrollment without an HSA is associated with worse access to care in privately insured cancer survivors and individuals without a cancer history. HSA enrollment coupled with an HDHP may mitigate this effect. Associations did not vary by cancer history. Emergency department (ED) visits didn't vary significantly by insurance type in cancer survivors.

    What We Did:

    The 2010 to 2017 National Health Interview Survey was used to identify a nationally representative sample of privately insured adults ages 18 to 64 years (cancer survivors, n = 4,321; individuals without a cancer history, n = 95,316). The sample was categorized into six groups: three groups of cancer survivors enrolled in low-deductible health plans (LDHPs), HDHPs with HSA, and HDHPs without HSA; and three groups of adults without a cancer history enrolled in LDHPs, HDHPs with HSA, and HDHPs without HSA. Separate multivariable logistic regressions were conducted to assess the association between HDHP enrollment with or without HSA status and delayed/forgone care because of cost and ED visits.

    What We Found:

    There were no differential impacts of HDHP enrollment and HSA status on access to care and ED visits by cancer history. However, we found that, even when covered by private insurance, cancer survivors enrolled in an HDHP with or without an HSA (8.9% and 13.9%, respectively; both P < .05) were more likely to experience delayed/forgone care compared with cancer survivors enrolled in low-deductible health plans (7.9%). Moreover, only one third of high-deductible health plans enrollees, regardless of cancer history, had an HSA, which was associated with less delayed/forgone care. For ED visits, cancer survivors reported similar percentages (approximately 20%) of visits regardless of HDHP enrollment and HSA status.

    Bias, Confounding Factors:

    Our findings that HSA enrollment appears to mitigate problems with access to care among those with HDHPs could be confounded by greater financial capability among those who are eligible for and enroll in an HSA (eg, financial literacy, knowledge of financial options, and assets) than those who are eligible but without an HSA. We did not have information about the reasons for enrollment in an HDHP (eg, because of lower premiums or employers' limited plan choices).

    Real-Life Implications

    Health plan benefit managers, payers, and policy makers should identify reasons for low HSA participation rates, provide more education about the benefits of different health plan options to help patients understand the implications of health plans and HSAs, and develop tools to forecast medical expenses and facilitate HSA enrollment.


  • ACS and St. Baldrick's launch "Cancer Doesn't Care"

    ​The goal is to raise $4.4 million by this fall

    The American Cancer Society and the St. Baldrick's Foundation are proud to announce, "Cancer Doesn't Care," the next phase of our joint campaign to raise funds to fight childhood cancers. This major fundraising initiative – which runs through August and September – will utilize an email campaign, social, and other marketing to help us get the word out about this crucial partnership. 

    ACS and St. Baldrick's have committed to working together to raise a total of $11 million dollars to fund the most innovative biological and clinical laboratory studies related to childhood cancer, with $4.4 million being raised by this fall. 

    The objective of the Cancer Doesn't Care campaign is to reach our first fundraising goal of $4.4 million so that we can begin offering new research grants related to childhood cancer as part of our partnership with St. Baldrick's. 

    About the Cancer Doesn't Care Campaign

    The Cancer Doesn't Care campaign captures the idea that cancer can change a family's life in a flash without warning. To do that, we show a scene that everyone can relate to, but this scene – once filled with giggles and naps and fun – now sits in waiting for that child to return. This campaign is raw, honest and was developed with the support of real families who have lived with this reality every day. 

    Beginning in early August, you will see the Cancer Doesn't Care campaign featured on ACS and St. Baldrick's master brand social media sites, cancer.org/stbaldricks, and stbaldricks.org/acs. You can help by sharing posts out to your own personal social network and encouraging friends and family to donate to help conquer kids' cancers.

    For additional information on this partnership, please refer to the February news article announcing our partnership with St. Baldrick's. If you have questions, please contact Melissa Northrop, senior director, Principal Partnerships, or TJ Koerner, senior scientific director, Extramural Research.  


  • Rapidly growing older population increases demand for cancer care

    ​A new report from the American Cancer Society details rates of new cancer cases and cancer deaths among adults 85 years old and older, often called the "oldest old." The number of Americans in this age group is expected to nearly triple from 6.4 million in 2016 to 19 million by 2060. 

    It's the fastest-growing population group in the U.S. Because cancer risk increases with age, this rapidly growing older population will increase demand for cancer care.

    The report, "Cancer Statistics for Adults Aged 85 Years and Older, 2019," was published today in CA: A Cancer Journal for Clinicians, a peer-reviewed journal of the American Cancer Society. A companion piece was published in January as a Special Section in "Cancer Facts & Figures 2019."

    The report provides information about incidence and mortality rates and trends, survival, treatment, and the unique challenges affecting cancer in the oldest old.

    • People 85 and older represent only 2% of the population, but 8% of all new cancer diagnoses. That translates to about 140,690 cases in 2019.
    • The most common cancers are the same as for the general population: lung, breast, prostate, and colorectal cancers.
    • Cancer is the second-leading cause of death in the oldest old, following heart disease.
    • About 103,250 cancer deaths among this age group are expected in 2019, accounting for 17% of all cancer deaths.
    • As of January 1, 2019, an estimated 1,944,280 people 85 and older were cancer survivors, representing 1/3 of all the men and ¼ of all the women in this age group. They are the fastest-growing group of cancer survivors.
    • Among adults age 85 and older with no history of cancer, the risk of a cancer diagnosis in their remaining lifetime is 16.4% for men and 12.8% for women.

    Concerns about overtreatment and undertreatment

    The researchers found that the oldest old were being screened at higher rates than they expected. Most guidelines generally recommend against cancer screening in those with less than a 10-year life expectancy because the risks of screening and treatment (if cancer is found) tend to outweigh the benefits. At the same time, the authors note that age alone does not predict life expectancy, physical function, or the ability to tolerate treatment.

    They also note that treating older patients with cancer is often complicated because they are more likely to have other serious health problems. This might result in some older patients getting less aggressive treatment than younger patients in similar situations. Patients with cancer who are 85 years and older have the lowest relative survival of any age group.

    Authors say more research on cancer in the oldest Americans is needed to better understand how to meet their needs. “The rapid growth and diversification of the population aged 85 years and older will increase demand and complexities for cancer care and could have a substantial impact on medical care resource allocation. There is an urgent need to develop a more comprehensive evidence base to guide treatment decisions for these understudied patients with cancer through increased enrollment in clinical trials and to leverage research designs and infrastructure for generating evidence on older adults with cancer.”

    This study was led by Carol DeSantis, MPH, and supported by leading geriatric oncology experts from City of Hope, University of Rochester Medical Center, and Duke University Medical Center, analyzed data from the National Cancer Institute, the North American Association of Central Cancer Registries, and the National Center for Health Statistics.

    Thank you to Stacy Simon, the author of this story which first appeared on cancer.org.

  • ACS's Becky Siegel quoted at length in NYT article on rising colorectal cancers among young adults

    ​Check out this story in the July 31 New York Times about data from Canada and the U.S. showing a sharp increase in colorectal cancer among adults in their 20s and 30s.

    Rebecca Siegel, MPH, an epidemiologist and scientific director of our Surveillance Research department is quoted at length.

    Until there is more research into what is causing the increase in colorectal cancers, Ms. Siegel encourages younger people to be more proactive about identifying signs early on. Persistent constipation, cramps, bloating, blood in stool, unexplained weight loss, and fatigue can all be symptoms.

    Younger people and their doctors often overlook the warning signs because “cancer is not on their radar,” Ms. Siegel said.

    The American Cancer Society recommends that colorectal cancer screening begin at age 45 for people with average risk.


  • Hurricane disasters affect patient care

    Lung cancer patients who had a hurricane disaster declared during radiotherapy had worse overall survival than those who completed treatment in normal circumstances. The finding comes from a report by American Cancer Society investigators published in JAMA, which suggests several mitigation strategies, including arranging for transferring treatment and eliminating patient out-of-network insurance charges during disasters.

    Natural disasters such as hurricanes can interrupt the provision of oncology care. Radiotherapy is particularly vulnerable because it requires dependable electrical power and daily presence of specialized teams and patients for treatment delivery. Disruptions are especially concerning for patients undergoing treatment for locally advanced non-small cell lung cancer (NSCLC) because treatment delays as little as two days can impact survival.

    "While we could not analyze every potentially explanatory factor for the poorer outcomes in our study, treatment delay is one of the few hurricane-related disruptions that can actually be prevented," said Dr. Leticia Nogueira, lead ACS investigator. "Cancer patients receiving radiotherapy are a vulnerable population, and right now, there are no recommended strategies to mitigate treatment delays, so disaster management efforts that include tactics to identify patients, arrange for their treatment to be transferred, and to eliminate out-of-network insurance charges should be considered."

    The authors say research is needed to evaluate the potential impact of other types of natural disasters on cancer and other diseases and their treatments.

    Learn more on cancer.org.


  • ACS research finds more screening doesn’t fully explain the rise in colorectal cancer cases

    ​Colorectal cancer (CRC) is being diagnosed more often in the United States among adults younger than age 55. Does this mean more of them are getting colorectal cancer? Or are doctors finding it more often because more younger adults are having colonoscopies? In a study published in the Journal of Medical Screening, researchers at the American Cancer Society (ACS) found that colonoscopy trends don’t completely line up with the rates of colorectal cancer diagnosis by age, so more screening doesn’t fully explain the rise in CRC cases.

    ​Fewer people 55 and older in the United States are being diagnosed with colorectal cancer, in part because more of them are having colonoscopies. With this screening tool, doctors can find and remove growths before they become cancerous. But it’s a different story for younger adults: Among people in their 40s, for example, colon cancer rates have increased by 1.3% per year since the mid-1990s, and rectal cancer rates have gone up by 2.3% per year since the early 1990s.

    ​To better understand the increased colorectal cancer rates, ACS researchers looked at US data from 2000 to 2015 for 53,175 adults aged 40 to 54. The researchers looked at the percentage of people who said they’d had a they’d had a colonoscopy in the past year. They also looked at the percentage of people who were diagnosed with colorectal cancer during the 15-year period.

    ​The study divided people into three age ranges: 40 to 44, 45 to 49, and 50 to 54. Colonoscopy rates didn’t increase for every age group, but CRC rates did. Specifically, colonoscopy rates went up for the 45 to 49 and 50 to 54 age groups but were fairly stable for the 40 to 44 group. Colorectal cancer rates increased in every group. 

    ​“In this study, some patterns in colorectal cancer diagnoses were consistent with colonoscopy trends, like the rise in both colonoscopy and early-stage cancer among 50- to 54-year-olds, whereas others weren’t,” said Stacey Fedewa, PhD, lead author of the study. “For example, there was no increase in colonoscopy among people in their early 40s to match the increasing rates of colorectal cancer in this age group.”

    ​If the increase in CRC rates was only because colonoscopies were finding more tumors, then researchers would expect to see large increases in early-stage cancers. That’s because screening is most likely to find cancer when it is localized or limited to the place where it started with no sign of spreading. But only some age groups had increased diagnoses at an earlier stage.

    ​However, ACS researchers did find that the number of people diagnosed with later stage colorectal cancer increased for all age groups, with people ages 40 to 44 having the steepest increase.

    ​“This study only addressed one hypothesis—increasing colonoscopy—as to why colorectal diagnoses are increasing in younger adults,” Fedewa said. “It’s thought that changes in established risk factors for colorectal cancer could also be contributing to the increase. Those risks include obesity, drinking too much alcohol, poor diet (such as eating too little fiber and too much red/processed meat), physical inactivity, and smoking.”

    ​The ACS recommends that most people – those at average risk – start regular screening at 45. People can choose from among several types of tests, including stool-based tests, colonoscopy, CT colonography (virtual colonoscopy), and sigmoidoscopy. People with an increased risk may need to start screening before age 45. Learn more by reading the full ACS guidelines for colorectal cancer screening.

    What to know about colorectal cancer

    ​Use these links to do all you can to lower your risk for getting colorectal cancer.

    Article written by Sandy McDowell, Senior Editor, Research and appears on cancer.org.


  • The costs of cancer in 2015: 8.7 million years of life and $94 billion in lost earnings

    ​New analysis identifies which cancers and which states are associated with the greatest cost

    Cancer took more than 8.7 million years of life and $94.4 billion in lost earnings among people ages 16 to 84 in the United States in 2015. The calculation comes from a new report by American Cancer Society researchers that appears early online in JAMA Oncology.

    Cancer is the second-leading cause of death in the U.S., expected to cause more than 606,880 deaths in 2019. Cancer deaths impose significant economic burden in the U.S. because of productivity losses due to premature death. Accurate information on the economic burden of cancer mortality can help in setting policies and prioritizing resources for cancer prevention and control. However, contemporary data are lacking for the U.S. nationally and by state. 

    To update estimated lost earnings due to death from cancer, investigators led by Farhad Islami, MD, PhD, (pictured here) calculated person-years of life lost using numbers of cancer deaths and life expectancy data in individuals aged 16 to 84 years who died from cancer in the U.S. in 2015. They created estimates for cancer deaths overall and for the major cancers in the U.S. nationally and by state. The estimates are for lost earnings alone, and do not include other costs associated with cancer, including costs of treatment and caregiving. 

    A total of 492,146 cancer deaths occurred in people ages 16 to 84 in the U.S. in 2015, translating to a total of 8,739,939 life years lost. Overall lost earnings were $94.4 billion, and $191,900 per cancer death. Lost earnings were $29.0 million per 100,000 population overall.  

    Lung cancer cost the most in lost earnings ($21.3 billion; 22.5% of total), followed by colorectal ($9.4 billion; 10.0%), female breast ($6.2 billion; 6.5%), and pancreatic ($6.1 billion; 6.5%) cancers. By age, lost earnings were highest for leukemia in ages 16 to 39 while lung cancer was highest in ages 40 and over. 

    Lost earnings per 100,000 population varied considerably by state, ranging from $19.6 million per 100,000 in Utah to $35.3 million per 100,000 in Kentucky. States with the highest age-standardized lost earning rates were in the South, followed by states in the Midwest. States with the lowest age-standardized lost earning rates were in the West, Northeast, and Hawaii. 

    If all states had Utah’s lost earnings rate in 2015, lost earnings in the U.S. would have been reduced by 29.3%, or $27.7 billion, and life years lost nationwide in 2015 would be reduced by 2.4 million. 

    “Years of life lost and lost earnings were high for many cancers for which there are modifiable risk factors and effective screening and treatment, which suggests that a substantial proportion of our current national mortality burden is potentially avoidable,” said Farhad. “Applying comprehensive cancer prevention interventions and ensuring equitable access to high-quality care across all states could reduce the burden of cancer and associated geographic and other differences in the country. Health care professionals can contribute to achieving this goal because they play a central role in the delivery of cancer prevention, screening, and treatment.” 

    Robin Yabroff, PhD, senior author of the study, added, “These findings have implications for health policy makers. Health insurance coverage, which varies substantially by state, is one of the strongest predictors of access to care. Ensuring equitable access to high-quality care through increased health insurance coverage options could reduce differences in the burden of cancer across states. Medicaid expansion, in particular, helps the most disadvantaged populations.”
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