Early Onset Colorectal Cancer (Eocrc) In A 43-Year-Old Woman: Current Guidelines Miss Patients At Risk For Eocrc

INTRODUCTION: The incidence of colorectal cancer (CRC) among individuals less than 50 years old is increasing and is estimated to double by 2030. Risk factors for early onset CRC (EOCRC), outside of hereditary CRC syndromes or personal history of IBD, are not well understood. We present a case of EOCRC in a 43-year-old woman. CASE DESCRIPTION/METHODS: The patient presented with six months of worsening hematochezia, abdominal pain, and constipation. Her past medical history included cervical dysplasia status post loop electrosurgical excision and thyroid follicular adenoma status post thyroid lobectomy. Her family history was significant for CRC in her father, diagnosed at age 80. CT abdomen/pelvis showed circumferential rectal wall thickening and prominent perirectal lymph nodes. Colonoscopy revealed a partially obstructing 3cm rectal tumor with associated severe stenosis that was only traversed with an EGD scope. Pathology showed colonic mucosa with high-grade dysplasia. A staging CT chest did not reveal metastases. Her clinical picture was suspicious for colorectal cancer and colorectal surgery recommended neoadjuvant chemotherapy followed by low anterior resection with diverting loop ileostomy. DISCUSSION: This patient's presentation was typical of EOCRC, which tends to present with left-sided disease and in patients older than 40 years. Her risk factor was a family history of CRC in her father; although, he was diagnosed at age 80 at an index colonoscopy. A family history of CRC, even in second- or third-degree relatives, has been associated with increased risk. Some studies have suggested that BMI, tobacco use, coronary artery disease, hypertension, stroke, diabetes, and socioeconomic status are risk factors for EOCRC. Other research indicates that combinations of age, male sex, personal history of IBD, or African American or Asian race are risk factors. Our current U.S. Preventive Services Task Force guidelines do not account for EOCRC. It is difficult to balance the cost effectiveness of initiating the American Cancer Society qualified recommendation to start screening at age 45 versus increasing screening rates and diagnostic colonoscopy completion rates among patients over age 50. As evidenced by our patient, simply lowering the screening age may not be an effective intervention to capture EOCRC phenotypes. Further research is needed to improve understanding of the associated biological and environmental risk factors to improve early identification of individuals at high risk for EOCRC.Figure 1.: Partially-obstructing rectal tumor prior to biopsy.