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The American Cancer Society estimates that colorectal cancer — cancers of the colon and rectum — will be the second-leading cause of cancer deaths in Iowa this year, up from No. 4 just five years ago.
While colorectal cancer deaths in people age 50 and older have been decreasing — likely because this age group has been getting recommended screening tests — people younger than 50 are seeing both a rise in diagnoses and deaths. In fact, the rate of colorectal cancer has more than doubled for this age group since the 1990s.
This has led the American Cancer Society to update its guidelines and recommend screenings for colorectal cancer begin at age 45, instead of 50, and even earlier for anyone with risk factors.
“We are seeing a higher incidence throughout the country and in Iowa of our younger population of 40-year-olds and, unfortunately, even younger getting colon cancer,” said Liddy Hora, senior manager of cancer control strategic partnerships for the American Cancer Society in Iowa. “The earlier you catch cancer, the higher percentage that will survive cancer. It’s treatable.”
People under the age of 50 accounted for 12 percent of all colorectal cancer cases in the United States last year, with 18,000 cases, 1,570 of them in Iowa. While the exact cause of the increase is unknown, factors like diets low in fiber, increased consumption of processed food and red meat and increased rates of obesity and sedentary lifestyles could be factors.
UnityPoint Health gastroenterologist Dr. Dean Abramson said that in the past a young person with symptoms like rectal bleeding would have been thought to have hemorrhoids or constipation.
“We need to have people more aware of this occurring in younger people, and we need to have health care providers also more aware so we don’t make the potentially fatal assumption that this is all benign, that colon cancer doesn’t happen in young people,” he said. “We now know it does.”
Higher-risk factors for colorectal cancer include having a first-degree relative — a parent or a sibling — who has had colorectal cancer or polyps and people with inflammatory bowel disease such as ulcerative colitis, and people who are obese, smoke or heavy users of alcohol. Also, some patients have a genetic syndrome that elevates their risk for colorectal cancer.
Screenings down during pandemic
When colorectal cancer is found at an early stage before it has spread, the five-year survival rate is about 90 percent. But only about four out of 10 colorectal cancers are found at this early stage. When cancer has spread outside the colon or rectum, survival rates are lower.
“Currently, four out of every 10 people who should get tested and screened for colon cancer don’t and are missing out on the possible life-saving opportunity,” Hora said. “With COVID, we have seen throughout the United States — and Iowa has been affected, too — we have seen a 33 percent decrease in all cancer screenings. So this is on top of the already low numbers. This is very alarming.”
With 95 percent of colorectal cancers starting as a polyp — an abnormal clump of cells that forms on the lining of the colon or rectum — screenings make colorectal cancers one of the easiest to treat if caught early.
“Ideally, it’s great to find a colon cancer early because that really affects survival,” Abramson said. “But it’s probably even better to find an aggressive colon polyp and remove it to prevent cancer from ever forming.”
There are several options for screenings:
- Colonoscopy — recommended every 10 years starting at age 45 until age 75, more frequently if polyps are found and removed.
- A CT colonography — every five years; still requires a bowel prep.
- Stool-based tests, such as FIT or fecal immunochemical test — done every year.
- DNA tests such as Cologuard — every three years.
“The gold standard is colonoscopy and for good reason,” said Dr. Ujjwal Kumar, Mercy Medical Center gastroenterologist in Cedar Rapids. “Because one, it gives you peace of mind that you’re good for 10 years. Two, if you find something, you can take care of it right there and then, versus if your fecal test is positive, then you’ll be due anyway for a colonoscopy to get it checked.”
Kumar said the CT colonography might miss smaller polyps, which is why it must be done every five years. And again, if a polyp is found, a colonoscopy is required to remove it.
“So you might as well get a colonoscopy and get it done and get it over with,” Kumar said.
While a colonoscopy with sedation is painless for most people and takes only a few hours, many shy away from the procedure because of the bowel preparation required the day before to clean out the colon.
“If you look at it from another perspective, the inconvenience of having a bowel prep, versus if you have colon cancer and go through a surgery, it’s a no-brainer,” Kumar said. “And it’s not horrible. It’s just the volume (of the prep) that you have to drink that can be the problem.”
Another possible barrier for early screenings is whether a colonoscopy is covered by insurance. While the American Cancer Society guideline update, released in 2018, is relatively new, some insurance carriers have caught on and are covering screenings at age 45, Hora said.
UnityPoint Health’s Abramson said insurance usually will cover diagnostic colonoscopies but not always a screening procedure. If patients have no symptoms and no family history of colon cancer at age 45, they might need to start with a stool test to detect if there is blood in the stool or DNA fragments that would reflect colorectal cancer. If those tests are positive, then the patient will undergo a colonoscopy that would be covered by health insurance as diagnostic.
Hora recommends people contact their insurance company and see what would be covered before getting tested.
“It’s good to not have any surprises,” Hora said.
Hora and her colleagues at the American Cancer Society have been working with the major health care systems and rural systems in Iowa, the Iowa Department of Public Health, the Primary Care Association and the Iowa Cancer Consortium to educate doctors on the updated guidelines and to promote colon cancer screenings.
On top of educating health care workers, they also have been working to get the information out to the public through social media.
“As patients and Iowans, we have to be our own advocate,” Hora said.
While colorectal cancers can be asymptomatic, early warning signs include:
- Frequent rectal bleeding with stools
- Changes in bowel habits (very constipated or frequent diarrhea) or shape of stool
- Unexplained weight loss
- Abdominal pain