Cancer mortality is falling, with one exception: colorectal cancer is taking more and more of its lives among young people. The explanations of Prof. Dr. Amadeus Dobrescu, MedLife surgeon

Survival after a cancer diagnosis has increased significantly in recent years: recent data from the US show that five-year survival (the standard follow-up interval in oncology) has reached approximately 70% for cases diagnosed between 2015 and 2021. More effective screening, detection in early stages, when treatment can be curative, and the evolution of personalized therapies – explain part of this good news. There is, however, an increasingly visible exception: colorectal cancer, which in recent years is diagnosed in more and more young people (under 45), often in advanced stages. Univ. Prof. Dr. Amadeus Dobrescuprimary surgeon specialist in oncological surgery, collaborator of MedLife Medici's Hospital from Timișoara, says that the phenomenon is already seen in practice: “Unfortunately, it is no longer a rarity to meet very young patients. I even had a 23-year-old patient with such a pathology, diagnosed in an advanced stage of the disease”.

In the US, colorectal cancer has already become the leading cause of cancer death in adults under 50, although overall cancer mortality has declined sharply in recent decades. In an analysis widely cited in the international press, the overall rate of cancer deaths in people under 50 fell by about 44% between 1990 and 2023, but mortality from colorectal cancer increased by an average of 1.1% per year since 2005.

If in countries with well-designed screening programs mortality can be reduced through early detection, in countries where prevention is difficult to reach the population, patients tend to come later. In Romania, the OECD country profile explicitly notes that the availability of colorectal cancer screening has been limited, having been carried out “only through pilot projects since 2019”, which contributes to differences with the EU average in avoidable mortality from this type of cancer.

Cases at younger and younger ages

Beyond the statistics, the difference can be seen in the cases that reach the doctor: more and more young people, even up to 30 years old, some in advanced stages. “The younger the patients, the more aggressive the form of cancer can be”, emphasizes Dr. Dobrescu, explaining that, in practice, the evolution can be rapid, and early diagnosis is extremely important. The doctor gives a recent example: a 23-year-old woman, who arrived in the emergency room with a complication of colorectal cancer, was operated on, and a year after the operation she returned for another operation to restore normal intestinal transit.

Why young people reach “advanced stages”: disease considered rare, symptoms ignored, little suspicion

Colorectal cancer is still mentally associated with the over 50s. Moreover, in the practice of doctors, most patients are in the 50-70 age group.

But specialists from the National Cancer Institute (NCI) in the US point out that there are four warning signs that should be carefully investigated even before this age: persistent abdominal pain, transit changes (diarrhea or other repeated stool changes), rectal bleeding and iron deficiency anemia (iron deficiency). In the NCI analysis, rectal bleeding had the strongest association with disease, followed by iron deficiency anemia.

When the disease is not detected in time, and patients arrive with complications, in the emergency, there is a need for complex treatment and, sometimes, surgical decisions taken in a high-risk context. On the other hand, when patients go to investigations from the first changes that raise questions, and the cancer is diagnosed early, the chances that the surgical treatment will be curative are very high, emphasizes surgeon Amadeus Dobrescu.

What the patient gains when the operation can be done minimally invasively

Currently, cancer treatment in general is a multimodal treatment, decided by a multidisciplinary team consisting of a surgeon, gastroenterologist, radiologist, oncologist, radiotherapist, etc. “In addition to the surgical treatment, there is also the chemo-radiotherapy treatment”, says the doctor. In other words: the optimal operative moment is decided according to the staging and location of the tumor, the patient may also need neoadjuvant, chemotherapy and/or radiotherapy (especially in rectal cancer), to reduce the risk of recurrence.

One of the great advantages of early detection of colorectal cancer is the possibility of minimally invasive surgery: laparoscopic or robotic. “The oncological safety is the same as in classical surgery”, he says, emphasizing that the result is judged according to the oncological principles (resection margins, lymph nodes, operating piece), and the team's experience is essential.

The real differences, in practice, are for the patient: smaller incisions, less postoperative pain, faster resumption of transit and nutrition, earlier mobilization, shorter hospital stay and faster reintegration. These are advantages that, in patients' lives, translate into days gained, easier recovery and a better state of mind, essential for a good evolution after a cancer diagnosis.

In robotic surgery, the doctor sees a particular benefit in low rectal cancers, where working space is difficult and every millimeter counts. “The nerve bundles are visualized much more clearly, there is a lower risk of urinary and sexual dysfunctions”, he explains, pointing out a detail that we are less aware of at the beginning: not only survival matters, but also the quality of life after treatment.

One of the biggest fears of patients is the stoma (an opening in the abdomen through which the stool is collected in a special bag, temporarily or permanently). Dr. Dobrescu says that the installation of a stoma does not depend on the type of operation: classical or minimally invasive, but on the location (it is especially necessary in low rectal/occlusive tumors), on the stage and on the context: “in emergencies with occlusion, for example, it may be safer to make a temporary stoma, which will later be abolished, than to force a risky anastomosis”, explains the doctor.

“First of all, the safety of the patient must come first,” emphasizes the surgeon. And in some cases, the transit can be resumed after a period of time established together with the surgeon.

“A colonoscopy-gift at 50, or even after 40”

Although the exact causes of colorectal cancer are not fully known, there are some steps each of us can take to prevent the disease or its complications. First on the list of the most important steps we can take is screening. In the absence of a coherent national colorectal screening program, access to prevention often depends on doctor's recommendation and when people present for screening.

“I tell everyone that, at the age of 50, they should get a colonoscopy as a gift. In the current conditions, in which cancer appears more and more often in young people, I think the age of the first colonoscopy should be closer to 40”, recommends Dr. Dobrescu. A clear distinction made by the doctor is aimed at those who have cases of colorectal cancer in the family, but also in the case of those who turn to genetic tests that identify an increased predisposition to this type of cancer: the screening must be started earlier and personalized together with the attending physician, says the surgeon.

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