Time for colorectal cancer screening in India!

In developed countries, the rates of newly diagnosed colorectal cancer (CRC) and deaths due to CRC are decreasing over the past few decades. This has been possible due to better knowledge about the disease biology, improved screening, and early detection. Advances in treatments, both in surgery and systemic therapy, have been instrumental for this change. However, despite these advances, the increasing incidence of CRC in young people is worrisome. There is a lack of Indian data describing the incidence of CRC in younger patients. A study by Vasudevan and Mehta[1] in this issue of the journal presented a comprehensive data set on the epidemiological aspects of young-onset colorectal cancer (YO-CRC) patients from a large tertiary cancer care center in India. The study shows that about 25% of newly diagnosed CRC were diagnosed below the age of 40 years and were more likely to be in advanced stage (Stage III/IV), left-sided (predominantly more rectal adenocarcinomas), and nearly three times more likely to be signet-ring cell histology. With the follow-up information available for ∼70% of the data set (622/912), the authors concluded that overall survival was similar for YO-CRC and LO-CRC (late-onset colorectal cancer) even after making stage-for-stage comparisons. Median 5-year overall survival for Stage III was 70% (YO-CRC) versus 55% (LO-CRC), and for Stage IV was 32.4% versus 15.7%, respectively. Although there is a striking numerical difference, it was not statistically significant. Recently, the analysis of YO-CRC (defined as <50 years) from IDEA database was presented at the annual American Society of Clinical Oncology (ASCO) meeting 2021 by Fontana et al.[2] Although a greater number of high-risk YO-CRC patients (T4 and/or N2) completed planned chemotherapy, they had 26% higher risk of recurrence (3-year recurrence-free survival: 54.5% versus 64.5%, hazard ratio [HR]: 0.74, 95% confidence interval [CI]: 0.64–0.87), which translated into 19% higher risk of cancer-specific mortality (CSM) (CSM: 23.9% versus 20.7%, HR: 0.81, 95%CI: 0.67-0.99). This paradox is not yet fully understood; however, there may be some distinct intratumoral microbiome patterns in YO-CRC that may predict poor response to chemotherapy and increased toxicities.[3] In October 2020, the U.S. Preventive Services Task Force lowered the recommended age for CRC screening to 45 years owing to the rise in the incidence of YO-CRC patients over the past two decades.[4] This data set by Vasudevan and Mehta[1] is an eye-opener. This article must encourage those making treatment guidelines to undertake screening measures for CRC in India. Although comprising only 3% of all cancers in India, the incidence rates of CRC are rising (5.8 per 100,000 in 2004 to 6.9 per 100,000 in 2014).[5] With a broad-based population pyramid, India has only less than 10% population over 60 years.[6] This means that all the increased incidence trends of CRC in India will affect younger individuals the most. A simple fecal immunohistochemical test can successfully triage the patients in need of invasive colonoscopies.[7] With a sensitivity of 97% and a negative predictive value of 99.8%, this simple tool can be used for mass screening in appropriate individuals. Last year, the death of a famous Hollywood actor, Chadwick Boseman, caused a tremendous rise in public awareness about colorectal cancers.[8] The time is just right, and we must learn too.