Re: Early-onset colorectal cancer (2)

Thank you for highlighting the important issue of early-onset colorectal cancer [BCMJ 2023;65:207-210].

In the article, it is stated that “population screening strategies in British Columbia remain unchanged, but recognition of possible early-onset colorectal cancer requires the vigilance of health care providers.” Diagnosis cannot depend strictly on the vigilance of health care providers when 59% of the population does not have a family doctor or has difficult accessing one and there is a known lack of public awareness of colorectal cancer symptoms and a delay in presentation to the primary care provider.[1,2] Vigilance of health care providers assumes that providers are educated on the signs and symptoms of early-onset colorectal cancer, the reasons for considering it in the differential, and the significance of obtaining an urgent colonoscopy. It is well known that patients are often misdiagnosed and feel dismissed by their primary care provider.[2] Public and provider education regarding early-onset colorectal cancer is paramount.

It is also stated that “[t]he BC Guideline for colorectal cancer screening encourages physicians to evaluate younger adults with symptoms or a family history of colorectal cancer by using colonoscopy.” Delays in obtaining a colonoscopy are associated with an increased risk of advanced-stage disease, and the Delphi Initiative for Early-Onset Colorectal Cancer international management guidelines recommend that colonoscopy be performed within 30 days of presentation with alarming symptoms.[3] (Red flag symptoms precede 70% to 95% of early-onset colorectal cancer cases.[4]) The Canadian Association of Gastroenterology Wait Time Consensus Group recommends endoscopy within 2 months. However, an Island Health 2020 performance assessment showed that 34% of patients waited longer for colonoscopy than their priority benchmark, and a St. Paul’s Hospital 2016 retrospective chart review showed that symptomatic patients waited a mean of 86 days to endoscopy.[5,6] BC Colon Screening Program 2019 results showed a median wait time to colonoscopy of 134 days after an abnormal fecal immunochemical test, and 85 days for patients at higher-than-average risk (including those with a family history).[7] Given that symptomatic patients and patients eligible for screening colonoscopy are not being seen within target ranges, it seems highly unlikely that younger patients will receive timely access to colonoscopy once their symptoms are deemed worrisome enough by their primary care provider to warrant it. This statement as it stands is not sufficient; potential solutions need to be considered.

Four reasons are outlined as justification for not immediately adopting an earlier screening strategy. It is imperative to acknowledge that further discussion around lowering the screening age needs to occur through addressing various research gaps, including a comprehensive cost-benefit analysis of adopting population-based screening for individuals aged 45–50 at average risk of colorectal cancer, and a more detailed understanding of risk factor profiles, which could inform precision screening for early-onset colorectal cancer. Screening programs detect colorectal cancer at earlier stages of disease in the over-50 population, and, given that early-onset colorectal cancer patients are more likely to present with advanced disease, an understanding is warranted of whether lowering the screening age would reduce the stage of disease at diagnosis and, therefore, not only the physical and mental ramifications for the individual but also the downstream economic costs to both society and the health care system.
—Petra Wildgoose, MD, CCFP, MPH
Toronto

This letter was submitted in response to “Early-onset colorectal cancer.”

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References

1.    Angus Reid Institute. Doc deficits: Half of Cana­dians either can’t find a doctor or can’t get a timely appointment with the one they have. 7 Sep­tember 2022. Accessed 29 September 2023. https://angusreid.org/canada-health-care-family-doctors-shortage.

2.    Colorectal Cancer Alliance. Never too young survey report 2020. Accessed 29 September 2023. www.ccalliance.org/about/never-too-young/survey.

3.    Cavestro GM, Mannucci A, Balaguer F, et al. Delphi Initiative for Early-Onset Colorectal Cancer (DIRECt) international management guidelines. Clin Gastroenterol Hepatol 2023;21:581-603.

4.    Burnett-Hartman AN, Lee JK, Demb J, Gupta S. An update on the epidemiology, molecular characterization, diagnosis, and screening strategies for early-onset colorectal cancer. Gastroenterology 2021;160:1041-1049.

5.    Island Health. Island Health performance measures: Colonoscopy wait times. March 2020. Accessed 29 September 2023. www.islandhealth.ca/sites/default/files/2019-07/t-colonoscopy-wait-times.pdf.

6.    Janssen RM, Takach O, Nap-Hill E, Enns RA. Time to endoscopy in patients with colorectal cancer: Analysis of wait-times. Can J Gastroenterol Hepatol 2016;2016:8714587.

7.    BC Cancer Colon Screening, Provincial Health Services Authority. BC Cancer colon screening 2019 program results. March 2021. Accessed 29 September 2023. www.bccancer.bc.ca/screening/Documents/Colon-Program-Results-2019.pdf.