Young Onset CRC | YMyHealth

What does a person who has colorectal cancer (CRC) look like to you?

Maybe it’s an image of someone with gray hair and grown children, about a decade away from retirement. Perhaps even closer to that time.

While there are still plenty of people who are like that, it’s time the public and healthcare system fully changed its lens.

The picture of what a person who has or has survived colorectal cancer looks like has changed drastically. And the numbers are absolutely staggering.

By 2030, in six short years, it is predicted that 27,400 Americans between the ages of 20-49 will be diagnosed with colorectal cancer. That means that people who are in the prime of their lives—in college, graduating college, starting their careers, in the middle of building their careers, dating, getting married, having children, raising young children and more—will receive the news that they have early-age onset colorectal cancer.

That’s why it is more important now than ever that people in their 20s, 30s, and 40s be aware of what colorectal cancer is and how it appears in young people, their true susceptibility to the disease, and that they must prioritize colorectal cancers screenings for early detection.

As a fellow millennial and gastroenterologist, Vanessa Costilla, MD, knows firsthand how complex navigating the healthcare system is, especially when it comes to preventing colorectal cancer and getting a diagnosis. She shares her experience and expert advice with us on how to do that successfully in a time of skyrocketing early-age-onset colorectal cancer cases while the earliest screening age for people of average CRC risk remains 45.

Interview with GI Specialist Dr. Vanessa Costilla

Background and experience

Costilla, who practices at UMC Gastroenterology in Lubbock, Texas, has been officially practicing for seven years since completing her gastroenterology fellowship. In all that time and throughout her training, she has seen thousands of patients and performed more than 7.000 colonoscopies. Her patients range in age from 18 to 90 years old, and they are mainly women.

Common GI issues in young adults

The most common conditions and symptoms millennial-age patients visit Costilla for are acid reflux, abdominal pains, and a lot of irritable bowel syndrome (constipation or diarrhea type).

Since Lubbock is home to Texas Tech University, which is a very large, division one school, Costilla takes care of a lot of students as well.

“I find a lot of inflammatory bowel disease in my college-age students and young adult professionals. It’s a disease of young people and that’s when we tend to diagnose it,” she said.

Vanessa Costilla, MD, is a gastroenterologist at UMC Gastroenterology in Lubbock, Texas. She earned her medical degree from Texas Tech University Science Health Center and is double board-certified in internal medicine and gastroenterology. She did her residency in internal medicine at Mayo Clinic and completed her fellowship in gastroenterology at University of Texas Health Science Center.
She has performed **more than 7,000 colonoscopies**.

Challenges of young-onset colorectal cancer

One of the greatest challenges of diagnosing CRC in young people is that symptoms of conditions overlap. Also, not all doctors listen to young patients’ symptoms and partner with them to push for further testing.

“I've had a lot of patients who come in and say, ‘Oh, I've been told I had irritable bowel syndrome (IBS) my entire life. Patients can meet the IBS criteria easily. One criterion is having abdominal pain that is relieved by having a bowel movement. Despite fitting those criteria, sometimes there is something else going on endoscopically, pathologically, and is organically wrong- such as inflammation in the gut.”

She tells me that gastroenterologists like her think about IBS as being more an issue of motility (movement). So, with constipation-type IBS, your gut is not moving like it should. However, there is not necessarily a blockage causing that, she said.

“People ended up in my clinic because they're having symptoms, and so I applaud them for coming in. Often times I will tell you, I have had several patients who were diagnosed with IBS and ended up having inflammatory bowel disease or celiac disease, something else that just had not been looked for because they met the criteria for IBS,” Costilla said.

When younger people have symptoms and cannot get help from their healthcare providers, people quit looking. “It may be intimidating, but it is always very important to advocate for yourself and the symptoms you are having,” Costilla said

She reveals that what is challenging for physicians is walking the fine line between non-invasive and invasive testing. She always listens to her patients and respects their wishes about not having invasive tests.

“But if the symptoms they experience do not get better, I'm really going to push them to do more invasive diagnostic testing,” Costilla emphasized. “We do sometimes find very scary things, and then I'm glad that we went that direction.”

Colorectal Cancer Symptoms

There are multiple signs and symptoms that can tip you off to colorectal cancer. They include:

Changes in bowel habits, including diarrhea, constipation, or narrowing of the shape of stool, all that persists over a few days
Rectal bleeding with visible red blood
Blood in the stool (this can change your stool’s appearance from dark brown to black)
Constantly changing bowel habits (such as feeling like you have not fully passed all of your stool during a bowel movement)
Abdominal cramping or pain
Fatigue and weakness
Unintentional weight loss that is not happening for a particular reason.

“The biggest thing I would say is any form of bleeding. Bleeding is not normal. If you told me that you had rectal bleeding, even if it happened three times and hasn't happened again in the last few weeks, that rectal bleeding definitely requires an endoscopy or colonoscopy for evaluation, depending on where I think the bleeding is coming from,” Costilla said.

“Cancer can bleed intermittently. It doesn't mean that you're going to bleed every single time that you have a bowel movement.”

Another thing to watch out for: your stool caliber.

“If you notice that you're having a really hard time getting stools out despite treatment, let's say you're having worsening constipation that's not responding to your normal treatment that definitely warrants more intervention and more diagnostic workup,” Costilla explained.

Family History

Knowing your family history is crucial for making decisions about your colorectal health, screenings and for putting your symptoms into further context.

“If you have a first-degree relative (biological parents or siblings) who has had colon cancer or multiple second-degree relatives (grandparents, aunts, uncles) with colon cancer, its recommended that you start your screening at age 40 or 10 years before the youngest person in your family was diagnosed,” Costilla told us. So, if that youngest person was diagnosed at 40, then you should be starting your colonoscopy at age 30.”

This also goes for a family history of colon polyps.

Polyps are a mass of abnormal cells that grow on the inside lining of the colon. While colon polyps are common and many will never become cancerous, it’s important to remember that almost all colorectal cancers start from a polyp.

“You need to get screened earlier especially if your family member had the precancerous types of polyps, polyps that could have turned to cancer had they stayed there,” Costilla said. “For a family history of polyps, we still recommend actually starting at least at age 40 or 10 years before the youngest person in your family was diagnosed with precancerous polyps.”

Personal experiences treating young-onset CRC

Of the many personal experiences surrounding patients with young-onset CRC or potential onset, there are a few stories that stand out for Costilla.

The first is a story of the importance of prevention. She had a personal friend who at age 29 learned from her mom that her mom had an aggressive precancerous polyp in her 20s. At the time her friend was 29, shared the story with Costilla, and she did a colonoscopy. Sure enough, her friend who had no symptoms had a huge polyp in her right colon.

“Thank goodness she learned this family history from her mom and did the colonoscopy when she did because if she had waited until 45, we would likely not be dealing with a polyp, we’d be dealing with cancer,” Costilla said.

Another story is about noticing your symptoms and the importance of taking action. She had a 34-year-old patient who was a farmer. He was having rectal bleeding and thought for sure it was hemorrhoids. He asked her to just take those out. Instead, she recommended he do a colonoscopy.

When she did, they found a large precancerous polyp in his sigmoid colon. His parents had never had colonoscopies. When they were screened, they each had colon polyps. His siblings, who were also young, thankfully were clear on their screenings, but still his screening saved his life and offered powerful prevention to his parents and siblings.

Differences between younger and older CRC

In comparison to people who are older and diagnosed with CRC, Costilla finds young patients have more advanced cancers (Stage III and Stage IV). It is also common to have patients who have gone a long time without any alarming symptoms before getting screened.

Another subset of younger patients are ones who have genetic mutations that predispose them to colon cancer, making them at a higher risk, and they don’t know it. One of those is Lynch Syndrome, which you inherit through your family’s genes. Colon cancers in inherited syndromes look different than normal colon cancers.

“There appearance is more subtle. They sometimes are very flat polyps or alterations rather than huge polyps. Sometimes it doesn’t even look like it’s cancer, and its cancer inside a flat polyp,” Costilla said.

She would encourage people who have hereditary cancer syndromes or an extensive family history but haven't been officially diagnosed with that to have genetic testing. Knowing if you have a hereditary cancer syndrome is super important for you and your doctor. It will help your doctor know to look for a different type of polyp appearance on screening, and it will allow you to justify getting screening colonoscopies sooner—the key to early detection.

Reasons for increasing rates in millennials

The idea of genetic testing and using any other preventive tool at our disposal could not be important given the phenomenon of the rise in early-age onset colorectal cancer diagnoses.

While there is still a lot they don’t know, Costilla said, probably the biggest factors are obesity and diet, particularly processed foods—something that can be hard to avoid in U.S. That said, she wants you to know there is hope, and GI specialists and other physicians and researchers are on the case.

“GI societies are actually having national conferences and summits, and bringing communities of GI docs and oncologists together to study this to figure out what exactly is going on because we do need to figure that out and take action to see what we can do to help prevent this and reduce the incidence of colon cancer in our younger patients,” Costilla said.

Proactive Prevention

What can you do to prevent colon cancer, if you are between the ages of 20-49? Here are some proactive steps for prevention that Dr. Costilla recommends you take:

Dig into your family medical history (it empowers you to know that you need a colonoscopy earlier)
Avoid processed foods and eat less red meat
Avoid smoking
Eat a diet that is high in fiber and antioxidants (FYI: raspberries are good for both)
Exercise
Maintain a healthy weight
Choose your gastroenterologist wisely
When you choose an endoscopy center for your colonoscopy, ask about their adenoma detection rates (how often your GI detects polyps) and withdrawal times (how much time they spend looking inside your colon; longer is better). Make sure those values are good.
If you have a family medical history of polyps or colorectal cancer, ask your doctor if taking Aspirin would be the right proactive measure for you.
Advocate for yourself, your symptoms, and your colonoscopy at the doctor’s office

The Future

Colorectal cancer is one of the few cancers with a sure-fire way to prevent it. It’s why it is incredibly important to us at YMyHealth to increase awareness of and education about the disease and encourage fellow millennials and Gen Z to get screened.

The potential for policy and screening changes to the recommended age for first colonoscopy and insurance coverage are on the horizon, and given the increasing data on early-age onset cases, and the incredible advocacy efforts at the state and federal level with organizations like Fight CRC, it is clear that change to prevent this disease in younger ages is in our future. While the timing of that change is not certain, there is one thing that definitely is.

Remember, regardless of age, the power for colorectal cancer prevention is in your hands!

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The Realities of Early-Onset CRC According to a GI Specialist