Younger Adults See Rising Pancreatic & Colorectal Cancer Rates
In an interview, Arvind Bussetty, MD, and Arvind Trindade, MD, delved into the rising rates of gastrointestinal cancers among younger patients.
Clinicians have been seeing rising rates of cancers, specifically pancreatic and colorectal cancers, in younger patients in the past 10 years. However, the question loomed whether this was a real rise in diagnoses or a case of referral bias.1 Arvind Bussetty, MD, internal medicine resident at Robert Wood Johnson Medical School, and Arvind Trindade, co-chief of endoscopy for Robert Wood Johnson University Hospital and advanced endoscopist at RWJBarnabas Health, set off to research the topic.
From an analysis of the SEER database between 2000 and 2021, the study found there to be a significant increase in the incidence of both pancreatic and colorectal adenocarcinoma, particularly in younger age groups (15 to 34 and 35 to 54 years). Specifically, the annual percentage change for pancreatic cancer was highest in the 15 to 34 age group, significantly exceeding that in older groups. While colorectal cancer incidence decreased in those 55 and older, it significantly increased in the younger age groups.
In an interview with Targeted OncologyTM, Trindade and Bussetty discussed the study, offered their hypotheses behind these rising cases, and urged health care professionals to be proactive when treating younger patients who present with red flag symptoms.
Targeted OncologyTM: Can you summarize the rationale for this research?
Arvind Trindade, MD
Trindade: I am an interventional endoscopist, which means beyond just standard endoscopy, which is upper endoscopy, is screening for precancerous conditions of the esophagus or the stomach. We tend to do a lot of pancreas biopsies, and that is basically where the camera goes in the mouth, goes down into the esophagus and stomach, and then sound waves bounce across the stomach wall. We are able to visualize the pancreas. Over the past decade, we are seeing more younger patients being referred for diagnosis of pancreas cancer and found to have either incidental or symptomatic lesions in the pancreas.
These patients make you pause a little bit, because [you think], “Why is a 30-year-old coming to me for a pancreas mass?” That was not the case 10 to 15 years ago. Pancreatic cancer was always thought of as something seen in the older population, 50s and 60s and above. So, it prompted us to say, “Okay, we need to look at this formally and really decide is this a phenomenon or not? Or is it just referral bias?”
The best way of doing it is you need a large dataset. The best dataset set that we have was the SEER database. The SEER database is a government database which represents over 40% of the population and across the US for patients with cancer. We used that database to see [if there was] an increased incidence of pancreas cancer. Specifically, our goal was to break it up by age groups and see [if there is] a trend in one direction for an increase of incidence in certain age groups.
Arvind Bussetty, MD
Bussetty: I think it was an interesting topic. There have been studies that have looked at things like this before. I think that with changing guidelines and [the medical community] being more on top of cancer screening, especially in GI world with [the screening age for] colon cancer reasonably changing to 45 years old, I think these considerations are important. Even being on the wards, I see younger patients who unfortunately are diagnosed with cancer at these young ages. I think it is important for other providers to be cognizant of it, because even with pancreas cancer, we don't really have screening guidelines for it. But at least understanding that it could really happen in any cohort, any age population, is important to know.
Do you have any hypotheses as to why we’re seeing these higher incidences?
Trindade: It is important to note that this study does is not designed to look at why this is happening. Large database studies give you a lot of data and they give you a lot of trends, but they don't necessarily always answer those questions.
If I had to hypothesize, I think it is environmental. I think it is change in diet, eating processed foods. I think stress plays an important role, too. I think these are all things that are occurring in a younger age group. In terms of screening processes, unlike colon cancer, where we screen age appropriately, and other cancers like breast and prostate, we don't do that for pancreas. It is unrealistic to have everyone undergo an endoscopic ultrasound, because overall incidence [of pancreatic cancer] is a lot lower.
In addition, something like colon cancer, which is preceded by a polyp that you could take out, and a polyp takes about 10 years or so to develop [into] a cancer, that is preventative. Unlike in pancreas cancer, the precursors to pancreas cancer could take just a few months to progress. Just because you have a screening exam in month 1, 12 months later, you could have a full-blown pancreatic cancer.
So, it does not make sense to have somebody undergo a screening exam every year. And even if you do it every year, you could be missing an interval pancreas cancer. Unfortunately, we do not have the best tools to screen for a pancreatic cancer, but we do screen high-risk individuals, individuals with known genetic mutations or a family history of pancreatic cancer in a first-degree relative. We will screen those patients because they're deemed high risk, and we will do an endoscopic ultrasound for those patients, alternating with a high-resolution MRI every other year.
Are there any considerations in approaching a younger patient vs an older patient who is presenting with suspected GI cancers?
Trindade: If an older patient were to come into the clinic having vague abdominal symptoms—just not feeling well, maybe losing weight—I think the urgency for cross-sectional imaging is very high. We normally would get a CT scan right away. If a younger patient were to come into the clinic with those same symptoms, you may cough it up to dyspepsia or an ulcer or something and put them on an antacid medication and maybe have them come back to the clinic in 8 weeks and see how they are doing if they were not improving. Maybe [we would] then do an endoscopy to look for an ulcer. If that was normal, they then get cross-sectional imaging, and that whole process could take months and delay a diagnosis of a possible pancreatic cancer. Now, we are not saying that everyone that comes in with abdominal pain who is young is going to have pancreatic cancer, but we are saying maybe if they are presenting with some red flags, worrisome symptoms like weight loss, anemia, things like that, then maybe you should consider cross-sectional imaging sooner than you traditionally would have, or maybe at the same time as you would for an older patient.
I think it is an important study, and it has gotten a lot of attention in the media. I am getting a lot of questions about it, because people are shocked, just as we were seeing it endoscopically. We were not shocked about the results because we are seeing it clinically. But I think a lot of the public or other gastroenterologists are saying, “Yeah, we have noticed this trend too.” I think it is important for primary care physicians who have not seen this trend as much because of referral bias to really be aware, to screen for red flag symptoms that we talked about and try to diagnose it as early as we can, because pancreatic cancer is very lethal. It progresses rather quickly, and the earlier we catch it, the better outcomes we could have.
Bussetty: Being an internal medicine resident, I work on the on the clinical side as an outpatient internal medicine provider. With the patient population that I see, they don't get an easy way to see a gastroenterologist sometimes. Going off what Dr Trindade said, having primary care providers understand that someone may be an exception to the rule of the current screening guidelines, and that these findings of weight loss and other clinical symptoms may need to be taken more seriously. That needs to be higher on the differential sometimes, depending on [the patient’s] genetics [and] family history.
