Trends in Incidence of Early-Onset Colorectal Cancer in the United States Among Those Approaching Screening Age

Abstract

Importance: Early-onset colorectal cancer incidence rates among patients aged 45 to 49 years have been considered much lower compared with the rates among patients aged 50 to 54 years, prompting debate about earlier screening benefits at 45 years. However, the observed incidence rates in the Surveillance, Epidemiology, and End Results (SEER) registries may underestimate colorectal cancer case burdens in those younger than 50 years compared with those older than 50 years because average-risk screening is generally not performed to detect preclinical cases of colorectal cancer. Finding steep incidence increases of invasive stage (beyond in situ) cases of colorectal cancer from age 49 to 50 years would be consistent with high rates of preexisting, undetected cancers in younger patients ultimately receiving a diagnosis of colorectal cancer after undergoing screening at 50 years.

Objective: To assess the preclinical burden of colorectal cancer by analyzing its incidence in 1-year age increments, focusing on the transition between ages 49 and 50 years.

Design, setting, and participants: Data from the SEER 18 registries, representing 28% of the US population, were used to conduct a cross-sectional study of colorectal cancer incidence rates from January 1, 2000, to December 31, 2015, in 1-year age increments (ages 30-60 years) stratified by US region (South, West, Northeast, and Midwest), sex, race, disease stage, and tumor location. Statistical analysis was conducted from November 1, 2018, to December 15, 2019.

Main outcomes and measures: Incidence rates of colorectal cancer.

Results: A total of 170 434 cases of colorectal cancer were analyzed among 165 160 patients (92 247 men [55.9%]; mean [SD] age, 51.6 [6.7] years). Steep increases in the incidence of colorectal cancer in the SEER 18 registries were found from 49 to 50 years of age (46.1% increase: 34.9 [95% CI, 34.1-35.8] to 51.0 [95% CI, 50.0-52.1] per 100 000 population). Steep rate increases from 49 to 50 years of age were also seen in all US regions, men and women, white and black populations, and in colon and rectal cancers. The rate ratio incidence increase in the SEER 18 registries from 49 to 50 years of age (1.46 [95% CI, 1.43-1.51]) was significantly higher than earlier 1-year age transitions. Steep rate increases in the SEER 18 registries were found from 49 to 50 years of age in localized-stage (75.9% increase: 11.2 [95% CI, 10.7-11.7] to 19.7 [95% CI, 19.0-20.3] per 100 000) and regional-stage (30.3% increase: 13.2 [95% CI, 12.7-13.8] to 17.2 [95% CI, 16.7-17.8] per 100 000) colorectal cancers. A total of 8799 of the 9474 cases (92.9%) of colorectal cancer in the SEER 18 registries from 2000 to 2015 that were diagnosed among individuals aged 50 years were invasive.

Conclusions and relevance: Steep incidence increases between 49 and 50 years of age are consistent with previously undetected colorectal cancers diagnosed via screening uptake at 50 years. These cancers are not reflected in observed rates of colorectal cancer in the SEER registries among individuals younger than 50 years. Hence, using observed incidence rates from 45 to 49 years of age alone to assess potential outcomes of earlier screening may underestimate cancer prevention benefits.

Figure 1.. Colorectal Cancer Incidence Rates per 100 000 Population in 1-Year Age Increments in the US Surveillance, Epidemiology, and End Results 18 Registries Among Patients Aged 30 to 60 Years, 2000-2015

Only adenocarcinomas were analyzed. The arrowhead indicates the incidence rate increase from 49 to 50 years of age (46.1% increase: 34.9 [95% CI, 34.1-35.8] to 51.0 [95% CI, 50.0-52.1] per 100 000 population).

Figure 2.. Colorectal Cancer Incidence Rates per 100 000 Population Stratified by Stage in US Surveillance, Epidemiology, and End Results 18 Registries Among Patients Aged 30 to 60 Years, 2000-2015

Within the figure key, the percentage increase in incidence from age 49 to 50 years for each stage is reported. The orange numbers indicate yearly case counts from 45 to 50 years of age in localized stages, and the blue numbers indicate yearly case counts from 45 to 50 years of age in regional stages. ^aCase counts for 49 and 50 years of age specifically.

Figure 3.. Five-Year Relative Survival by Age in the US Surveillance, Epidemiology, and End Results 18 Registries Among Patients With Colorectal Cancer Aged 30 to 60 Years, 2000-2015

The only statistically significant difference in yearly age transition was from 49 to 50 years. The arrowhead indicates a statistically significant increase in survival from 49 to 50 years of age (absolute increase, 6.9%; relative increase, 10.1%).