Colorectal Cancer: What Gen-Xers and Millennials Need to Know

Jorge Reguero Hernandez, MD, smiles as he talks to a female patient in an exam room.

Jorge Reguero Hernandez, MD, is treating more young patients for colorectal cancer.  Credit: Robert A. Lisak

Yale Medicine doctors warn that people as young as age 20 need to be aware of the warning signs.

Know the Signs and Symptoms
  • Rectal bleeding: This means blood coming from the rectum, or blood in the stool or in the toilet after a bowel movement.
  • Unusual stools: Keep an eye out for any changes, including dark or black stools.
  • Low energy or tiredness: This could be due to anemia from blood loss. If you are a young woman with chronic anemia that you assume is due to menstrual bleeding, it’s a good idea to explore other causes as well.

Nobody in their 20s, 30s or 40s gets colorectal cancer, right? Wrong. The truth is that colorectal cancer is on the rise in young adults, and has been for years. That’s why Yale Medicine surgeons who treat it are urging people younger than 50—even college students—to talk to their doctors about any suspicious symptoms, such as constipation, rectal bleeding or sudden changes in bowel movements.

Yale Medicine Colon & Rectal Surgery doctors report seeing young patients with a diagnosis of colorectal cancer more often these days. A few months ago they diagnosed colon cancer in a father of four in his 30s who thought for months that his rectal bleeding was caused by hemorrhoids. During a recent week, all of the seven patients the practice saw who were diagnosed with rectal cancer were young; the oldest was 35. The youngest colorectal cancer patient diagnosed at this location in recent months was 18.

In February, the American Cancer Society reported on the largest analysis of the trend so far in the Journal of the National Cancer Institute. They found people born in 1990—who would be 27 years old this year—have double the risk of colon cancer and quadruple the risk of rectal cancer compared to people born around 1950.

What makes the increase particularly mysterious is the fact that the overall incidence of colorectal cancer has dropped by 45 percent since the mid-1980s. While the cancer is still most frequently diagnosed in people over 55, the study found that patients younger than 55 were 58 percent more likely to be diagnosed with advanced disease.  

Even though colorectal cancer is often highly treatable, the diagnosis can be a major ordeal for Millennials and Generation Xers, who range in age from their early 20s to just over 50. It can interrupt careers and damage personal finances. Young people diagnosed with colorectal cancer may need to make quick, critical decisions about such matters as preserving sperm or eggs in case treatment impacts their fertility.

“It is always a shocking diagnosis,” says Jorge Reguero Hernandez, MD, one of two Yale Medicine colorectal surgeons who see patients in the Yale New Haven Health Park Avenue Medical Center in Trumbull.

The other surgeon in the Trumbull practice is Vikram Reddy, MD, PhD, who, about a decade ago, conducted one of the first studies identifying the rising incidence of colorectal cancer among young people. “We’re still seeing the trend, so it wasn’t temporary,” Dr. Reddy says.

Both doctors are passionate about educating people so the cancers will be diagnosed early, when they are most treatable. “If anyone has any change in their bowel habits, if they have any bleeding—even if they think it’s a hemorrhoid, and it doesn’t go away—just get a colonoscopy,” Dr. Reddy says.

At Smilow Cancer Hospital, Yale Medicine's colorectal surgeons treat a high volume of patients for all types of cancers of the colon and rectum. They work closely with other specialists, including oncologists, geneticists, gastroenterologists and radiologists to determine the best treatment.

For more information about colorectal cancer and the Smilow Screening & Prevention Program, click here. To schedule an appointment with a Yale Medicine colorectal surgeon, call 203-785-2616.

Why is there an uptick?

Nobody knows for sure why colorectal cancer numbers are rising in young people. “It could be the result of obesity, which is more prevalent, or poor diet. We know a healthy diet and lifestyle can reduce the risk of colorectal cancer,” says Charles Fuchs, MD, MPH, the new director of Yale Cancer Center and physician-in-chief of Smilow Cancer Hospital. A sedentary lifestyle, high blood sugar, vitamin D deficiency and eating a lot of red meat have all been associated with the disease. Heavy alcohol use and conditions such as type 2 diabetes are also possible causes.

Dr. Fuchs is a leading expert on colon cancer. His interest in the disease became personal when his wife, Joanna Fuchs, MD, a cardiologist, was diagnosed at the age of 44. She first noticed her symptoms during a vacation. Today, 11 years later, she is cancer-free, thanks to the fact that her cancer was diagnosed at an early stage and to laparoscopic surgery to remove the diseased part of her colon. Because of their family history, the Fuchs’ three children will start colorectal cancer screenings in their early 30s.

Vikram Reddy, MD, PhD portrait

Vikram Reddy, MD, pictured in front of a healing garden, conducted one of the first studies to identify a rise in colorectal cancer in young people. 

When someone is diagnosed with cancer at a young age, people also suspect genetics, but experts still haven’t been able to use genetics to explain the surge. The most common genetic condition associated with colon cancer is Lynch Syndrome, which typically involves tumors on the right side of the colon. That’s not what’s causing these cases. “We’re seeing a lot of young people whose colorectal cancer seems to be happening sporadically, as opposed to being caused by a particular genetic syndrome,” Dr. Reguero Hernandez says. 

Scientists at Yale and elsewhere are trying to learn more. “There may be other genes associated with predisposition for colorectal cancer that have yet to be discovered,” says Jessica DiGiovanna, MS, a licensed certified genetics counselor for the Smilow Cancer Genetics and Prevention Program. There are approximately 20,000 human genes, but scientists have only been able to map approximately one third of these genes to the human condition. For this reason, scientists are still working to identify genes that can help predict a person’s risk for particular diseases.

Meanwhile, researchers have been making progress in such areas as molecular tumor profiling, which analyzes DNA and other biological characteristics of tumor tissue samples. This can help determine treatment decisions.

However, Dr. Reddy says, “We haven’t identified all of the genetics around cancer, and we don’t understand the environmental triggers. So right now, my group is trying to do the research to treat the disease, rather than identify why people get it.” 

Should young people get colonoscopies?

Even though colorectal cancer is rising in young people, the incidence is still too low to justify routine colonoscopies for them. “Once you develop a screening test for a disease, you have to make sure that the number of screenings you do will prevent enough cancers to justify the costs of and risks associated with the tests,” says Dr. Reguero Hernandez. 

A colonoscopy is performed with the patient under general anesthesia. The doctor inserts a flexible tube with a light and camera on the end through the rectum to examine the colon. The tube also allows a doctor to remove any polyps (small bumps on the surface of the colon or rectum) that may be precancerous, heading off many cancers before they develop. For that reason, colonoscopy is considered to be one of the biggest reasons for the overall decrease in colorectal cancer.

Colonoscopies are recommended for most people at age 50, and repeated every 10 years. They are recommended at age 45 for African-Americans, who have a higher risk of colorectal cancer; and sometimes earlier for people who have a family history. But Drs. Reguero Hernandez and Reddy do prescribe colonoscopies for people of all ages who have symptoms such as rectal bleeding that they can’t diagnose with a different problem.

Short of a colonoscopy, Dr. Reddy recommends physical rectal exams in the office for anyone who reports a suspicious change in bowel movements. He says a simple rectal exam can often discover a suspicious mass in the rectum (although it can’t determine whether or not it’s cancerous). If the office exam turns up blood in the stool, the doctor can then send the patient for a colonoscopy.

If you’re not satisfied that your doctor has properly evaluated your symptoms, it’s smart to get a second opinion or even a third.

What can young people do to stay healthy?

Young people—like everyone else—need to communicate with their doctor if they notice any of the following symptoms. 

Rectal bleeding: This includes blood coming from the rectum, or blood in the stool or in the toilet after a bowel movement.

Unusual stools: Watch for any changes in the way your stool looks. Keep an eye out for dark or black stools, which may indicate bleeding from a tumor. Talk to your doctor if you have stool that is narrow, thin or ribbon-like, which may signal that a tumor is obstructing your bowels or rectum.

Changes in bowel movements: Look for loose stool (diarrhea) or constipation (less than three bowel movements a week), especially if the changes last two weeks or more.

Low energy or tiredness: This could be due to anemia from blood loss. If you are a young woman with chronic anemia that you assume is due to menstrual bleeding, it’s a good idea to explore other causes as well.

Dr. Jorge Reguero Hernandez, MD, with assistant Hope Serra

Dr. Reguero Hernandez and assistant Hope Serra deal with more young patients these days.

Don’t assume anything. Your symptoms may be different than those of someone you know who had colorectal cancer. The left side of the colon is narrow, so people who get cancer there tend to get more changes in bowel habits and bright red blood in their stool. The right side of the colon is wider, making these patients more likely to have anemia and less likely to get symptoms caused by an obstruction such as a polyp. Some people have no symptoms at all, so it’s important to talk to your doctor if colorectal cancer runs in your family. He or she may decide to recommend a colonoscopy before 50.

Don’t be afraid of the tests, either. Many people are put off by the preparation for a colonoscopy, which includes taking a strong laxative the day before to clean out the bowels. But colonoscopy is considered the gold standard for diagnosing colorectal cancers, and it saves lives.

To avoid colorectal cancer, consider making the following changes to your lifestyle:

  • If you smoke, quit: That includes e-cigs. If you smoke, your risk is higher not only for lung cancers, but for colorectal and other cancers.
  • Drink responsibly: The American Cancer Society advises no more than two drinks a day for men and one for women.
  • Exercise: You have a greater risk of developing colorectal cancer if you are sedentary. Being more active might lower your risk.
  • Lose weight: If you are overweight or obese, you have a higher risk of both developing colorectal cancer and dying from it.  This is especially true for colon cancer.
  • Consume adequate fiber: You should take in 25 grams of fiber a day to maintain a healthy colon. This means eating more fresh fruit, vegetables, whole grains, beans and legumes. The typical American diet is 10 to 15 grams of fiber a day. "It may be difficult, but it can be done,” Dr. Reguero Hernandez says.

What if you get colorectal cancer?

While every case is different, the good news is that surgery for both colon and rectal cancers can be highly successful—even for many patients with advanced disease, Dr. Reguero Hernandez says. While the treatment depends on the extent of the cancer, most patients will need surgery to remove the affected part of the colon. Some may need additional chemotherapy and/or radiation. And some patients will need a colostomy, a procedure to connect the bowel to an opening in the abdomen for stool to pass through into a disposable bag. A colostomy may be temporary or permanent, depending on the surgery.

Surgery for rectal cancer is more highly specialized and intricate because of the location of rectal tumors—and the importance of preserving the ability to control bowel movements. Dr. Reddy says it's important to choose a surgeon who has done many of these procedures.

Even with good treatment, a cancer diagnosis can be emotionally devasting, says Philana Gudricza, licensed clinical social worker and an oncology patient navigator for the Smilow Cancer Hospital. “Cancer is almost like an intruder in your house. It’s that level of threat,” she says. Gudricza helps patients navigate such matters as financial concerns, transportation and family issues. It’s also important to seek out support beyond treatment—including social and psychological counseling. 

Many patients worry about how cancer treatment will affect their appearance and sexuality—especially if they are single and hope to have a long-term relationship in their future.

One such patient, a young single woman, brought a pile of clothes to the appointment at which doctors were going to mark a location on her body for a colostomy bag, which she would need to divert her bowel movements away from her colon after surgery. The staff worked with her to position the bag so that it wouldn’t create a visible lump. “She was very, very self-conscious,” Gydricza says, and her concerns were taken seriously.

Gudricza and other social workers do their best to make sure patients like this know they will be vital after treatment. “We tell them they still can be very sexy and beautiful,” she says.