Treating Young Patients With Colorectal Cancer: Talking With a Surgeon

More frequently in the US, young patients are being diagnosed with colorectal cancer. In light of this trend, and amidst Colorectal Cancer Awareness Month in March, CancerNetwork® spoke with Marc Lehrer Greenwald, MD, the chief of Colorectal Clinical Services and surgeon-in-chief at North Shore University Hospital, about his practices for treating younger patients.

During the conversation, Greenwald discussed the potential causes for the uptick of colorectal cancer in younger patients, several young patients he has recently worked with, and North Shore University Hospital’s adoption of precision medicine, among other topics.

Some of the highlights from that conversation are gathered here.

CancerNetwork: How has the daily feel of your practice changed as more younger patients are being diagnosed with colorectal cancer?

Greenwald: There’s a huge concern out there about the rising incidence of colorectal cancer in the younger age population of under 50 years. We know that colorectal cancer incidence is decreasing in the population over 50, and that’s primarily because of screening. The younger age group certainly hits the headlines, and it’s true that the incidence is increasing. The overall numbers are still maybe a tenth of what we see in the older population, but the increasing incidence is definitely a concern. We don’t feel that as much because the numbers are still low, but it certainly is dramatic when a young person comes into the office with colorectal cancer. It’s dramatic and traumatic. We do feel that and we do notice it, but I think the numbers that you see published speak for themselves. Because all of us who treat colorectal cancer see these patients a little less frequently, we’re not as acutely aware of it because of the patients we see in the office. We’re acutely aware of it because of the numbers that are published, which are impressive.

Why do you think the incidence of colorectal cancer is rising in younger patients?

There’s a lot published out there about it. We really think it’s environmental. Processed foods—we do know that all the healthy habits are good for every organ system. Processed foods are bad for everything. Obesity, which is the number 1 health problem in the country, is a proinflammatory condition, which increases the risk of a variety of medical conditions, and cancer is certainly one of them. We do know that exercise improves your risk… Because we’re seeing it in young people, it’s about lifestyle. That starts with what their parents are feeding them and how they’re brought up. That’s probably it. When I talk to patients about this, I discuss some of the studies that were done years ago when they looked at populations in rural and agrarian societies that were unaffected by Western living. If they studied these populations, the incidence of colorectal cancer was considerably lower than in Western society. Those populations don’t really exist anymore, but if you follow those groups of people, once they emigrated to a Western country, and then you followed them for some generations, they soon developed the same incidence of colorectal cancer that the other people in their neighborhood did. It clearly is an environmental problem. We have to live healthier from the start. Hopefully, that will help, and potentially increasing screening for younger people [will help] as well, as some of these new screening mechanisms come on board.

What differences are there between younger and older patients diagnosed with colorectal cancer?

There’s no doubt that for the [patients with] Lynch syndrome, who are going to be microsatellite instability–high (MSI-H) by definition, we often see them younger. Are the sporadic cases MSI-H? I’d have to look at the data to see what the current numbers are; the overall gestalt that I have is that those patients are typically MSI-H, even if they don’t have a germline mutation, or certainly the ones whom I’ve mostly seen, which is a good thing. Now, we have different and highly successful treatments, particularly for the patients with rectal cancer who are MSI-H. Some of the data that have come out have been really terrific in terms of treating patients with immunotherapy checkpoint inhibitors. I’ve seen that in my practice as well; some of these patients have relatively locally aggressive tumors that have melted away with immunotherapy, which is obviously a wonderful thing.

What cases involving patients in their 20s or 30s with colorectal cancer stand out to you?

One of them was a 22-year-old who just graduated from an Ivy League institution and was spending the summer working at an animal shelter because she was trying to apply to [veterinary] school. Very bright young woman. She came to the hospital with abdominal pain, and she had partially obstructing colon cancer. Now, she has no family history, and we operated on her. The issue becomes, and we discussed this—we discuss this with the oncologist, we discuss it at our tumor boards, and it’s discussed in the literature—[but] it is what to do with these patients. Now, she could have been prepped, and she was. She had a colonoscopy, and they couldn’t evaluate the colon proximal to the lesion, which was in the descending colon. She had bowel function where she moved her bowels every 1 to 2 days. We talked about a segmental resection, and I recommended a subtotal colectomy for a couple of reasons. One, it decreases the length of the colon, so there’s less surface area to develop cancers in the future; you have to presume she’s at high risk for…a metachronous cancer at some point, even if she turns out to be [Lynch syndrome] negative. Also, we couldn’t really look at the proximal colon because of the partial obstruction. That’s my preference. That’s what I offered her, and she was interested in doing that, so that’s what we did.

I think it’s important because surveillance is now easy. She only has maybe 30 cm or 25 cm of colon left, so it’s just a flexible sigmoidoscopy. Her bowel function is pretty good, even after a month. She’s only moving her bowels about 2 or 3 times a day, and it’s semi-formed. It’s only going to get better. It turns out she was lymph node negative, and she was MSI-H. She’s going to be observed very closely. I don’t know about her germline testing. I don’t recall, right now, whether it’s come back as [Lynch syndrome positive] or not, but if it is, she’ll see the genetics team and get all the help she can in that regard as well.

The other patient was a 35-year-old [man] who had 3 to 4 first-degree relatives across a couple of generations. By the old definition—before we had the genetics—he met Lynch [syndrome] criteria. He also had a descending colon cancer that was partially obstructing, not presenting as an emergency, but presenting after a colonoscopy. We did the same operation for him for pretty much the same reasons, and he was happy to do that as well. We’re presuming he has Lynch [syndrome] because he fits the familial pattern. We’ll get the genetic testing for him. He will, of course, see the oncology team, and the genetics team is here as well.

Both these people are going to do quite well, which is great. We talked about rectal cancer and the patients who have MSI-H rectal cancers earlier, and there’s a lot of experience. But I did have a young lady who’s actually a daughter of a physician, who was about 26 or 27 when she was diagnosed. She was treated with immunotherapy and has done quite well. The tumor has melted away, and she’ll just get observed. These are all great success stories, and fortunately—maybe I forget them on purpose—I don’t really recall ones that are not as successful. Hopefully, we’ll continue to have these success stories because these are young people.

What changes have your team made in the surgery department that have made a large difference in care?

I’m a big proponent of evidence-based medicine and following clinical practice guidelines. That’s why we really pushed to become an NAPRC [National Accreditation Program for Rectal Cancer] program through the American College of Surgeons. Just to back up a little bit, we started an enhanced recovery program at North Shore in 2013, which was a pretty early adopter. It was not easy to get everybody to get on board with clinical practice guidelines that really span the entire continuum, from pre-operative testing to discharge and follow-up after surgery, in terms of how to manage the patients surgically because we have a lot of good surgeons who have really good outcomes. They felt like they were “already doing a good job”. But the thing is that you can do better. When you use evidence-based clinical practice guidelines, it raises the bar for everybody. The whole institution improves, and patient management improves. As surgeons, we’re individuals; if something doesn’t go well, it’s on us, and if something goes well, we’re proud of what we do. Because that creates an individualistic view of what’s happening, it’s very hard to get surgeons to buy into practice guidelines and follow them. We started early with that, and once people joined, they realized how great the patients were doing. When the patients do well, it also helps everybody who manages patients because you know what to expect and what the patients are going to look like. This carries over.

The answer to your question about where to go forward in terms of improving patient care is just more evidence-based medicine, more clinical practice guidelines, and more of everyone really following the same [plan] to get the best results for our patients because everybody knows where to stand and what’s supposed to happen with the patients. Our rectal cancer tumor boards have improved tremendously once we became members of the program, and we’ve now been reaccredited. Everybody understands [each other]; the oncologists understand the surgeon’s language, the surgeons understand the oncology language, and the patients know. Our attendance can sometimes be up to 30 people, all with different disciplines. I tell the patients they’re going to get 30 opinions at one time when we present them, and the patients really appreciate it.

With oftentimes tighter surgical windows in younger patients, how do you coordinate with other disciplines to make sure all optimal procedures can be done?

Having navigators through the oncology program really helps. At the cancer center here, we have a team that works with young patients on fertility issues. Certainly, for the patients with rectal cancer, it’s a huge thing, especially if they’re getting radiation. The oncologists and the team that works with younger patients are wonderful in that regard. From a surgeon’s point of view, the one thing is when we’re doing pelvic surgery, if we’re doing abdominal surgery, particularly with minimally invasive [procedures], it’s rare that adhesions or scar tissue become an issue, but with the pelvic surgery, it’s certainly an issue. Using minimally invasive [procedures] and robotic techniques can help in that regard.

Younger patients can also have different external challenges regarding financial toxicity or career disruptions. How does your team combat those?

We all listen. A good physician should always be thinking about the entire patient, not just the disease. That’s something we teach the residents. The patient is not the disease. The patient is an entire person with a problem. You have to take care of the entire person. When we discuss [a case] as a tumor board, not only do we run through the MRI, the pathology, and the CT scans, but we talk about the patient. We’re always talking about the patient. Young people are one thing, and we’ll get to that, but as you get to even the older population, somebody who’s in a wheelchair or somebody who’s incontinent and has rectal cancer, they are going to be treated differently than a young person who has good control or a young person who is still single and looking to meet a life partner. [You consider] the potential disfigurement with different surgeries. Are they going to need a temporary ostomy? Are they going to need a permanent ostomy?

All these things must be considered when you are recommending treatment. If there are options, then they need to be considered even more. Sometimes, the cure is the cure, and the other options are not as good. That’s a tough presentation, particularly when you must tell a young person that they’re going to need an ostomy. But on the other hand, if it’s done right, and you do it right with all the help and the support services? We have a wonderful enterostomal therapy team here; if you do that right, the patients are going to be proud survivors. If you look on the internet, you could find young women in 2-piece bathing suits flashing off their ostomy at the beach because they are proud survivors, and that was their only option. They are happy they’re alive. It’s all about how you present it. Now, yes, we do everything we can to avoid giving a young person or anybody an ostomy if it can be avoided, and that’s part of the discussion. But there are times where it just can’t be avoided. How you present that and how you participate with the patient in that decision-making together is so important.

Reference

Siegel RL, Wagle NS, Star J, Kratzer TB, Smith RA, Jemal A. Colorectal cancer statistics, 2026. CA Cancer J Clin. 2026;76(2):e70067. doi:10.3322/caac.70067