研究确定了年轻人患结直肠癌风险的体征和症状

IF 503.1 1区 医学 Q1 ONCOLOGY CA: A Cancer Journal for Clinicians Pub Date : 2023-09-04 DOI:10.3322/caac.21810
Mike Fillon
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After losing her job because of the number of sick days she had taken, with her health still not improving, she went to her county hospital’s emergency room for a colonoscopy. “They found a baseball-sized tumor,” says Chambers-Raney. “I was 44 years old and up until then was told I was too young to have something serious like colon cancer.”</p><p>Recognizing the alarming trend of younger people being diagnosed with colorectal cancer (CRC), in 2018, the American Cancer Society, followed by other health organizations, began recommending lowering the age for screening from the age of 50 years to the age of 45 years. A new study appearing in the Journal of the National Cancer Institute (doi:10.1093/jnci/djad068) is the latest to validate this change.</p><p>In the study, the researchers looked for abdominal pain, rectal bleeding, diarrhea, and iron-deficiency anemia, with each indicating an increased risk for early-onset CRC. 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Johnson Chair in Surgical and Medical Oncology, and codirector of gastrointestinal oncology at Vanderbilt University Medical Center in Nashville, Tennessee. “However, I think these data do have limitations and need to be recognized for that in regard to early diagnosis and relative risk.”</p><p>Dr Eng has concerns that a large chunk of potential data is being excluded. “I worry that we’re missing out on an important patient population,” she says. “Specifically, many young people don’t have their own insurance and, of course, there are other socioeconomic issues leading to disparities in an insurance database; as a result, many would not be included in the data. They’re also presuming the patients are documenting everything. I don’t think we should presume that.”</p><p>Dr Cao says that it is crucial for clinicians to raise awareness among primary care physicians, gastroenterologists, emergency medicine physicians, and other clinical specialties regarding the impact of CRC among younger adults and the prevalent issue of diagnostic delays. “By ensuring that medical practitioners across various disciplines are knowledgeable about this pressing concern and the alarming signs and symptoms associated with early-onset colorectal cancer, they can facilitate prompt and appropriate evaluation for younger adults presenting with potential indicators of the disease,” she says.</p><p>Dr Cao also recommends that cancer researchers tackle the growing burden of early-onset CRC. “It is essential to broaden the scope of research priorities beyond the investigation of risk factors that contribute to its rising incidence.” Of particular significance, she says, is the urgent need to prioritize research endeavors aimed at improving early detection. “It is essential to develop strategies and interventions that are accessible, culturally sensitive, and considerate of socioeconomic factors. 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引用次数: 0

摘要

八年前,来自德克萨斯州休斯顿的宝拉·钱伯斯-兰尼(Paula Chambers-Raney)患有胃痛、便血和贫血。她的初级保健医生告诉她,她得了痔疮。然后,在接下来的18个月里,其他临床医生告诉她,她可能患有肠易激综合征,她可能吃了一些红色的东西,她应该多吃绿叶蔬菜来治疗贫血。由于请了太多病假,她失去了工作,但她的健康状况仍然没有好转,于是她去了县医院的急诊室做结肠镜检查。“他们发现了一个棒球大小的肿瘤,”钱伯斯-兰尼说。“我当时44岁,在那之前一直被告知我太年轻,不可能得结肠癌这样的严重疾病。”认识到年轻人被诊断患有结直肠癌(CRC)的惊人趋势,2018年,美国癌症协会和其他卫生组织开始建议将筛查年龄从50岁降至45岁。发表在《国家癌症研究所杂志》(doi:10.1093/jnci/djad068)上的一项新研究是证实这一变化的最新研究。在这项研究中,研究人员寻找腹痛、直肠出血、腹泻和缺铁性贫血,这些都表明早发性结直肠癌的风险增加。他们试图确定这四种被认为是危险信号的症状是否可能是检测早发性结直肠癌的关键。为了完成这项工作,研究人员从IBM MarketScan商业数据库中进行了一项嵌套病例对照研究,其中包括来自美国各地约1.13亿年龄在18-64岁之间的参保成年人的个人索赔数据。初步分析仅限于18-49岁的成年人,在索引日期之前至少连续入组2年。在二次分析中,他们包括50-64岁的成年人。主要分析侧重于识别在诊断指标日期前3个月至2年出现的红旗适应症。“最终,总体目标是提高年轻时CRC的早期发现,这对改善患者预后具有重大潜力,”高级研究作者Yin Cao说,他是密苏里州圣路易斯华盛顿大学医学院外科公共卫生科学系的副教授。她说:“据我们所知,这项研究是第一次大规模研究,与匹配的对照组和老年诊断的CRC患者的体征和症状进行比较,以确定早发性CRC的预测性红旗体征和症状。”研究人员发现,19.3%的早发性CRC患者在诊断后3个月至2年内出现症状,中位诊断间隔为8.7个月。此外,49.1%的患者在确诊后3个月内首次出现症状。此外,对于在诊断前3个月内出现首次危险体征或症状的患者,中位诊断间隔出现得很快——不到1个月。曹博士指出,尽管最近对筛查指南进行了调整,现在建议从45岁开始筛查,但大约一半的早发性结直肠癌病例在45岁之前被诊断出来。“由于大多数早发性结直肠癌患者已经并将继续在症状出现后被诊断出来,因此迫切需要识别潜在的危险信号和症状,以促进早期发现。然而,我们对体征和症状的了解,特别是在早发性结直肠癌的典型检查之前,迄今为止是有限的。“我确实发现这项研究提供了信息,它增加了关于患者有一种、两种、三种或更多种症状的总体风险的文献,”医学教授、大卫·h·约翰逊外科和内科肿瘤学主席、田纳西州纳什维尔范德比尔特大学医学中心胃肠肿瘤学联合主任凯西·英格博士说。“然而,我认为这些数据确实有局限性,需要认识到早期诊断和相对风险。”Eng博士担心大量潜在数据被排除在外。“我担心我们会错过一个重要的患者群体,”她说。“具体来说,许多年轻人没有自己的保险,当然,还有其他社会经济问题导致保险数据库中的差异;因此,许多人不会被包括在数据中。他们还假设病人记录了一切。我认为我们不应该这样假设。”曹博士说,临床医生必须提高初级保健医生、胃肠病学医生、急诊医生和其他临床专业人员对年轻人中结直肠癌的影响和普遍存在的诊断延迟问题的认识。 她说:“通过确保各个学科的医生都了解这个紧迫的问题以及与早发性结直肠癌相关的令人担忧的迹象和症状,他们可以促进对出现这种疾病潜在指标的年轻人进行及时和适当的评估。”曹博士还建议癌症研究人员解决早发性结直肠癌日益增加的负担。“有必要扩大研究重点的范围,而不仅仅是调查导致其发病率上升的风险因素。”她说,特别重要的是,迫切需要优先考虑旨在改善早期检测的研究工作。“至关重要的是,要制定易获取、具有文化敏感性并考虑到社会经济因素的战略和干预措施。通过采取全面和包容的方法,我们可以最大限度地发挥我们的努力的影响,并确保早期发现的好处延伸到来自不同背景和社区的个人。”Eng博士说,让人们更多地认识到这一新兴问题的研究是有帮助的:“我想,在过去,临床医生只是排除了这种可能性,或者没有把它作为一个很大的可能性,但现在他们应该更加意识到,这些实际上可能是结直肠癌的症状。她补充说:“就我个人而言,我希望在45岁之前就开始筛查,但我有点偏见,因为我在诊所里经常见到的是45岁的患者。”“但我希望,随着认知度的提高,我们能够更早地识别出出现早期症状的患者,这将使人们更加认识到将年龄降至45岁以下的重要性。”直到肿瘤被切除后,钱伯斯-兰尼才知道她在基因上有患结直肠癌的倾向。好消息是她已经5年没有任何疾病的迹象了。钱伯斯-兰尼现在是美国癌症协会的CRC筛查倡导者,他说:“如果这些指导方针已经到位,它将为我节省很多痛苦和恐惧。”“我认为对所有临床医生来说,采用这些指导方针很重要。患者也应该把它们纳入自己的个人工具箱中。”有关美国癌症协会指南的更多信息,请访问https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21457。
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Study identifies signs and symptoms of colorectal cancer risk at younger ages

Eight years ago, Paula Chambers-Raney from Houston, Texas, suffered from stomach pain, blood in her stool, and anemia. Her primary care physician told her that she had hemorrhoids. Then, over the next 18 months, other clinicians told her that she might have irritable bowel syndrome, she had probably eaten something red, and she should eat more green leafy vegetables for her anemia. After losing her job because of the number of sick days she had taken, with her health still not improving, she went to her county hospital’s emergency room for a colonoscopy. “They found a baseball-sized tumor,” says Chambers-Raney. “I was 44 years old and up until then was told I was too young to have something serious like colon cancer.”

Recognizing the alarming trend of younger people being diagnosed with colorectal cancer (CRC), in 2018, the American Cancer Society, followed by other health organizations, began recommending lowering the age for screening from the age of 50 years to the age of 45 years. A new study appearing in the Journal of the National Cancer Institute (doi:10.1093/jnci/djad068) is the latest to validate this change.

In the study, the researchers looked for abdominal pain, rectal bleeding, diarrhea, and iron-deficiency anemia, with each indicating an increased risk for early-onset CRC. They sought to determine if these four symptoms—identified as red flags—might be key to the detection of early-onset CRC. To perform this work, the researchers conducted a nested case-control study from the IBM MarketScan Commercial Database, which includes individual claims data from approximately 113 million insured adults aged 18–64 years from across the United States. The primary analyses were restricted to adults aged 18–49 years with at least 2 years of continuous enrollment before the index date. For the secondary analyses, they included adults aged 50–64 years.

The primary analyses focused on identifying red-flag indications that appeared 3 months to 2 years before the index date of diagnosis. “Ultimately, the overarching objective is to improve the early detection of CRC at younger ages, which holds significant potential for improving patient outcomes,” says senior study author Yin Cao, ScD, MPH, an associate professor of surgery in the Division of Public Health Sciences of the Department of Surgery at Washington University School of Medicine in St. Louis, Missouri.

“To our knowledge, this study is among the first large-scale studies to identify predictive red-flag signs and symptoms for early-onset CRC compared to a matched control group and in comparison with signs and symptoms in people with CRC diagnosed at older ages,” she says.

The researchers found that 19.3% of people with early-onset CRC had symptoms beginning within 3 months to 2 years of their diagnosis with a median diagnostic interval of 8.7 months. In addition, 49.1% first showed symptoms within 3 months of their diagnosis. Also, the median diagnostic interval appeared quickly—less than 1 month—for patients who had their first red-flag sign or symptom within the 3 months before their diagnosis.

Dr Cao notes that despite recent adjustments to screening guidelines, which now recommend screening from the age of 45 years, approximately half of all early-onset CRC cases are diagnosed before the age of 45 years. “As the majority of people with early-onset CRC have been and will continue to be diagnosed after symptom presentation, there exists a pressing and unaddressed clinical need to identify potential red-flag signs and symptoms that can facilitate early detection. Yet, our knowledge of signs and symptoms, especially preceding the typical workup for early-onset CRC, is thus far limited.”

“I do find the study informative, and it adds to the literature in regard to overall risk if a patient has one, two or three or greater symptoms,” says Cathy Eng, MD, professor of medicine, the David H. Johnson Chair in Surgical and Medical Oncology, and codirector of gastrointestinal oncology at Vanderbilt University Medical Center in Nashville, Tennessee. “However, I think these data do have limitations and need to be recognized for that in regard to early diagnosis and relative risk.”

Dr Eng has concerns that a large chunk of potential data is being excluded. “I worry that we’re missing out on an important patient population,” she says. “Specifically, many young people don’t have their own insurance and, of course, there are other socioeconomic issues leading to disparities in an insurance database; as a result, many would not be included in the data. They’re also presuming the patients are documenting everything. I don’t think we should presume that.”

Dr Cao says that it is crucial for clinicians to raise awareness among primary care physicians, gastroenterologists, emergency medicine physicians, and other clinical specialties regarding the impact of CRC among younger adults and the prevalent issue of diagnostic delays. “By ensuring that medical practitioners across various disciplines are knowledgeable about this pressing concern and the alarming signs and symptoms associated with early-onset colorectal cancer, they can facilitate prompt and appropriate evaluation for younger adults presenting with potential indicators of the disease,” she says.

Dr Cao also recommends that cancer researchers tackle the growing burden of early-onset CRC. “It is essential to broaden the scope of research priorities beyond the investigation of risk factors that contribute to its rising incidence.” Of particular significance, she says, is the urgent need to prioritize research endeavors aimed at improving early detection. “It is essential to develop strategies and interventions that are accessible, culturally sensitive, and considerate of socioeconomic factors. By taking a comprehensive and inclusive approach, we can maximize the impact of our efforts and ensure that the benefits of early detection extend to individuals from various backgrounds and communities.”

Dr Eng says that studies that bring greater awareness of this burgeoning problem are helpful: “I guess, in the past, clinicians just ruled it out or didn’t take it as a strong possibility, but now they should be more aware, that these could in fact be symptoms of colorectal cancer.

“Personally, I would like screening to begin earlier than age 45, but I am a bit biased because that’s the patient population that I see quite frequently in my clinic,” she adds. “But I hope that, with increased recognition, hopefully we will be able to identify patients earlier who have an earlier stage of presentation, and that will bring increased recognition to the [importance of] reducing the age to even lower than 45.”

Only after her tumor was removed did Chambers-Raney learn that she was genetically predisposed to having CRC. The good news is that she has had no evidence of the disease for 5 years. “If these guidelines had been in place, it would have saved me a lot of pain and fear,” said Chambers-Raney, who is now a CRC screening advocate for the American Cancer Society. “I think it’s important for all clinicians to adopt these guidelines. Patients should also include them in their own personal toolboxes.”

For more information on the American Cancer Society guidelines, visit https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21457.

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来源期刊
CiteScore
873.20
自引率
0.10%
发文量
51
审稿时长
1 months
期刊介绍: CA: A Cancer Journal for Clinicians" has been published by the American Cancer Society since 1950, making it one of the oldest peer-reviewed journals in oncology. It maintains the highest impact factor among all ISI-ranked journals. The journal effectively reaches a broad and diverse audience of health professionals, offering a unique platform to disseminate information on cancer prevention, early detection, various treatment modalities, palliative care, advocacy matters, quality-of-life topics, and more. As the premier journal of the American Cancer Society, it publishes mission-driven content that significantly influences patient care.
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