Delays Between CRC Presentation, Treatment Not Associated With Poor Survival in Young Adults

Longer times between presentation of disease and treatment were not associated with poor survival or advanced disease in patients younger than 50 years with colorectal cancer (CRC), according to a study in JAMA Network Open.¹

The findings are important because the rate of CRC has been rising rapidly since the 1990s among adults younger than 50 years.²

“This population is also more likely to present with metastatic disease compared with older adults and has worse survival,” the authors wrote. “However, the reasons for worse outcomes in young adults is unclear.”

Not only has the rate of colorectal cancer been rising rapidly since the 1990s among adults younger than 50 years, but this population is more likely to present with metastatic disease.

The retrospective cohort study included 5026 patients between the ages of 19 and 40 years diagnosed with CRC in Ontario, Canada, between 2007 and 2018. The patients were identified using the Ontario Cancer Registry. The analysis was performed between December 2019 and December 2022.

The median (IQR) age was 44 (40-47) years and 48% were female. Nearly half (47.4%) had no major comorbidity and a quarter (25.1%) had metastatic disease.

The researchers identified a subset of 2548 patients considered lower urgency who were less likely receive cross-sectional imaging before diagnosis compared with the remaining patients. The lower-urgency patients were also more likely to have rectal cancer (35.1% vs 26.5%; P < .001).

The median (IQR) time from presentation to start of treatment (overall interval) was 108 (55-214) days for the overall cohort and 141 (85-246) days for the lower-urgency subset. Patients with a lower stage of disease had longer wait times. The median (IQR) overall interval was:

• 152 days (87-261 days) for stage I CRC
• 108 days (54-217 days) for stage II CRC
• 107 days (58-210 days) for stage III CRC
• 83 days (39-183 days) for metastatic CRC

Nearly a third (31.3%) of patients died during the study, the majority from CRC (66.1% of deaths). The 5-year overall survival (OS) was 69.8% (95% CI, 68.4%-71.1%) and the 5-year cause-specific survival (CSS) was 78.2% (95% CI, 77.0%-79.4%). The 10-year OS was 63.0% (95% CI, 61.5%-64.6%) and the 10-year CSS was 75.0% (95% CI, 73.7%-76.4%).

As stage of disease increased, survival decreased. For patients with stage I CRC, the 5-year OS was 95.5% (95% CI, 93.9%-97.1%) compared with only 20.5% (95% CI, 18.0%-23.0%) for patients with metastatic disease.

Using both spline regression and adjusted Cox proportional hazard models found that shorter overall intervals were associated with worse OS. There were similar findings for the lower-urgency subset.

“Advanced and metastatic disease was strongly associated with shorter time to treatment, likely explaining why younger patients with CRC with overall intervals less than 100 days had worse outcomes, particularly those with intervals less than 6 weeks (overall mortality: HR, 1.73 [95% CI, 1.46-2.06]),” the authors wrote.

The use of population-based data and patients from a high-quality cancer registry were strengths of the study. The authors also noted that this was the largest study on the topic to their knowledge. However, there were limitations, such as the use of a complex algorithm developed for Ontario databases based on administrative and billing codes to identify the date of first presentation. In addition, the study does not identify the length of time between symptom onset and presentation.

“This large, population-based cohort study did not find adverse survival with longer times from presentation to treatment among patients with CRC aged younger than 50 years,” the authors concluded. “Postpresentation delays do not appear to drive advanced disease and poor outcomes in young adults.”

Reference

1. Castelo M, Paszat L, Hansen BE, et al. Analysis of time to treatment and survival among adults younger than 50 years of age with colorectal cancer in Canada. JAMA Netw Open. 2023;6(8):e2327109. doi:10.1001/jamanetworkopen.2023.27109

2. Simon S. Colorectal cancer rates rise in younger adults. American Cancer Society. March 5, 2020. Accessed August 3, 2023. https://www.cancer.org/research/acs-research-news/colorectal-cancer-rates-rise-in-younger-adults.html