|Year : 2013 | Volume
| Issue : 4 | Page : 337-340
Colorectal cancer in young adults in a tertiary care hospital in Chhattisgarh, Raipur
V Sudarshan, N Hussain, R Gahine, J Mourya
Department of Pathology, Pt. JNM Medical College, Raipur (CG), India
|Date of Web Publication||24-Dec-2013|
Department of Pathology, Pt. JNM Medical College, Raipur (CG)
Source of Support: None, Conflict of Interest: None
Context: Carcinoma of the colon and rectum is a relatively uncommon malignancy in India when compared with the western world. Colorectal cancer is generally a disease affecting individuals 50 years of age and older and is much less common in persons under 40 years of age. It is also a very uncommon pediatric malignancy. Aims: To study the age, gender, site of primary tumor, histopathological type, and pathologic stage of colorectal cancer cases with specific reference to young adults. Settings and Design: Tertiary care hospital, Retrospective study. Materials and Methods: We conducted a retrospective study of all colorectal carcinomas (CRC) which were diagnosed during the past 8 years i.e., from January 2003 to December 2010. Patients were divided in to two groups - 40 years and younger, and older than 40 years. The records were analyzed in detail for age, gender, site of primary tumor, histopathological type, and pathologic stage. The results of the two groups were compared and also with information from other centers. Statistical Analysis Used: Nil. Results: Two hundred and thirty three patients were diagnosed to have CRC. Patients diagnosed below 40 years of age comprised 39.05% and those under age 20 comprised 4. 29%. Among those under 40 years of age, majority were males (63.73%), most occurred in the rectum (84.61%). Most of them were poorly differentiated mucin-secreting adenocarcinomas (80.21%) and presented at advanced pathologic T stage (71.42%). This was similar to those reported in other literatures. However, the incidence of colorectal cancer in patients younger than 40 years is much more in our study when compared with reports from other places. Conclusions: CRC in our institution is more often seen in younger individuals than what is reported in population-based cancer registries from other parts of the country. The reasons for this are not clear. Therefore, further studies are required to address the role of diet and personal habits with CRC in this region. Also, a high index of suspicion among young adults is necessary.
Keywords: Adenocarcinoma, colorectal carcinoma, young adults
|How to cite this article:|
Sudarshan V, Hussain N, Gahine R, Mourya J. Colorectal cancer in young adults in a tertiary care hospital in Chhattisgarh, Raipur. Indian J Cancer 2013;50:337-40
|How to cite this URL:|
Sudarshan V, Hussain N, Gahine R, Mourya J. Colorectal cancer in young adults in a tertiary care hospital in Chhattisgarh, Raipur. Indian J Cancer [serial online] 2013 [cited 2019 Aug 23];50:337-40. Available from: http://www.indianjcancer.com/text.asp?2013/50/4/337/123621
| » Introduction|| |
Colorectal cancer is the fourth most common cancer in men and the third most common cancer in women worldwide.  Although distributed worldwide, the incidence is higher in industrialized and western countries.  Many Asian countries, including China, Japan, South Korea, and Singapore, have experienced an increase of 2-4 times in the incidence of colorectal cancer during the past few decades. The rising trend in incidence and mortality from colorectal cancer is more striking in affluent than in poorer societies and differs substantially among ethnic groups. Although changes in dietary habits and lifestyle are believed to be the reasons underlying the increase, the interaction between these factors and genetic characteristics of the Asian populations might also have a pivotal role.  Most cases of colorectal cancer do not have a well-documented inherited component, these are referred to as sporadic cases. Such cases result from at least seven somatic mutations and take decades to evolve. 
Carcinoma of the colon and rectum is a relatively uncommon malignancy in India when compared with the western world. The age standardized rates of colorectal cancer in India have been estimated to be 4.2 and 3.2/100,000 for males and females, respectively, compared to 35.3 and 25.7, respectively, in the USA. , Colorectal cancer is generally a disease affecting individuals 50 years of age or older. ,, Age-specific incidence of colorectal cancer in the United States appears to rise steadily from the second to sixth decade of life.  Adenocarcinoma is an unusual disease in patients under 40 years of age, and generally presents as advanced disease. It has been estimated that between 2 and 3% of colorectal cancers occur in patients younger than the age of 40 years.  Men have proportionately higher incidence of rectal cancer than women. ,,
In recent years, we have observed an increased incidence of colorectal cancers in younger age group. We retrospectively reviewed the histopathology records to testify this observation. Although exact incidence rate cannot be provided by a hospital-based study, the information would be useful in showing patterns of malignancies in our region. The present study was therefore designed to report age, gender, site of primary tumor, histopathological type, and pathologic stage in patients with colorectal carcinomas (CRC) with special reference to young adults. The need for early detection is emphasized.
| » Materials and Methods|| |
This retrospective observational study was conducted in the Department of Pathology. Histopathological records of all cases of malignant tumor which were received and diagnosed during last 8 years i.e., from January 2003 to December 2010 were studied. Patients diagnosed to have CRC by histopathology were analyzed for demographic information, such as age and gender and site of primary tumor. The slides of all patients with CRC were reviewed for typing of malignancy and pathologic staging. Only carcinomas were included in the study. All young patients (defined as those 40 years old or younger) were studied separately. Cancer of the anus was not included. Clinical details were obtained from case records.
As the histopathology section of the Pathology department, receives biopsy specimens from the whole region, urban as well as rural, the data from this institute, although not an absolute representation, may still be considered a fair indicator of trends in distribution of colorectal cancer and may be taken as representative of this part of the country.
Since we did not have any previous data of cancer patients in this region, our data were analyzed on the same lines as that of colorectal cancers registered in population-based cancer registries (PBCR)  from Bangalore, Barshi, Bhopal, Chennai, Delhi, Mumbai, Ahmedabad, and Kolkata in 2004-2005 to estimate any deviation in any parameter if at all.
| » Results|| |
A total of 233 cases were diagnosed to have CRC.
The median age at diagnosis was 43 years and age range was 9-70 years. The detailed age distribution of CRC patients is shown in [Table 1]. A total of 91 (39.05%) patients of age 40 years or younger were diagnosed. Three cases were diagnosed in the pediatric (defined as <20 years) age group.
Of the 233 cases, 134 (57.51%) were males and 99 (42.48%) were females. Male predominance was seen in both above (53.52%) and below 40 years (63.73%).
In the majority of tumors for all patients, 192 (82.40%) occurred within the rectum. Rectal predominance was seen in both the age groups (80.98% in >40 year age group, 84.61% in <40 year age group).
Histopathological examination showed majority of tumors to be well-differentiated adenocarcinomas. Among those above 40 years also majority were having well-differentiated adenocarcinomas. However, among those below 40 years of age, majority had poorly differentiated mucin-secreting adenocarcinomas. Higher pathological T stage was seen in the younger age group when compared with patients above 40 years. Also the younger age group showed more advanced N stage when compared with patients above 40 years [Table 2].
|Table 2: Comparison of demographic profile and histopathological findings in the two age groups |
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| » Discussion|| |
Incidence of colorectal cancer rises sharply after the age of 45, and 90% of cases occur in persons over the age of 50.  Genetic and familial etiologies account for less than 20% of colorectal cancers in the US. The remaining 80% of cases are random, with dietary factors affecting the risk significantly. 
In SEER statistics 2008, the median age at diagnosis for cancer of the colon and rectum was 71 years.  The median age in our series was 43 years, which is a much younger age group than the published figures (≥50 years). ,, The youngest patient in our series was a 9-year-old male.
Ninety-one cases (39.05%) presented before the age of 40 years. This was comparable with those reported by Pal et al.,  Gupta et al.,  and Nath et al.  but was higher than those in the PBCR  from Bangalore, Barshi, Bhopal, Chennai, Delhi, Mumbai, Ahmedabad, and Kolkata in 2004-2005 [Table 3].
|Table 3: Colorectal carcinomas profile of cases compared with population-based cancer registries report 2004-2005 from Bangalore, Barshi, Bhopal, Chennai, Delhi, Mumbai, Ahmedabad and Kolkata |
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It is apparent from the present study that incidence of colorectal cancer at an age below 40 years in our institute is more often seen in younger individuals than what is reported in PBCR from other parts of the country. In this series, the male to female ratio was 1.35:1 which was in accordance with male preponderance reported in the literature. ,,, Many studies report more favorable prognosis for females, as with other malignancies.  Among those under 40 years of age too majority were males (86.81%). Rectal tumors accounted for 82.40% and colonic tumors for 17.60%. Similar rectal predominance has been reported by others. ,,, However, colonic predominance has been reported in some studies. ,, Both the age groups in our series showed male predominance. Also rectal predominance was seen in both the age groups.
The concern for colorectal cancer affecting young population below 40 years old was due to the poor prognosis attached to it. There are several studies in the literature that report a more advanced stage and a poorer prognosis in patients younger than 40 years.  Minardi et al.  found a large proportion of Dukes' stage C (37%) in young patients with colorectal cancer. In our study among those younger than 40 years, majority i.e., 80.21% cases were poorly differentiated mucin-secreting adenocarcinomas and 71.42% cases presented at advanced pathologic stage (T3 and T4).
The reason for this is not clear. A genetic basis for tumorigenesis has been implicated in early onset CRC among young patients. The increase in incidence in rectal cancer in this region may not, however, be related to familial adenomatous polyposis (FAP) as none of our cases showed adenomatous polyposis coli. Also, although these patients develop CRC early, patients with FAP are known to have a greater proportion of right-sided colon lesions, with fewer cancers diagnosed in rectum.  However, there is a high possibility of genetic background to at least some young rectal cancers in India. Microsatellite instability has been identified in most of the patients with early onset of CRC,  suggesting genetic etiology. The Bethesda criterion recommends that all patients who develop CRC before age 45 undergo testing for tumor microsatellite instability to identify individuals at risk for HNPCC (hereditary non-polyposis colorectal cancer).
The higher incidence in our region may also be due to increased adoption of western life style such as increased consumption of foods with little nutritional value and high on calories. Another possible explanation for the increase in incidence of the rectal cancers that we observed could be because of increased availability of colonoscopy for diagnosis.
| » Conclusion|| |
Although the incidence of colorectal cancer in Indian older age group subjects is currently very low when compared with Western population, the younger generation is experiencing an increase in incidence. In our institution CRC is more often seen in younger individuals than what is reported in PBCR in other parts of the country. All patients including those in younger age group presenting with rectal bleeding or other alarming signs and symptoms should be properly evaluated including endoscopy to rule out malignancy. A high index of suspicion among young adults is necessary.
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[Table 1], [Table 2], [Table 3]