Although the incidence and mortality rates in colorectal cancer have dropped by 3.6% each year from 2007 to 2016 for people aged 55 and older—mainly because of increased colorectal cancer screening, advances in therapy, and reductions in smoking—these rates have increased by 2% each year during the same time for those younger than age 55.1 The third most common cancer diagnosed in both men and women in the United States, colorectal cancer, it is estimated that, in 2021, about 150,000 people will be diagnosed with the cancer, including 18,000 individuals younger than age 50, and nearly 53,000 will die of the disease.2 Colorectal cancer is having an especially devastating effect on Black individuals, who are about 20% more likely to be diagnosed with this type of cancer and 40% more likely to die of the disease than most other groups,3 even when the cancer is caught at an early stage.4
The alarming rise in cases of young-onset colorectal cancer—defined as colorectal cancer diagnosed before the age of 50—prompted the American Cancer Society, in 2018, to change its recommendations for the start of colorectal cancer screening from age 50 to age 45 for individuals at average risk. In addition, research by the American Cancer Society has found that people younger than age 55 are 58% more likely to be diagnosed with late-stage disease than older adults, making a cure more difficult.5
Causes of Young-Onset Colorectal Cancer
Although the uptick in colorectal cancer incidence in younger adults may correlate with the increasing rates of obesity in the United States, it is unclear what role obesity and other common risk factors, including diet, inactivity, and family history, may be playing in the early onset of this disease.
Charles R. Rogers, PhD, MPH, MS, MCHES®
The results of a study by Charles R. Rogers, PhD, MPH, MS, MCHES®, and his colleagues may provide another intriguing clue to the potential risk factors for the development of colorectal cancer in young adults: geography. Dr. Rogers is Assistant Professor in the Department of Family & Prevention Medicine and Founding Director of the Men’s Health Inequities Research Lab at the University of Utah School of Medicine; and Associate Member of Huntsman Cancer Institute and the University of Michigan-Mixed Methods Program.
Study Findings on Geography and Colorectal Cancer
The study aimed to identify counties in the United States with high mortality rates among non-Hispanic Black men diagnosed with colorectal cancer before the age of 50 to better understand the incidence and mortality disparities among this patient population. To identify early-onset colorectal cancer hotspots, Dr. Rogers and colleagues obtained data from the Centers for Disease Control and Prevention from 1999 to 2017. They then linked these data to Surveillance, Epidemiology, and End Results data for males between the ages of 15 and 49 with colorectal cancer.
The study analysis identified 232 hotspot counties for the cancer, the vast majority of which, 92%, are in the South, including in southern to central Appalachia, the southern Mississippi River, and eastern Texas, as well as the coastal southeast and eastern regions of Virginia and North Carolina. Dr. Rogers found that men in these counties had a 24% higher risk of dying of the disease than those living in non-hotspot areas. When the data were adjusted for differences in smoking rates, the mortality risk for those living in the hotspots was 12% higher. In addition, the study found that Black men had a 31% higher risk of dying of colorectal cancer than White men. Those who were divorced, separated, or widowed also had worse outcomes—a 43% increased risk for mortality compared with married or coupled men.
Although the rates of smoking, a known risk factor for colorectal cancer, were higher in this studied population than in the general population—24% compared with approximately 14% for all current adult smokers in the United States—the study also found that significantly higher proportions of adults in these hotspot counties had little leisure-time physical activity and limited access to healthy foods. Other potential explanations for poorer outcomes in young adult Black men, according to Dr. Rogers, may include an enduring history of unique challenges faced by this population, such as inadequate access to health care, poor health literacy, low educational attainment, lack of insurance, and high rates of poverty.6
However, these factors alone do not fully explain what is propelling the incidence and mortality rates from early-onset colorectal cancer among young Black men—and women—in the United States, especially in the South.
“A few months after our study was published in May 2020, the actor Chadwick Boseman died at the age of 43 from colorectal cancer, and I began getting e-mails and phone calls from people around the country asking if they lived in a colorectal cancer hotspot,” said Dr. Rogers. “Out of curiosity I also checked to see where Mr. Boseman grew up. It was in Anderson, South Carolina, one of the colorectal cancer hotspots. However, he later lived in New York and California—two non-hotspot states—did not smoke or have obesity, and presumably had access to good health care. Our study doesn’t give all the answers as to why colorectal cancer is so prevalent in young Black men, but it does provide some additional clues to the puzzle we are trying to solve and raises awareness of the disease.”
Our study doesn’t give all the answers as to why colorectal cancer is so prevalent in young Black men, but it does provide some additional clues to the puzzle we are trying to solve….— Charles R. Rogers, PhD, MPH, MS, MCHES®
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The ASCO Post talked with Dr. Rogers about the contributing factors for early-onset colorectal cancer in young adult Black men and the roles zip code, racism, and other social determinants of health may be playing in the higher incidence and death rates from the disease.
Understanding Racial Disparities in Early-Onset Colorectal Cancer
Why did you decide to study early-onset colorectal cancer in young adult men and not young adult women?
I have been researching this specific cancer from a behavioral perspective for a long time. I grew up in North Carolina, and as a young adult, I had never heard about colorectal cancer. I had only heard of prostate cancer for Black men and breast cancer for Black women. In 2009, I saw my beloved aunt at our family reunion and noticed she had lost a lot of weight. Four months later, she became very ill, and after several misdiagnoses, it was determined that she had stage IV colorectal cancer. She was just 52. She succumbed to the cancer nearly 8 years later.
That family incident started me on a career researching disparities in colorectal cancer. I saw, back then, that as a Black male, I had a 52% higher chance of dying of the disease than a White male. As educated as I was, I didn’t realize how big a problem colorectal cancer is for Black people, especially young adults, and I wanted to understand what the links are between this cancer and younger individuals. I focused on men because they are often a difficult-to-reach population and tend to have higher rates of colorectal cancer incidence and mortality than women. Also, Black men have the highest chances of getting and dying of colorectal cancer compared with all other racial/ethnic groups, male and female.
Sometimes, your zip code can matter more than your DNA when it comes to cancer risk factors.— Charles R. Rogers, PhD, MPH, MS, MCHES®
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Determining the Link Between Zip Code and Cancer Development
Compared with men in non-hotspot areas of the country, the men living in these hotspot counties were more likely to be Black and single and have contributing risk factors, including obesity, a history of smoking, and a lack of health insurance. Is there something inherent about living in these counties that made these individuals particularly susceptible to the development of colorectal cancer?
I think it is a mix of factors. Most of the people who grew up around me in North Carolina had lifestyles that increased their risk for colorectal cancer. The diets and lifestyles of people living in Southern states may encourage the development of different types of chronic diseases compared with the diets and lifestyles of people living in other parts of the country.
I’m now researching whether there are young-onset colorectal cancer hotspots in Utah and whether there are differences in incidence rates between rural and suburban areas of the state.
Focusing on the Role Racism Plays in Health Disparities
What role do you think race/ethnicity played in worse outcomes for the young Black adults in your study?
Race is a social construct that can’t necessarily influence cancer outcomes, but how you are treated because of your race can. What I mean by this is that we have to focus on racism and not race when it comes to health equity. I would argue that there are numerous social determinants of health, racism included, that are contributing to worse health outcomes for Black people. Lack of insurance is one, but even if these individuals have insurance, they are unlikely to get a colonoscopy. When they do go to the doctor, they often have symptoms of advanced colorectal cancer because of the delay in seeking medical care.
We have to focus on racism and not race when it comes to health equity.— Charles R. Rogers, PhD, MPH, MS, MCHES®
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So, the barriers are multifactorial. They include access to care, economic status, and sometimes your zip code can matter more than your DNA when it comes to cancer risk factors. I try to approach my research in a holistic way to understand why Black men are not completing early detection screening for colorectal cancer. It may be because of a lack of knowledge about the risks for this cancer, but I want to know what else may be going on. It may be they are not getting screened because they mistrust the medical profession, or they may have poor communication with their physician.
We need more research to determine what exactly is causing higher incidence rates of young-onset colorectal cancer in Black people besides the common risk factors. We have to dispel the myth that colorectal cancer is an older person’s disease and that it is a death sentence. Colorectal cancer is a preventable disease when precancerous polyps in the colon or rectum are removed during a colonoscopy and, when diagnosed early, a curable one.
There needs to be more attention paid to early-onset colorectal cancer and why this cancer is having such a devastating effect on so many Black individuals. We need to normalize having conversations about early-onset disease and more conversations about screening options, including stool-based screening. And finally, there also must be more awareness on the provider side about the importance of building rapport and trust with minority patients while aiming to break down the barriers preventing minority individuals from seeking health care.
DISCLOSURE: Dr. Rogers has received funding from the National Cancer Institute, 5 For the Fight, V Foundation for Cancer Research, Huntsman Cancer Institute, Research Foundation of the American Society of Colon and Rectal Surgeons, Exact Sciences, and the University of Utah School of Medicine.
REFERENCES
1. Colorectal Cancer Alliance: Know the facts. Available at www.ccalliance.org/colorectal-cancer-information/facts-and-statistics. Accessed November 29, 2021.
2. American Cancer Society: Key statistics for colorectal cancer. Available www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html. Accessed November 29, 2021.
3. American Cancer Society: Colorectal cancer rates higher in African Americans, rising in younger people. Available at www.cancer.org/latest-news/colorectal-cancer-rates-higher-in-african-americans-rising-in-younger-people.html. Accessed November 29, 2021.
4. Holowatyj AN, Ruterbusch JJ, Rozek LS, et al: Racial/ethnic disparities in survival among patients with young-onset colorectal cancer. J Clin Oncol 34:2148-2156, 2016.
5. American Cancer Society: When should you start getting screened for colorectal cancer? Available at www.cancer.org/latest-news/american-cancer-society-updates-colorectal-cancer-screening-guideline.html. Accessed November 29, 2021.
6. Rogers CR, Moore JX, Qeadan F, et al: Examining factors underlying geographic disparities in early-onset colorectal cancer survival among men in the United States. Am J Cancer Res 10:1592-1607, 2020.
