Pioneering a new care model for young-onset colorectal cancer: innovations in clinical care and scientific discovery
2020; Future Medicine; Volume: 9; Issue: 3 Linguagem: Inglês
10.2217/crc-2020-0011
ISSN1758-1958
Autores Tópico(s)Colorectal Cancer Screening and Detection
ResumoColorectal CancerVol. 9, No. 3 EditorialOpen AccessPioneering a new care model for young-onset colorectal cancer: innovations in clinical care and scientific discoveryLeah H Biller & Kimmie NgLeah H Biller *Author for correspondence: E-mail Address: leah_biller@DFCI.HARVARD.EDUhttps://orcid.org/0000-0001-7386-7121Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA & Kimmie NgDana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USAPublished Online:26 Oct 2020https://doi.org/10.2217/crc-2020-0011AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInRedditEmail Keywords: cancer centercolorectal cancer epidemiologydelivery of careearly-onset colorectal canceryoung-onset colorectal cancerIn the USA, colorectal cancer (CRC) is the third most common cancer in men and women and the second leading cause of cancer-related deaths in men and women combined, with an estimated 147,950 new cases and 53,200 CRC-related deaths anticipated in 2020 [1]. Out of these, 17,930 cases and 3640 deaths are expected to occur in patients younger than 50 years (defined here as young-onset colorectal cancer [YOCRC]) [1]. While the rate of CRC among those 65 years and older declined by 3.3% per year, the incidence of YOCRC has increased by approximately 2% per year since the 1990s [1]. By 2030, it is predicted that the incidence of YOCRC will continue to rise by over 90% for individuals aged 20–34 years and more than 27% for those 35–49 years of age [2].The reasons for this concerning phenomenon remain poorly understood. While hereditary predisposition is more common in younger CRC patients than older patients, an identifiable genetic syndrome is present in only 16–20% of YOCRC cases and cannot alone explain the rising incidence [3,4]. Modifiable risk factors such as obesity and decreased physical activity have been associated with risk of CRC in general [5] and thus, it has been hypothesized that recent trends of increased obesity rates may be contributing to higher rates of YOCRC. While studies have found an almost twofold increased risk for CRC among obese compared with nonobese individuals [6], an analysis of state-based obesity prevalence did not find a correlation with YOCRC incidence [7]. Further investigation is needed to better understand the interaction between obesity and other potentially modifiable factors such as dietary exposures and gut microbial dysbiosis with the development of YOCRC.Just as the genetic and lifestyle risk may differ among younger patients compared with CRC in those age 50 and older, there are some pathologic and molecular features of YOCRC that suggest it may be a biologically distinct disease. Large national databases and patient-level registries have almost uniformly found that YOCRC preferentially originates in the distal colon and rectum [1,8–10], which has treatment implications for both localized and metastatic disease. Furthermore, these cancers are more likely to be diagnosed at an advanced stage (stage III or IV) [11,12]. While it is not known whether this is due to delays in diagnosis or a more aggressive underlying biological phenotype, YOCRC tumors are more often associated with high risk features such as, poor differentiation or signet cell histology [12]. There may also be differences in the genomic landscape, with younger patients less commonly having APC, BRAFV600E and NRAS mutations when compared with older adults [8,10,13].The role of dedicated centers for young-onset colorectal cancer patientsSpecialized care of specific demographics (such as, adolescent and young adult patients with breast cancer and/or hematologic malignancies) has been demonstrated to improve overall patient satisfaction [14], as well as uptake of important referrals (such as reproductive endocrinology), without delaying oncologic care [15]. Similarly, due to the distinct needs of geriatric patients, it is well recognized that geriatric-based assessments and programs may better predict chemotherapy toxicity [16] and even survival [17] for this subset of cancer patients.We would argue that YOCRC patients are a unique demographic by virtue of their divergent incidence trends and clinicopathologic features, coupled with the psychosocial challenges of age at diagnosis and would therefore also benefit from focused care in a dedicated center. Importantly, patients between the ages of 40 and 49, a cohort by definition excluded from most adolescent and young adult programs, make up over 70% of YOCRC [1] and otherwise remain largely unstudied. To better meet the needs of the growing YOCRC population, Dana-Farber Cancer Institute (DFCI; MA, USA) launched the Young-Onset Colorectal Cancer Center in March 2019. The Center's mission is threefold:to provide expert and compassionate clinical careto promote scientific discovery and innovation to elucidate underlying biological mechanisms, identify risk factors and facilitate development of novel therapiesto improve prevention and early detection by raising public awareness of the rising burden of CRC in young adultsComprehensive clinical & psychosocial careYOCRC patients require comprehensive multidisciplinary care, including upfront genetic counseling and testing for all patients, as 33% of YOCRC with hereditary predisposition may not have a suggestive family history [3]. To enhance and better personalize the clinical care of patients, the DFCI Young-Onset Colorectal Cancer Center also performs next generation sequencing of YOCRC tumors using the DFCI OncoPanel platform (MA, USA). These results are reviewed by a multidisciplinary molecular tumor board through a novel program called GI TARGET (GastroIntestinal Treatment Assistance Regarding Genomic Evaluations of Tumors), which provides a detailed personalized report for therapy options and clinical trial recommendations. As recent reports have identified a decline in clinical trial proportional enrollment among 15–39 year old cancer patients overall [18], tools such as GI TARGET and upfront tumor sequencing may help identify therapeutic options and increase YOCRC representation on clinical trials.YOCRC patients also have many complex psychosocial needs related to age and stage of life that must be continually addressed as part of comprehensive clinical care. The 2018 Young-Onset Colorectal Cancer Survey Report (an annual international survey conducted by the Colorectal Cancer Alliance) found that 80% of the responding patients had children under age 18 and over 65% did not receive any counseling regarding fertility preservation [19]. Many may also be financial providers for their family or responsible for caring for older parents. Cancer diagnosis and treatment can be isolating and overwhelming, with 85% of patients reporting anxiety and depression, but only 55% seeking treatment [19]. To assist with systematically identifying and then managing these issues, the DFCI Young-Onset Colorectal Cancer Center has a dedicated program coordinator who meets with all patients on their initial visit and helps navigate patients to appropriate support services (including fertility/sexual health, nutrition and integrative medicine) while serving as a liaison between clinical and research teams. There is also a dedicated social worker with expertise in the young-adult cancer population to help support patients and families. Custom group programming initiatives (including peer support groups, webinars/seminars and annual patient and family conferences) have been specifically developed to help mitigate feelings of isolation and lack of contact with patient peers of similar age.Scientific discovery & innovationThere unfortunately remain many unknowns with YOCRC that have stymied progress in prevention, early detection and treatment, and it is therefore imperative that centralized, multi-center collaborations are created to investigate underlying risk factors for YOCRC incidence and survival. The National Institute of Health has even selected understanding the etiology of rising rates of young-onset cancers (including CRC) as a provocative question for 2020 [20], highlighting the great need for this research. We believe that in order to most efficiently obtain enough patient data to study these questions, we must work together to comprehensively collect matched biospecimens serially over time and harmonize methods of data collection to most effectively pool patients and resources to advance the field for this understudied population.To that end, the research cornerstone of the DFCI Young-Onset Colorectal Cancer Center is the Beyond CRC Project: BEtter understanding of Young-ONset ColoRectal Cancer. This international, multi-center, prospective, longitudinal cohort study is comprised exclusively of YOCRC patients. While existing contemporary cohorts have been limited by small sample sizes, lack of racial and ethnic diversity, nonuniform collection of data and limited stool specimens for microbiome analysis, the Beyond CRC project is specifically designed to systematically collect clinical history (including detailed dietary and lifestyle factors) and biospecimens (blood, tumor and stool) to be used for this research.Public awarenessThere is also a need to better inform and educate the community-at-large about the increasing incidence of YOCRC and the importance of CRC screening for both prevention and early detection. Because of rising rates of YOCRC, the American Cancer Society included a qualified recommendation that average-risk individuals start CRC screening at age 45 rather than the prior (and well-publicized) recommendation at age 50. Spreading awareness about the significance of family history of polyps and CRC is also important, as this may impact recommendations for both age to start and frequency to continue colonoscopy screening for younger individuals. The DFCI Young-Onset Colorectal Cancer Center promotes seminars, webinars and social media presentations about YOCRC and also has partnered with patient advocates and foundations to help increase public engagement and leverage this important platform for ongoing government advocacy and funding of critical scientific investigation.ConclusionYOCRC patients have unique clinical and psychosocial needs that would benefit from comprehensive care provided in specialized and dedicated YOCRC centers. While there is not yet data that these centers improve quality of life and overall survival among YOCRC patients specifically, clinical benefit has been shown in other subpopulations of cancer patients. We recognize that not all cancer clinics have the ability to build and create dedicated centers, but we anticipate that some of the care models and support services could ultimately be transferred and implemented in other clinic settings. Multi-center collaboration will be imperative to optimizing clinical care, in addition to supporting research for this growing and understudied patient population in order to improve strategies for prevention and early detection as well as clinical outcomes for YOCRC patients.Author contributionsBoth authors contributed equally to conception and design as well as drafting and critically revising this editorial. They had final approval of the published version.AcknowledgmentsThe authors acknowledge the Dana-Farber Cancer Institute Young-Onset Colorectal Cancer Center team: L Brais, M-B Brown, H Hanna, K MacDougall.Financial & competing interests disclosureK Ng is the Director of the Dana-Farber Cancer Institute Young-Onset Colorectal Cancer Center and has received grant funding from the National Cancer Institute, US Department of Defense and Cancer Research UK. She has received institutional research funding from Revolution Medicines, Evergrande Group, Genentech and Pharmavite. She has served on an advisory board for Array Biopharma. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.Open accessThis work is licensed under the Creative Commons Attribution 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/References1. Siegel RL, Miller KD, Goding Sauer A et al. Colorectal cancer statistics, 2020. CA Cancer J. Clin. doi:10.3322/caac.21601 (2020) (Epub ahead of print).Google Scholar2. Bailey CE, Hu C-Y, You YN et al. Increasing disparities in the age-related incidences of colon and rectal cancers in the United States, 1975–2010. JAMA Surg. 150(1), 17 (2015).Crossref, Medline, Google Scholar3. Pearlman R, Frankel WL, Swanson B et al. 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(2020). https://provocativequestions.cancer.gov/current-rfas-and-pqsGoogle ScholarFiguresReferencesRelatedDetailsCited BySPECIAL FOCUS: Early-onset colorectal cancerFranklin G Berger25 November 2020 | Colorectal Cancer, Vol. 9, No. 3 Vol. 9, No. 3 Follow us on social media for the latest updates Metrics Downloaded 409 times History Received 14 April 2020 Accepted 30 April 2020 Published online 26 October 2020 Published in print September 2020 Information© 2020 Kimmie NgKeywordscancer centercolorectal cancer epidemiologydelivery of careearly-onset colorectal canceryoung-onset colorectal cancerAuthor contributionsBoth authors contributed equally to conception and design as well as drafting and critically revising this editorial. They had final approval of the published version.AcknowledgmentsThe authors acknowledge the Dana-Farber Cancer Institute Young-Onset Colorectal Cancer Center team: L Brais, M-B Brown, H Hanna, K MacDougall.Financial & competing interests disclosureK Ng is the Director of the Dana-Farber Cancer Institute Young-Onset Colorectal Cancer Center and has received grant funding from the National Cancer Institute, US Department of Defense and Cancer Research UK. She has received institutional research funding from Revolution Medicines, Evergrande Group, Genentech and Pharmavite. She has served on an advisory board for Array Biopharma. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.Open accessThis work is licensed under the Creative Commons Attribution 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/PDF download
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