NESS - The Conundrum of the Young Colon Cancer Patient

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The Conundrum of the Young Colon Cancer Patient
*Ramzi Amri, Liliana G Bordeianou, *Patricia Sylla, David L Berger
Massachusetts General Hospital, Harvard Medical School, Boston, MA

Objective: To determine the impact of age on preoperative characteristics and outcomes of surgically treated colon cancer patients.
Design: Retrospective cohort study using an institutional review board-approved data repository.
Setting: High-volume tertiary care center.
Patients: All surgically treated colon cancer patients (2004-2011), stratified over four age groups: under 50, 50-65, 65-75, and over 75.
Main outcome measures: Baseline characteristics and long-term outcomes.
Results: We included 1071 patients: 125 aged under 50, 331 aged 50-65, 292 aged 65-75, and 323 over 75. Patients under 50 presented with significantly higher rates of IBD (8.8% vs. 2.8%; P=0.011) and HNPCC (5.6% vs. 1.3%; P=0.0014), which contributed to higher rates of metastatic (20% vs. 7.7%; P<0.001), and node-positive disease (51.2% vs. 38.9%; P=0.0042). Patients under 50 subsequently had the worst outcomes, while patients over 75 had the most clement, both in terms of total metastasis (40.8% vs. 19.8%; P<0.001) and cancer-related death rates (27.2% vs. 12.7%, P<0.001). In multivariate analysis, younger patients were shown not to differ significantly from older patients in stage-for-stage outcomes. Rather, differences in outcome are due to higher stage disease on presentation.
Conclusions: While older patients appear correctly identified as low-risk by current screening standards, a higher proportion of patients under 50 present with advanced-stage disease, giving them the worst prognosis of all age groups. Known hereditary and/or high-risk disease forms only explain a part of this effect. While other potential causes are yet unknown, age-related differences in tumor biology, or underdetection by current screening efforts, are potential explanations.
Age Categories
Overall <50 50-65 65-75 >75 P
N=1071 N=125 N=331 N=292 N=323
Comorbidity and history
History of Polyps (%) 12.9 4.0** 10.9 14.7 16.7* 0.002
Personal history of CRC (%) 2.5 0** 0.9* 2.7 5.0** 0.002
First-degree relative CRC (%) 12.1 11.2 13.0 11.3 12.4 0.910
Inflammatory bowel disease (%) 3.5 8.8** 4.5 3.1 0.9** 0.001
HNPCC (%)^a 1.8 5.6** 1.5 1.4 0.9 0.007
Cancer presentation
Screening diagnosis (%) 26.9 12.0** 39.3*** 31.1 17.0*** <0.001
Emergency presentation (%) 9.3 6.4 9.4 10.3 9.9 0.682
Clinically metastatic presentation (%) 14.8 24.8*** 16.0 14.0 9.9*** 0.001
N+ disease (%) 40.3 51.2** 43.5 35.1* 37.6 0.008
M+ stage (%) 9.2 20.0*** 9.7 7.2 6.2* <0.001
Microsatellite instability (%) 4.3 13.6*** 3.9 2.1* 3.1 <0.001
Long-term outcomes
Metastasis in follow-up (%) 12.5 15.2 14.8 11.6 9.9 0.29
All metastatic disease (%) 27.4 40.8*** 30.8 26.0 19.8*** <0.001
Cancer-related death (%) 19.0 27.2** 19.9 21.2 12.7*** 0.002
All death (%) 35.3 32.0 26.3*** 36.0 45.2*** <0.001
^aincludes post hoc diagnosis
*/**/***: Denotes values significantly different from remaining population with *: P<0.05; **: P<0.01***: P<0.001:

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