Colorectal cancer rates are rising in young people. What does that mean for detection and surgical treatment options?

Back in 2004, Shekar Narayanan, M.D., a colorectal cancer surgeon, treated a 21-year-old woman with early stage colorectal cancer. The patient had a minimally invasive procedure to remove a tumor a few years earlier, but the cancer had returned. Back then, colorectal cancer was considered rare in young adults, so it was common to take a more conservative approach to staging and treatment in this age group.

Dr. Narayanan performed a colectomy—an invasive procedure in which a large part of the colon is removed—and created a colostomy, requiring the young patient to use a colostomy bag. Just three years later, at age 24, the cancer had metastasized. By age 25, the patient had died.

Treatment for colorectal cancer has come a long way since then. Today, says Dr. Narayanan, that patient would have likely had her lymph nodes removed and examined at the outset instead of relying on a minor surgical procedure. But despite these advances in understanding and treatment, there’s still a long way to go: Colorectal cancer is steadily rising among people in their 20s and 30s, and colorectal cancer surgeons like Dr. Narayanan are screening, testing and treating more young adults than ever before.¹ And while diagnostic and treatment approaches continue to advance, the rising rates mean that innovation is crucial to keep pace.   

Colorectal cancer has historically been seen as a disease of the elderly, but that perspective started to shift in the 1990s when more and more young people started getting diagnosed.² Since then, rates of colorectal cancer in young adults have steadily risen, by about 3% each year.³

Now, roughly 10% of colorectal cancers around the globe are in people under 50, and it’s the leading cause of cancer deaths in that same group, a study from the American Cancer Society recently found.⁴

As for what’s behind the concerning uptick? “The theories are numerous, but no one really knows why. But it’s being looked at far and wide because it’s alarming,” says David Longcope, M.D., a colon and rectal surgeon. The causes, he says, are likely multifactorial: Ultra-processed foods, sedentary lifestyles, increased obesity rates, gut microbiome diversity changes and environmental exposures, including viruses and pollution, have all been linked to colorectal cancer in young people.  

Routine screening for colorectal cancer in the U.S. kicks off at age 45 and continues through age 75. While the gold standard diagnostic test is a colonoscopy, there are less invasive tests to choose from as well, including stool tests to scan fecal samples for blood or DNA changes associated with the disease.^5,6

However, these tests can have high false positivity rates, sometimes leading to unnecessary follow-up tests and anxiety, says Dr. Narayanan. They occasionally produce false negatives, too, and often fail to catch precancerous polyps. Plus, a follow-up colonoscopy is still needed when the kits come back positive, says Dr. Narayanan.

Usually, people with certain inflammatory bowel diseases like ulcerative colitis and Crohn’s disease, genetic disorders like Lynch syndrome or those with a family history of colorectal cancer, are given the green light to start screening earlier than 45. Outside of these groups, however, doctors don’t typically do routine screenings.⁶

This is concerning because 70% of young people diagnosed have no family history of the disease, says Dr. Longcope. As a result, younger people aren’t getting diagnosed until later stages when colorectal cancer is harder to treat—and deadlier.  

At first glance, the obvious solution would be to ramp up detection efforts in young adults through preventative colonoscopies to help identify and proactively remove polyps. “We’ve increased screening in people over 50 in the last 10 to 20 years from 50% to 75%, and so we have seen a decrease of colorectal cancer in that age group,” says Dr. Longcope. “We’re finding polyps before they become cancerous.”  

But mass screening for young adults would be costly, both Dr. Longcope and Dr. Narayanan acknowledge, which could be a reason it’s not commonplace. And many believe the incidence among young adults, though rising, is still too low to justify routine screening.⁷ For example, an analysis from 2023 on colorectal screening programs noted that mass screenings for young people wouldn’t be cost-effective for health insurers.⁸

There’s also the question of whether young adults would be compliant. Dr. Longcope says that, when the eligibility age for screenings was lowered from 50 to 45, individuals in that age group had far less compliance (around 35%) than those folks 50 and over (about 70%).  

Only about 35% of adults between the ages of 45 and 50 get screened, while upwards of 75% of people 50 and over get tested.⁹ Those who don’t comply with screening recommendations are often concerned about the out-of-pocket costs of the tests along with coordinating logistics, like coordinating transportation and time off work. Others may have heard that the procedures—and the preparation requirements—are uncomfortable and painful, or they underestimate their risk because they have no symptoms or family history.¹⁰ “You’d have to assume that the compliance rates in younger adults would be even less,” says Dr. Longcope. 

Both Dr. Longcope and Dr. Narayanan agree: New methods to improve how colorectal cancer is identified in young adults are urgently needed. One such route being explored is genetic testing. Researchers are racing to identify new genetic markers that predispose people to colorectal cancer in the hopes that the next generation of gene tests can pinpoint people who may benefit from being screened at age 35 or even younger, says Dr. Longcope.  

In addition, a new wave of rapid blood tests that detect abnormal DNA cells associated with colorectal cancer and precancerous polyps are increasingly commercially available. They’re less sensitive than colonoscopies, can also be pricey and are primarily paid for out of pocket, says Dr. Narayanan. But, eventually, as their efficacy rate improves and price tag drops, they may be deployed more widely to detect tumors at a more treatable stage in young people, he suggests.  

Artificial intelligence (AI) is also poised to transform how doctors diagnose colorectal cancer by identifying patterns regarding who is most at risk, says Dr. Longcope. Scientists are investigating whether AI can improve the sensitivity and accuracy of the diagnostic tools we already have. “What if we can use AI to find even smaller polyps or other abnormalities that we’re not seeing with the naked eye during colonoscopies?” Dr. Longcope says.  

Once someone has been diagnosed with colorectal cancer, the treatment path looks similar, regardless of whether they are 75 or 35, says Dr. Longcope. The process starts with imaging scans to determine the extent to which the cancer has spread. Staging informs the type of treatment, whether surgery, chemotherapy, radiation, immunotherapy or a combination of interventions, that will work best for each person’s type of cancer.

Colorectal cancer is primarily treated with surgery, Dr. Longcope notes. Historically, the surgeries were invasive and time-consuming and involved removing large sections of the bowel or colon. In many cases, people’s quality of life suffered. Afterward, the bowel was several inches shorter, Dr. Longcope says, which could lead to an increased frequency in bowel movements. Patients were also more likely to experience pain, impaired social functioning, sexual dysfunction and financial stress.

Open surgery is still performed in the case of tumors that are large, aggressive or embedded in other bodily structures and organs such as the small intestines, uterus or the abdominal wall, says Dr. Longcope. But minimally invasive techniques, including laparoscopic and robotic surgery, have become increasingly common in recent years, especially in younger patients and women of child-bearing age, because recovery is quicker and people have better short-term outcomes.¹¹

These modern approaches create less scar tissue, lead to fewer complications (like hernias) and protect fertility in those who wish to have children. The oncologic outcomes are in line with those of open surgery.¹¹

Dr. Longcope says the instruments used to treat colorectal cancer—the staplers, energy devices and graspers—are also continually advancing in an effort to boost safety and efficiency.  

The ECHELON LINEAR™ Cutter from Ethicon, a Johnson & Johnson MedTech company, for example, can help staples hold more strongly and reliably, which can reduce surgical risks in tumor removals, such as  leaks, Dr. Longcope says. The ETHICON™ 4000 Stapler System, a laparoscopic stapler, can also help reduce the risk of leaks and bleeding at the staple line.^12,13

“The tools are always improving and making our jobs easier, which makes surgery safer and allows us to focus on the task at hand, which is to get all the cancer out and get the patient recovered and home as quickly as possible,” Dr. Longcope says. 

AI also holds the potential to assist with many colorectal surgery tasks—like identifying diseased lymph nodes and microscopic cancer cells that may otherwise escape the naked eye, says Dr. Longcope. Though this use of AI is still in the experimental stage, it may one day lead to safer surgeries and greater survival rates, evidence suggests.¹⁴ 

Some patients will require chemotherapy or radiation after surgery. In cases where the cancer has spread beyond the colon, treatment may begin with chemotherapy and, less commonly, radiation, says Dr. Longcope. Immunotherapy is another option, and in some cases, it may be a substitute therapy.  

Even with today’s surgical advances and post-surgery treatment options, some people will still see their disease progress to more advanced stages or present with metastatic colorectal cancer. In metastatic disease, treatment options remain limited and treatment resistance is common. Johnson & Johnson Innovative Medicine is actively working to change the trajectory of metastatic colorectal cancer care by advancing research into novel mechanisms, biomarker-driven approaches and innovative therapeutic combinations.¹⁵ 

One of the most powerful tools in the fight against colorectal cancer is raising awareness. Historically, young people experiencing colorectal symptoms—such as abdominal pain or rectal bleeding—would often be dismissed. In other cases, patients themselves may have ignored or felt embarrassed by their symptoms, delaying care and diagnosis. “People would think, ‘Why would this happen to me? I’m young, I’m healthy, I’m 35, I have no family history,’" says Dr. Narayanan.

As colorectal rates in young adults continue to rise, so, too, has awareness among both the public and healthcare providers. “People are much more concerned about it,” says Dr. Longcope. As a result, more patients are speaking up about their symptoms, and more primary care physicians are ordering screening tests and referring patients to gastroenterologists for follow-up evaluations.

“People are doing a much better job of saying, ‘Let’s just be safe. Let’s see what’s going on. We don’t want to take any chances’—and it’s wonderful,” he says.