Why does the incidence of colorectal cancer (CRC) continue to rise among healthy young people? It’s a question that physicians at NewYork-Presbyterian and Columbia want to answer.
CRC has historically been considered a disease of older adults. However, cases are now decreasing in those 65 and older, while there has been an alarming rise in early-onset colorectal cancer (EOCRC) cases among individuals under 50. In fact, the American Cancer Society reports that colorectal cancer is now the leading cause of cancer death in men and the second-leading cause in women under 50. And by 2030, the incidence of EOCRC is expected to double.
“These patients usually don’t have major comorbidities and conduct a healthy lifestyle,” says Beatrice Dionigi, M.D., FACS, FASCRS, a colorectal surgeon at NewYork-Presbyterian and Columbia. “Most of them don’t carry a genetic predisposition to develop colon cancer, yet they present to the hospital most of the time sick and in advanced stages.”
Dr. Dionigi works closely with her NewYork-Presbyterian and Columbia colleagues, gastroenterologist Joel Gabre, M.D., and medical oncologist Yoanna Pumpalova, M.D., to both treat these patients and develop a better understanding of what is driving this trend. In 2024, they established the Early-Onset Colorectal Cancer Program at the Herbert Irving Comprehensive Cancer Center at NewYork-Presbyterian and Columbia to provide patients with comprehensive care. Unlike conventional care models where patients see different specialists over multiple visits in different days, this program integrates specialists from gastroenterology, oncology, surgery, and genetics into a single, coordinated clinic.
An adenocarcinoma and bleeding in the ascending colon seen during an endoscopy.
The benefits are twofold: expedited decision-making and enhanced continuity of care, which is particularly crucial for younger patients navigating the shock of a cancer diagnosis. “Patients see both a surgeon and an oncologist in the same visit, which helps alleviate confusion and streamlines their treatment journey,” says Dr. Dionigi. “This is critical for all our patients, especially the ones who will require complex surgical interventions, chemotherapy, and genetic counseling.”
Patients are referred to the program after receiving a CRC diagnosis following a colonoscopy with their gastroenterologist. During their initial appointment, they meet with both Dr. Dionigi and Dr. Pumpalova and leave with a medical and/or surgical plan in place, as well as information about how they can contribute to ongoing EOCRC research.
Examining the Cells of Early-Onset Patients
The integration of translational research within the clinical setting allows for real-time application of novel insights. When Dr. Dionigi performs surgery to remove a patient’s tumor, some of the tissue is sent to Dr. Gabre’s lab for in-depth sequencing analysis and to be grown into organoids to be further analyzed. “The initial question we all want to answer is: Do the tumors from young onset patients have different immune cell profiles than those from late or average onset patients?” says Dr. Gabre.
Dr. Gabre’s lab is creating organoids from the cells of patients with colon cancer to learn how the disease differs in younger and older patients. Photo courtesy of Columbia University Irving Medical Center
The team is profiling each individual cell in tumors from younger and older patients. Through examining different types of cells, “we’re trying to compare whether there are differences between early-onset and late-onset cases to gain some insights into the cause and potential therapeutic opportunities,” says Dr. Gabre.
There is some evidence in our early work that perhaps diet or the microbiome could be accelerating these tumors’ growth.
— Dr. Joel Gabre
Recent advances in tumor profiling have allowed researchers to identify unique molecular pathways involved in EOCRC. Dr. Gabre’s team is employing single cell sequencing approaches along with novel computational tools developed at Columbia to carefully profile each cell inside the tumor and in the tumor’s microenvironment. This profiling along with growing patients’ tumors as organoids in the lab provide a powerful approach to validate findings from sequencing.
Preliminary results from his research suggest that EOCRC tumors exhibit a distinct inflammatory signature compared with late-onset CRC, which has been linked in previous studies with dietary factors — particularly saturated fats — to tumor development. “Our profiling is showing that the tumors of young patients are similar to those of older patients, but there is some evidence in our early work that perhaps diet or the microbiome could be accelerating these tumors’ growth,” says Dr. Gabre.
The Need for Increased Awareness
The surge in EOCRC cases underscores the urgent need for increased awareness among both healthcare providers and the public. “The Colorectal Cancer Alliance conducted a survey of early-onset patients and found that they often have to see multiple providers before they get to a gastroenterologist or a colorectal surgeon for a colonoscopy,” says Dr. Gabre. “That is alarming. It’s not right to have rectal bleeding or abdominal pain for several weeks or to be unable to eat. The sooner they get to us, the sooner we can figure out what’s going on and treat them early.”
Dr. Dionigi adds, “Our patients, many of whom have no risk factors, are facing life-altering diagnoses. Our role as clinicians is not just to treat the disease but to provide them with a path forward — whether that’s through surgical innovation, cutting-edge research, or simply being there to support them through their journey.”
