Re: Early-onset colorectal cancer (1)

I want to express my gratitude to Dr Gray for his article addressing early-onset colorectal cancer [BCMJ 2023;65:207-210]. While I value the article for its concise summary of this critical topic, I have several concerns, especially as a family physician and a patient personally impacted by early-onset colorectal cancer.

At the age of 36, I was diagnosed with stage IV colorectal cancer, despite being previously healthy and lacking any family history or known risk factors. My journey to diagnosis was fraught with delays and misdiagnoses. Initially, a specialist misdiagnosed my condition as hemorrhoids during an appointment I had waited 4 months for, providing me with a false sense of reassurance that only extended the time until my proper diagnosis. It wasn’t until my rectal bleeding became severe that I presented to hospital. Even then, because my hemoglobin levels were within the normal range, I was considered low risk and almost sent home. I had to insist on an urgent colonoscopy, which finally took place the following day. Prior to the procedure, the possibility of malignancy was not discussed or considered, as all listed differentials were benign etiologies.

This was my experience navigating the health care system as a patient, despite being a physician who is well attuned to my own health. Regrettably, my story is not unique; I have connected with others in their 30s diagnosed with advanced-stage early-onset colorectal cancer who faced similar difficulties in accessing care. A common theme among them is that they were told by their primary care providers and specialists that they were “too young to have cancer.” It appears that there is a significant lack of awareness among both primary care physicians and specialists regarding the increasing incidence of early-onset colorectal cancer, especially in cases where there is no family history or obvious risk factors, as was the case with me.

The article commences with the well-intentioned statement that “[t]he BC Guideline for colorectal cancer screening encourages physicians to evaluate younger adults with symptoms or a family history of colorectal cancer by using colonoscopy.” However, based on my experience as a family physician with years of practice in primary care, gaining access to a gastroenterologist for colonoscopy assessment is extremely challenging. Many times, I have had referrals flagged as “urgent” go unacknowledged, triaged as low priority with an 8- to 12-month wait, or worse, rejected for unjust or unclear reasons. I believe that many of my family physician colleagues can relate to similar experiences.

A recent systematic review on the role of colonoscopy in younger patients presenting with anorectal bleeding found that approximately 10% had a neoplastic lesion detected.[1] This underscores the importance of timely access to colonoscopy assessment for younger patients with colorectal cancer symptoms. I strongly advocate for a more efficient referral and access system for colonoscopy, particularly when colorectal cancer is suspected based on symptoms. I believe that implementing a centralized referral system, akin to the BC Colon Screening Program, which offers consolidated access to endoscopists (including gastroenterologists and general surgeons), would significantly enhance the current system’s capacity to provide timely access to patients with concerning colorectal cancer symptoms, including those in the early-onset age range.

Last, I would like to acknowledge the success of the BC Colon Screening Program in patients aged 50–74 years. It has notably reduced the administrative burden for primary care providers and improved colorectal cancer screening access for our patients in this age group. On the question of lowering the screening age, I respectfully disagree with Dr Gray and advocate for lowering the screening age to 45, a topic on which I defer to my colleague, Dr Petra Wildgoose, for further discussion and exploration.
—Marko Yurkovich, MD, CCFP
Vancouver

This letter was submitted in response to “Early-onset colorectal cancer.”

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References

1.    Colles T, Ziegelmann PK, Damin DC. The role of colonoscopy in young patients with rectal bleeding: A systematic review and meta-analysis. Int J Colorectal Dis 2023;38:230.