Duke Cancer Institute (DCI) formed a new working group to tackle an alarming trend: the rising rates of young-onset gastrointestinal (GI) cancers. The group — with experts representing diverse disciplines across research and clinical practice — aims to identify attributable risk factors in patients under 50. These discoveries will help clinicians better risk-stratify patients and implement screening recommendations for cancer interception.

Two members of this group include Duke researchers Meira Epplein, PhD, cancer epidemiologist, and Katherine S. Garman, MD, gastroenterologist. Epplein and Garman also lead Duke Cancer Institute’s Cancer Risk, Detection, and Interception Research Program. While the program studies all cancers, Epplein and Garman have expertise in GI cancers.

The new working group will extensively research which factors or combinations of variables could be causing the increase in colorectal and other GI cancers in younger patients. “What’s changed in our environment, diet, microbiota, immune systems, etc., and how could we intervene before tipping the threshold to develop cancer? We see a trend and want to stop it before it becomes an epidemic,” says Epplein.

Epplein explains that young-onset gastrointestinal cancers are still rare, but rates are increasing. “Cases of GI cancer under age 50 account for one in eight diagnoses, with 75% of cases occurring between ages 40 and 49. We estimate about 15% are due to genetics, leaving a lot of unanswered questions about what’s causing most cases,” says Epplein. 

Since there aren’t screening guidelines for patients between ages 40 and 44 with an average risk, patients with GI cancers often go undiagnosed until they become symptomatic, leading to a later-stage diagnosis. And as more symptomatic younger patients get endoscopies and colonoscopies, Garman says clinicians are seeing more high-risk early lesions that could develop into cancer if left untreated. “We’re very motivated to understand this better, so our patients benefit from earlier approaches that support prevention.”

The only GI cancer with standard screening protocols for people with average risk is colorectal cancer. The age of screening among average-risk groups was recently lowered to 45, but even younger patients may benefit. “Colorectal cancer rates are going down, but there’s still a gap. We need to identify younger patients’ risks and create evidence-based guidelines for them,” says Garman.

Patients with family histories of GI cancers, particularly colorectal cancer, have more screening options. Garman explains that patients with a first-degree relative who had colorectal cancer should start screening 10 years before the family member’s age at diagnosis. “Patients might qualify for genetic testing and screening tests, and if possible, they should learn their family histories and talk about it with their primary care physicians.”

Duke’s Cancer Genetics Clinic offers genetic testing for colorectal, gastric, and pancreatic cancers for patients with a family history.

The Young Onset Gastrointestinal Cancer Initiative (YOGI), funded by DCI, includes multi-disciplinary experts in gastroenterology, GI oncology, population health, epidemiology, immunology, biostatistics, environmental exposures like plastics, genetics, and modifiable risk factors. Researchers will enroll a cohort of young patients coming to Duke for colonoscopy and other GI testing for an observational study that uses a tissue repository to examine cellular changes over time, and examine clinical factors, such as metabolic syndrome, chronic inflammation, pre-existing GI conditions, stress, and the gut microbiota.

“We hypothesize that exposures are affecting the GI tract microbiota, the protective mucous layer and the barrier that would otherwise protect the GI tract,” says Garman. “H. pylori bacteria is a strong consideration, along with chronic antibiotic use, oral bacteria associated with periodontal disease, and viruses,” says Epplein. Epplein is an expert on H. pylori and its implications for population health. 

Garman adds that if a patient has a colonoscopy at age 45 for screening, and a large polyp is found, it likely started several years prior. “We want to learn what’s damaging the GI tract early in a person’s life; then, we can intercept it by finding and removing high-risk lesions.”