1. Epidemiology of Colorectal Cancer in England: is it changing?
Somerset, Wiltshire, Avon and Gloucestershire SSG meeting
Adam Chambers
Colorectal Registrar Severn Deanery

2. Outline Worldwide trends in colorectal cancer epidemiology
Changes in age-specific incidence in England
South west data compared to English data
Comparison with findings in other countries
Future directions

3. Is (colo)rectal cancer increasing among young adults (<40years) in England?

4. Worldwide Incidence 2012 2030 1.4 million 2.2 million
Ferlay et al., GLOBOCAN 2012, IARC

5. CRC incidence increases with HDI
Low HDI
Medium HDI
High HDI/Very high HDI
↔ Incidence
↑ Mortality
↑ Incidence
↓ Mortality
↓ Incidence
Gambia
Mozambique
Philippines
Brazil UK
Denmark US
Austria
Ferlay et al., GLOBOCAN 2012, IARC

6. Aims
To determine whether the incidence of colorectal cancer is increasing among young adults (<40 years)
To determine whether this differs according to site (colon vs. rectum) or gender

7. Methods
Data collected by National Cancer Registration & Analysis Service (NCRAS) – 100% data completeness to 2010 and 98.4% to 2016
Operated by Public Health England (PHE)
Adults aged ≥20 years from 1974 to 2015
Identification using ICD9 ( ) & ICD10 (C18-C20)
Grouped into 10 age bands
Office for National Statistics (ONS) for mid-year populations estimates

8. Statistical Analysis Modelling
Age-specific rate =
Number of new cases in age group
Mid-year population estimate of age group
Age-standardised rate =
∑ (European standard population in age group X age-specific rate)
∑ European standard population in age group
Modelling
Joinpoint Regression to estimate annual percentage change/changes in incidence
Age-period-cohort modelling

9. Largest study of CRC incidence worldwide
Total CRC cases : 1,145,639
Colon: 726,887
Rectum: 418,752

10. The Elderly (>90 years)
-2.1%
+3.0%
Incidence CRC (per 100,000)
+1.3%
Annual Percentage Change (%) in Colorectal Cancer Incidence

11. Screening Age (60-74 years)
+1.0%
-0.8%
+4.5%
-1.0%
60-69 years
+1.3%
-0.8%
+1.4%
-4.6%
70-74 years
Incidence CRC (per 100,000)
Incidence CRC (per 100,000)
Annual Percentage Change (%) in Colorectal Cancer Incidence

12. Pre-screening middle age (40-59 years)
+1.6%
-0.7%
Incidence CRC (per 100,000)
+1.8
+1.2%
Incidence CRC (per 100,000)
-1.0%
Annual Percentage Change (%) in Colorectal Cancer Incidence

13. The Young (<40 years) 20-29 years 30-39 years
-4.8%
+20.7%
+12.7%
-26.1%
-2.9%
Incidence CRC (per 100,000)
Incidence CRC (per 100,000)
+0.8%
+1.4%
Annual Percentage Change (%) in Colorectal Cancer Incidence

14. South West vs English CRC incidence rates

15. CRC incidence by anatomical site and gender (20-40years)

16. Age-period-cohort: Colon vs. Rectum

17. Is this an isolated phenomenon?
USA
Canada
Brenner et al., Prev Med 2017
Siegel et al., JNCI 2017

18. Conclusions Increased incidence in young adults over last 20 years
Birth-cohort effect observed after 1965
Similar trend in both colonic (IRR=2) and rectal cancer (IRR=3)
Comparable trends seen in North America
South West data mirrors English data
Ecological data – no risk factor data

19. Future Directions Implications for screening and diagnosis - (qFIT)
Identification of differences in phenotype/biology in this age group
Understand the issues of living with CRC and its management for younger people
Promote awareness in at risk groups

20. Acknowledgments Mr David Messenger Dr Steve Dixon Dr Paul White
Consultant Colorectal Surgeon, University Hospitals Bristol
Dr Steve Dixon
Post-CCT Senior Clinical Fellow in Gastroenterology & MD candidate, University of Bristol
Dr Paul White
Associate Professor in Applied Statistics, University of West of England
Mr Mike Thomas

21. Sources of Funding
Elizabeth Blackwell Institute for Health Research Clinical Primer Fellowship
Medical Research Council Clinical Research Training Fellowship
David Telling Charitable Trust
(Mr Adam Chambers)

22. Earlier diagnosis is critical in the younger patient
<40 years
≥40 years
P-value
At presentation
Poorly differentiated
27%
14%
0.014
N2 disease at presentation
37%
16%
0.001
Metastatic disease at presentation
38%
22%
0.019
Treated with curative intent
Develop metastatic disease
56%
23%
0.003
5-year Overall Survival
54%
80%
0.029
Endreseth et al. (Norwegian Rectal Cancer Group), Dis Col Rectum 2006