ONE night, a 16-year-old boy was wheeled in through the emergency room. He was in agonising pain, had not passed motion for the past three days and was vomiting.
At his age, the usual suspects for such a presentation are severe appendicitis, a twisted bowel or food poisoning. Colorectal cancer is rarely on the radar.
But when I operated to relieve the blockage, the reality was undeniable and devastating. A malignant tumour had grown enough to completely choke his bowel.
As a surgeon, diagnosing cancer and performing surgery to save lives is an inherent part of my life. But delivering a cancer diagnosis to a teenager and his parents is a profoundly tragic task.
Unfortunately, this boy’s case is not an isolated anomaly anymore. It is a stark warning sign of a growing global health crisis: the rise of early-onset colorectal cancer (EOCRC).
Historically, colorectal cancer, or cancer in general, has been viewed as a disease of ageing, predominantly affecting those in their 60s and 70s. However, the demographic landscape is rapidly shifting.
While incidence rates in older populations are stabilising or declining — largely thanks to robust screening programmes and modern medicine — the rates among those under 50, and increasingly among adolescents and young adults, are surging worldwide.
To combat this silent epidemic, we must understand the unique challenges it presents, from the hurdles of early diagnosis to the aggressive nature of the tumours themselves.
This diagnostic blind spot is driven by several intersecting factors. The early warning signs of colorectal cancer—rectal bleeding, altered bowel habits, abdominal cramping and unexplained fatigue — are frequently misattributed to benign, common conditions.
This "symptom overlap" presents a unique challenge. Blood in the stool of young patients is often dismissed as haemorrhoids or anal fissures. Frequent abdominal pain is attributed to irritable bowel syndrome (IBS), food poisoning or even just the growing pains and dietary indiscretions of youth.
Young people are inherently busy. They may be in college, working hard in the office or busy building their families. The demands of everyday life often lead young people to ignore these serious symptoms.
To make things more challenging, healthcare providers are trained to play the odds. Because cancer is statistically rare in youths, physicians may unintentionally delay crucial
investigations like stool or blood tests or refer for colonoscopy.
Early-onset colorectal cancer is not simply the traditional disease occurring at an earlier age; it is often biologically and clinically distinct. Research indicates that tumours developing in young patients frequently exhibit more aggressive features.
When pathologists analyse these early-onset tumours under the microscope, they often find poorly differentiated cells, meaning the cancer cells look and behave very abnormally and multiply rapidly.
As a result, young patients have a higher incidence of specific aggressive tumour subtypes, such as mucinous or signet-ring cell carcinomas. These variants are notorious for spreading quickly through the layers of the bowel wall and into surrounding lymph nodes or other organs such as the liver or lungs.
Coupled with the diagnostic delays mentioned earlier, this biological aggressiveness creates a perfect storm. By the time young patients are finally diagnosed, they are far more likely to present with late-stage, advanced disease.
Furthermore, this aggressive tumour tends to recur early after surgery or does not respond well to chemotherapy after surgery. In the case of my 16-year-old patient, the tumour had grown relentlessly, hidden in plain sight, until it completely obstructed his colon.
This case must serve as a clarion call for both the public and the medical community. We can no longer afford to view colorectal cancer exclusively through the lens of age. We must normalise conversations about bowel health, as no one should put their health at risk because of embarrassment.
It is important to listen to your body and seek medical attention if you experience persistent warning signs, including unexplained bleeding from the rectum or blood in the stool. Persistent changes in bowel habits, such as chronic diarrhoea, constipation or a feeling that the bowel does not empty completely, should also be checked.
Other warning signs include persistent abdominal pain or cramping, unintentional weight loss and chronic fatigue.
Knowing your family history is vital. Genetic predispositions, such as Lynch syndrome or Familial Adenomatous Polyposis (FAP), drastically increase the risk of young-onset cancers. If you have a family history of colorectal cancer, early and aggressive screening is vital.
Operating on a 16-year-old for an obstructing bowel cancer is a sobering experience that stays with a surgeon forever. It is a stark reminder that while youth offer many advantages, it does not afford an impenetrable shield against cancer.
DR NABIL MOHAMMAD AZMI
Department of Surgery
Hospital Canselor Tuanku Muhriz
Kuala Lumpur
