When Abdominal Pain in a Teen Could Be Colorectal Cancer

A retrospective study presented at the American Academy of Pediatrics meeting in San Diego highlighted the diagnostic challenge posed by colorectal cancer in children and adolescents. The disease remains rare, but when it does occur, symptoms can be nonspecific and patients may already have advanced disease by the time it is diagnosed.

In this MedPage Today video, study authors Erica Arnold, MD, of Nationwide Children’s Hospital in Columbus, Ohio, and Danielle Cameron, MD, MPH, of Mass General Brigham Cancer Institute in Boston, discuss the findings, why diagnosis can be delayed, and what physicians should consider when persistent symptoms don’t fit the usual diagnostic picture.

The following is a transcript of their remarks:

MedPage Today: Colorectal cancer remains rare in children and adolescents, but a multicenter study presented at the American Academy of Pediatrics annual meeting in San Diego found most young patients were diagnosed with advanced disease. The study included 84 patients aged 21 and younger. The median time from onset of symptoms to diagnosis was 12 weeks, and 80% had stage III or IV disease.

Arnold: We also noticed that there were high rates of aggressive histologic features or tumor biology, including signet ring features, mucin, and poorly differentiated histology that were all higher than what we see in adult colorectal cancer, which signified to us that this seems like it really is a distinct disease from older adult colorectal cancer when it’s diagnosed in this young age group.

And, unfortunately, with what we saw in our cohort, that was affiliated with high rates of stage III and stage IV disease and unfortunately poor outcomes for these kids.

Cameron: Yeah, and that’s the challenge because if we did a screening colonoscopy on every teenager with abdominal pain, we would be overtreating or overtesting. And so thorough history and physical exam and doing less invasive studies to rule out other more common causes of abdominal pain would be prudent.

But I think what’s key is really maintaining a high level of suspicion and raising awareness that cancer is on the differential diagnosis will help us detect this a little bit earlier.

I think it’s multifactorial. Oftentimes patients will dismiss symptoms initially. The symptoms are often vague and not really severe, but persistent symptoms should prompt a patient and their family to seek medical attention. And then figuring out which provider is best suited to further work this up is also a challenge.

I’ve had patients who presented with low back pain, for example, and were initially seen by a rheumatologist or a physical therapist, someone who is not necessarily doing a workup for underlying malignancy.

MedPage Today: But delayed diagnosis may not be the only reason these cancers are so advanced when they’re found.

Arnold: With most of our cohort having stage III and IV disease, this showed us that these kids are not presenting early or this is a combination of the tumor biology that we saw. So, with how we did the study, it’s not clear to us if a delay in diagnosis or if the aggressive histologic features that we saw are what’s really driving this advanced stage when these patients are diagnosed, but it’s something that certainly needs further study.

Cameron: There are certain considerations for rare solid tumors, things that we might more commonly see in the adult population or vice versa. In a 20-some-year-old, we may see a more classic pediatric solid tumor.

And so whenever you’re encountered with an adolescent or college-age patient, remembering that they may not fit the usual box is really important and critical for figuring out who to refer to and what diagnoses to consider.