Taisuke Fujita, General Manager, Endoscopy, FUJIFILM Medical Systems U.S.A., Inc.

The picture of a colorectal cancer patient is changing: It’s not just your grandmother anymore. True, most diagnoses of colorectal cancer (CRC) occur between the ages of 65 and 74 years. However, in 2020, approximately 12 percent of CRC cases—a staggering 18,000—were diagnosed in people under 50.

In the United States, CRC is the third most common cancer after lung and breast cancer and is the second leading cause of cancer deaths. But, now CRC is attacking a younger patient population more than ever before—at an accelerating rate. If detected too late, colorectal cancer is deadly. Providers and industry alike must do everything possible to address the surge in CRC incidence in younger patients.

While gastroenterologists are on the front lines in the battle against CRC, interventional radiologists and radiologists sub-specializing in gastrointestinal radiology play an important collaborative care role. This article explores the current CRC landscape, and offers an overview of next generation technology designed for detecting CRC in a new generation of patients.

Historically, CRC was a disease relegated largely to older folks—from newly-minted retirees to the very elderly. But, slowly, the landscape started shifting, and a new picture began to emerge.

For several decades, the rates of CRC incidence have been rising in younger age groups. Specifically, since the mid-1980s rates have been creeping up in adults ages 20-to-39 years and since the mid-1990s in adults ages 40-to-54 years, with younger age groups experiencing the steepest increase.

In more recent times, the incidence rates for younger people continued to climb. For example, from 2012 through 2016, CRC incidence increased every year by 2 percent in people younger than 50 and 1 percent in people 50-to-64. Yet, simultaneously, there was a downward trend in CRC incidence among people 65 and older.

Over time, these changing incidence rates have made a dramatic difference in just who comprises the new CRC patient population.

Simply put, many of today’s CRC patients are significantly younger than they were in previous decades. In fact, according to the American Cancer Society, the incidence of CRC among people under 50 has skyrocketed an alarming 51 percent since 1994.

No one knows for sure why CRC is attacking younger people more often. Experts have voiced several theories, including today’s sedentary lifestyles, higher rates of obesity, a history of inflammatory bowel disease (IBD), and/or genetic factors.

But, there is even more disturbing news. Not only are more younger people being diagnosed with CRC, more of them are dying from it, as well.

In 2021, an estimated 52,980 people in the United States will lose their lives to CRC. The sad fact is that, although the overall death rate has continued to drop, deaths from colorectal cancer among people younger than 55 have increased 1 percent per year from 2008 to 2017.

The Need for Education, Communication and Screening

If detected early, many patients survive CRC and continue to lead productive, fulfilling lives. Early detection is the key to saving lives. But, how do we get there with a new, younger patient population?

We know screening works. From 2011 to 2016, the CRC incidence rate for people aged 65 and older dropped an average of 3.3 percent per year—and experts attribute it largely to colonoscopy screenings.

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Traditionally, colonoscopy screenings have been recommended for people aged 50 and up. It’s no surprise then that younger patients are less likely to get screened because they do not know they should be seeking screening.

The need for education is real and urgent. A 

 report noted that one troubling consequence of the young trend in colorectal cancer is that often both doctors and patients do not take symptoms seriously. As a result, young people are presenting with more advanced stage CRC.

 found that 26 percent of people aged 50 and younger have late-stage disease when they are diagnosed compared to 19 percent of people aged 65 and older.

The good news is that professional societies are taking a stand. In 2018, the American Cancer Society (ACS) lowered the starting age to 45 for colorectal cancer screenings for people at average risk for CRC. ACS experts have determined that screening starting at 45 could help save more lives. Now, the American College of Gastroenterology (ACG) is following suit, just recently updating its guidelines to recommend CRC screening for average-risk individuals starting at age 45.

Clinicians must do their part, too, by taking younger patients’ symptoms seriously, inquiring about a family history of colon cancer, and paying careful attention to younger patients who are overweight or obese. Any or all of these factors could indicate the need for a colon cancer screening.

In addition, there are a variety of tools physicians can utilize to educate the public about the changing face of today’s CRC patient. Providers can use their websites, social media, and community health fairs as communication vehicles to spread the word that CRC does not engage in age discrimination. Younger healthcare consumers need to know that they might be vulnerable to this disease, especially if they have a family history or have unexplainable symptoms.

Finally, in an era of collaborative care, clinicians from diverse specialties—gastroenterology, radiology, primary care, and OBGYN, for example—need to keep the issue of rising rates of CRC in younger patients top-of-mind and communicate with one another if they suspect symptoms in a patient.

While education and communication are important, clinicians who perform colonoscopy also need to arm themselves with the latest tools and technology to detect more colorectal cancers at the earliest stage possible.

Colonoscopy has long been the gold standard. Yet screenings have their limitations. For example, due to the skin folds in this part of the anatomy, it can be challenging for a clinician performing a colonoscopy to see every polyp. And, providers using a legacy technology may be missing out on advanced features that come with partnering with a tech vendor that is continuously innovating.

Now, a next-generation solution from Fujifilm in collaboration with SMART Medical Systems is poised to help detect more cancers in a new generation of patients.

Radiologists know Fujifilm for the outstanding quality of its diagnostic images. The company also applies its core imaging expertise to the field of endoscopy— innovating technologies that deliver exceptional visualization capabilities.

The new G-EYE 700-series endoscope system is a unique innovation that offers enhanced detection capabilities. Here’s how it works: The Fujifilm endoscope is equipped with a balloon at the bending section. On demand, the balloon can be inflated, flattening the colonic walls and improving the detection of hidden polyps.

Better detection of obscured polyps is the first step in catching more cancers sooner.

In addition, G-EYE’s diagnostic yield is expected to be further supplemented by leveraging the latest innovations in enhanced imaging available on Fujifilm’s ELUXEO Video Imaging System. For example, ELUXEO produces a unique light observation mode, known as Linked Color Imaging (LCI), which supports a more accurate delineation, as well as the detection of lesions and inflammation.

G-EYE also allows for controlled withdrawal and improved stability of the colonoscope throughout the procedure. The inflated balloon centralizes optics, assists in controlling the field of view, provides stabilization during therapy, and reduces bowel slippage, which is helpful during intubation or withdrawal.

This next-generation technology is now supporting clinicians and offering new hope to patients. In published clinical studies, G-EYE colonoscopy demonstrated a substantial increase over standard colonoscopy in the detection of polyps, which can be the precursors of colon cancer.

G-EYE is being used routinely at several institutions throughout Europe. Ralf Kiesslich, M.D., a renowned German gastroenterologist, conducted a multi-center international study of more than 1,000 patients. In this 

, he discusses his findings which were published in 

 (GIE). The main outcome of the study is that clinicians can increase the adenoma detection rate significantly by using the G-EYE balloon. In addition, the study found that more flat lesions and advanced lesions were identified by using G-EYE.

G-EYE was 510(k) clearance in 2020, and the first installation of a G-EYE700-series colonoscope in the United States took place at New York University Langone Medical Center (NYU) in December. Further evaluation is now underway at other leading institutions including Brigham and Women's Hospital.

"We are excited to be one of the first centers in the country evaluating this innovative technology," said Linda Lee, M.D., medical director of endoscopy at Brigham and Women's Hospital. "The G-EYE system was implemented seamlessly for everyday use, and early feedback from our physicians has indicated a number of promising benefits, including improved stability and visualization during withdrawal."

Perhaps most exciting, the G-EYE innovation is setting the stage for optimal use of artificial intelligence (AI) in endoscopy.

One of the challenges in optimizing the benefit of AI for improved detection has been the fact that AI can only flag what it can see or identify. Further investigation is required on this topic, but G-EYE may enhance utilization of AI with its unique ability to flatten colon topography, thereby improving visibility of the mucosal surface and uncovering hidden polyps. This opens the possibility for further improvement in detection and procedural efficiency.

Some 104,270 new cases of colon cancer and 45,230 new cases of rectal cancer will be diagnosed in the United States in 2021, according to the ACS. And, if 2020 is any indicator, a double-digit percentage of those cases will be diagnosed in people under the age of 50.

The growing spike in CRC among a younger patient population will likely remain a challenge for some time. Although both the ACS and the ACG now recommend people at average risk undergo CRC screening starting at age 45, the U.S. Preventive Services Task Force still recommends that CRC screening begin at the age of 50.

This is problematic because most insurance companies base their coverage on recommendations from the U.S. Preventive Services Task Force. In other words, most insurance companies are not presently covering the cost of colonoscopy screenings for people under 50. That means that for younger people, cost and lack of access remain barriers to screening.

Reversing the trend in the rising rates of CRC incidence in a younger patient population will require concerted effort on the part of healthcare providers, as well as technology vendors. Patient education and enhanced collaborative care are two important ways providers can lead the charge. At the same time, vendors must continue to innovate by developing advanced systems that help clinicians detect CRC faster and sooner. Next-generation technology is one of the greatest weapons when it comes to winning the CRC battle.

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Taisuke Fujita, General Manager, Endoscopy, FUJIFILM Medical Systems U.S.A., Inc.

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