Abdominal pain and hematochezia could be crucial red flags for early-onset colorectal cancer

In a recent review published in JAMA Network Open, a team of researchers discussed the presenting symptoms or red-flag signs commonly seen in individuals with early-onset colorectal cancer, the association between these signs and the risk of early-onset colorectal cancer, and the variation in the time elapsed between the presentation of these signs and diagnosis.

Study: Red Flag Signs and Symptoms for Patients With Early-Onset Colorectal Cancer. Image Credit: Jo Panuwat D / ShutterstockStudy: Red Flag Signs and Symptoms for Patients With Early-Onset Colorectal Cancer. Image Credit: Jo Panuwat D / Shutterstock


Recent trends indicate that while the rate of colorectal cancer among older individuals is decreasing, the incidence rates of early-onset colorectal cancer, where the disease is diagnosed in individuals below 50 years of age, have been increasing rapidly. Studies suggest that while the global trends are similar, the rates of early-onset colorectal cancer in the United States can increase by 140% by 2030.

These alarming predictions have led to an update in the screening guidelines for colorectal cancer to begin screening at 45 years for individuals who might be at average risk of the disease. Furthermore, the early detection of the disease is a priority since the survival rate for colorectal cancer patients is significantly higher if the disease is diagnosed and treated in the early stages.

Given that delayed diagnoses could occur due to numerous reasons, such as the clinician lacking knowledge about common colorectal cancer symptoms, patients downplaying the severity of the symptoms, or inability to recognize common red flags, it is essential to have a better understanding of the common presenting symptoms or red flags of early-onset colorectal cancer.

About the study

The present study aimed to answer three questions through a systematic review of studies on early-onset colorectal cancer and a meta-analysis. They first determined the symptoms and signs that present most commonly in early-onset colorectal cancer patients and then aimed to understand the association between these symptoms and signs and the risk of early-onset colorectal cancer. Lastly, they investigated the time between the first presentation of these symptoms and the diagnosis of early-onset colorectal cancer.

The review included studies that reported any symptoms or signs of non-hereditary colorectal cancer or diagnosis time for individuals below the age of 50 years. However, they excluded studies with less than 15 patients or those where a majority of the patients were younger than 18 years.

Relevant information, such as the proportion of early-onset colorectal cancer patients presenting each symptom or sign, the estimated association between symptoms and risk of early-onset colorectal cancer, and patient reports or medical records on time elapsed between symptom presentation and diagnosis, was extracted from the studies.

Stratified analyses were conducted to assess whether variations in risk estimates were based on factors such as age groups, geographic location, and risk of bias. The researchers assessed the heterogeneity between the risk estimates in the various studies, which was then also stratified according to the characteristics of the study.

The researchers reported the symptoms and signs described in at least three studies and the risk estimates for early-onset colorectal cancer. The reports of time to diagnosis, defined as the time between the date of presentation of symptom or sign and the date of diagnosis, were also stratified by the data source type since the measurement method varied across studies.


The results indicated that more than 50% of the early-onset colorectal cancer patients presented with abdominal pain and hematochezia, or the presence of blood in stool, and 25% of the patients had altered bowel habits.

Hematochezia was associated with a 5-fold to 54-fold increase in the risk of colorectal cancer, while abdominal pain was linked to a 1.3 to 6-fold increase in the likelihood of colorectal cancer. Furthermore, a four-to-six-month delay between the first presentation of one of the symptoms and diagnosis of the disease was found to be common.

While some studies have reported that younger individuals have a longer time to diagnosis as compared to middle-aged colorectal cancer patients, others have also claimed that younger patients being diagnosed with more advanced stages of colorectal cancer at presentation as compared to older ones might not be associated with delayed diagnosis, but other genetic and biological factors.

The researchers believe that these findings highlight the need for clinicians to consider early-onset colorectal cancer during the differential diagnosis if patients present with red flags such as hematochezia or abdominal pain. Further tests such as colonoscopies, ultrasonography, and computed tomography must be considered to either confirm or rule out early-onset colorectal cancer during the differential diagnosis.


Overall, the findings indicated that symptoms such as abdominal pain and hematochezia presented in over 50% of the early-onset colorectal cancer patients, while a quarter of them experienced alterations in bowel habits.

In the presence of these red-flag signs, the researchers believe that early-onset colorectal cancer should be considered as part of the differential diagnosis, and clinicians must perform additional tests to confirm or rule out early-onset colorectal cancer and avoid further delays in diagnosis.

Journal reference:
  • Demb, J., Kolb, J. M., Dounel, J., Cassandra, F., Advani, S. M., Cao, Y., CoppernollBlach, P., Dwyer, A. J., Perea, J., Heskett, K. M., Holowatyj, Andreana N, Lieu, C. H., Singh, S., Manon, S., Fanny, & Gupta, S. (2024). Red Flag Signs and Symptoms for Patients With Early-Onset Colorectal Cancer: A Systematic Review and Meta-Analysis. JAMA Network Open, 7(5), e2413157–e2413157. DOI: 10.1001/jamanetworkopen.2024.13157, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2819248 
Dr. Chinta Sidharthan

Written by

Dr. Chinta Sidharthan

Chinta Sidharthan is a writer based in Bangalore, India. Her academic background is in evolutionary biology and genetics, and she has extensive experience in scientific research, teaching, science writing, and herpetology. Chinta holds a Ph.D. in evolutionary biology from the Indian Institute of Science and is passionate about science education, writing, animals, wildlife, and conservation. For her doctoral research, she explored the origins and diversification of blindsnakes in India, as a part of which she did extensive fieldwork in the jungles of southern India. She has received the Canadian Governor General’s bronze medal and Bangalore University gold medal for academic excellence and published her research in high-impact journals.


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