Colonoscopy utilization and persistent disparities in early onset colorectal cancer: A multistate, multi-institution...

Early-onset colorectal cancer disease burden is rising, but it remains unclear whether this trend is driven by increased colonoscopy use or reflects a true epidemiologic shift, particularly across racial/ethnic groups. We analyzed predictors of early onset colorectal cancer, temporal trends in colonoscopy utilization (2017-2023), the correlation between utilization and the proportion of early onset colorectal cancer diagnoses over time, and differential predicted risk by health care engagement and ethnicity.

In a retrospective matched nested case-control study within a multi-institutional health care system population, 2,776 patients (1,388 patients with early-onset colorectal cancer and 1,388 negative controls) were analyzed. Nine hundred eighty-three patients were identified to have sporadic early onset colorectal cancer. Conditional multivariable logistic regression identified independent risk factors. Colonoscopy utilization and early onset colorectal cancer composition were normalized (2017 = 1.0) to generate indexed trends by race and ethnicity. Pearson correlations between utilization and proportion of annual early onset colorectal cancer diagnoses were calculated. Predicted probabilities of sporadic early onset colorectal cancer by number of medical visits were estimated, stratified by Hispanic versus non-Hispanic groups.

Between 2017 and 2023, colonoscopy utilization increased substantially across all age groups, with the greatest absolute volume among adults aged 41-50 years. Over the same period, early onset colorectal cancer diagnoses rose disproportionately, including a 93% increase among patients aged 41-50 years. Marked racial and ethnic disparities were observed: compared with 2017, early onset colorectal cancer diagnoses increased by 300% among Black patients, 192% among Hispanic patients, and 144% among Asian patients. In multivariable analysis, iron-deficiency anemia (odds ratio, 3.56; 95% confidence interval, 2.10-6.03), former alcohol use (odds ratio, 2.04; 95% confidence interval, 1.44-2.90), American Indian/Alaska Native race (odds ratio, 4.03; 95% confidence interval, 1.12-14.5), Black race (odds ratio, 1.94; 95% confidence interval, 1.07-3.53), and Hispanic ethnicity (odds ratio, 1.72; 95% confidence interval, 1.13-2.61) were independently associated with increased odds of early onset colorectal cancer. Trends in overall survival differed by ethnicity, with early-onset colorectal cancer Hispanic/Latino patients experiencing inferior outcomes. Greater health care utilization was strongly associated with lower odds of sporadic early onset colorectal cancer diagnosis, with each additional medical visit associated with a 25% reduction in sporadic early onset colorectal cancer odds (odds ratio, 0.75; 95% confidence interval, 0.72-0.78); however, this inverse association was attenuated among Hispanic patients, who demonstrated persistently higher predicted probabilities across increasing levels of health care engagement.

Colonoscopy utilization increased substantially among adults younger than the traditional colorectal cancer screening age between 2017 and 2023; however, these increases did not translate into proportional reductions in disparities in early onset colorectal cancer diagnosis or outcomes. Ethnic minority populations experienced disproportionate and persistently worse survival. These findings suggest that improvements in screening utilization alone are insufficient to mitigate early onset colorectal cancer disparities and underscore the need for targeted, equity-focused strategies beyond screening access.