The location of premalignant colorectal polyps under age 50: a further rationale for screening sigmoidoscopy



The incidence of colorectal cancer (CRC) among young adults has been dramatically rising, with guidelines for screening recently adjusted to start at age 45. However, knowledge of the precursor lesions is limited. We recently reported that 83% of CRC diagnosed under age 50 are left sided. Our aim was to analyze the location and histology of benign colorectal lesions found in a cohort of patients younger than 50, documenting the presence of advanced histology.


We used the database in the Department of Pathology to retrospectively review the location and histology of all benign colorectal neoplasms in patients under age 50 submitted to pathology examination during 2006–2016.


A total of 8364 lesions were examined from 4773 patients, and 3534 (65.5%) of the patients had only one polyp and the rest had multiple. Mean age was 41.9 years (range 16–49) while 3843 (72.8%) of the patients were between the ages of 40 and 49. In total, 4570/8364 lesions (54.6%) were distal to the splenic flexure. The most common pathology was tubular adenoma (63.7%), then hyperplastic polyps (16.6%), sessile serrated lesions (SSLs) (13.1%), and tubulovillous adenomas (6.3%). Tubulovillous adenomas, villous lesions, advanced adenomas, and adenomas with high-grade dysplasia were all predominantly left sided (left colon and rectum = 77.6%, 85%, 78.3%, and 87.6% respectively). Of the SSLs, 71.5% were in the right colon while 16.6% of hyperplastic lesions were right sided.


High-risk advanced adenomas are predominantly left sided. This focuses attention on the rectum and left colon where carcinogenesis is strong in the young.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 199

This is the net price. Taxes to be calculated in checkout.


  1. 1.

    Murphy CC, Sandler RS, Sanoff HK, Yang YC, Lund JL, Baron JA (2017) Decrease in incidence of colorectal cancer among individuals 50 years or older after recommendations for population-based screening. Clin Gastroenterol Hepatol 15:903–909

  2. 2.

    Ansa BE, Coughlin SS, Alema-Mensah E, Smith SA (2018) Evaluation of colorectal cancer incidence trends in the United States (2000–2014). J Clin Med 7(2):E22

  3. 3.

    Ahnen DJ et al (2014) The increasing incidence of young-onset colorectal cancer: a call to action. Mayo Clin Proc 89:216–224

  4. 4.

    Printz C (2015) Colorectal cancer incidence increasing in young adults. Cancer. 121:1912–1913

  5. 5.

    Bhandari A, Woodhouse M, Gupta S (2017) Colorectal cancer is a leading cause of cancer incidence and mortality among adults younger than 50 years in the USA: a SEER-based analysis with comparison to other young-onset cancers. J Investig Med 65(2):311–315

  6. 6.

    You YN, Dozois EJ, Boardman LA, Aakre J, Huebner M, Larson DW (2011) Young-onset rectal cancer: presentation, pattern of care and long-term oncologic outcomes compared to a matched older-onset cohort. Ann Surg Oncol 18(9):2469–2476

  7. 7.

    Wolf AMD, Fontham ETH, Church TR, Flowers CR, Guerra CE, LaMonte SJ, Etzioni R, McKenna MT, Oeffinger KC, Shih YT, Walter LC, Andrews KS, Brawley OW, Brooks D, Fedewa SA, Manassaram-Baptiste D, Siegel RL, Wender RC, Smith RA (2018) Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 68:250–281

  8. 8.

    Peterse EFP, Meester RGS, Siegel RL, Chen JC, Dwyer A, Ahnen DJ, Smith RA, Zauber AG, Lansdorp-Vogelaar I (2018) The impact of the rising colorectal cancer incidence in young adults on the optimal age to start screening: microsimulation analysis I to inform the American Cancer Society colorectal cancer screening guideline. Cancer. 124:2964–2973

  9. 9.

    Bailey CE, Hu CY, You YN, Bednarski BK, Rodriguez-Bigas MA, Skibber JM, Cantor SB, Chang GJ (2015) Increasing disparities in the age-related incidences of colon and rectal cancers in the United States, 1975-2010. JAMA Surg 150(1):17–22

  10. 10.

    Siegel RL, Fedewa SA, Anderson WF, Miller KD, Ma J, Rosenberg PS, Jemal A (2017) Colorectal cancer incidence patterns in the United States, 1974-2013. J Natl Cancer Inst 109(8)

  11. 11.

    Liang J, Kalady MF, Church J (2015) Young age of onset colorectal cancers. Int J Color Dis 30(12):1653–1657

  12. 12.

    Segev L, Kalady MF, Church JM (2018) Left-sided dominance of early-onset colorectal cancers: a rationale for screening flexible sigmoidoscopy in the young. Dis Colon Rectum 61(8):897–902

  13. 13.

    Myers EA, Feingold DL, Forde KA et al (2013) Colorectal cancer in patients under 50 years of age: a retrospective analysis of two institutions’ experience. World J Gastroenterol 19:5651–5657

  14. 14.

    Jones HG, Radwan R, Davies M et al (2015) Clinicopathological characteristics of colorectal cancer presenting under the age of 50. Int J Color Dis 30(4):483–489

  15. 15.

    Strul H, Kariv R, Leshno M, Halak A, Jakubowicz M, Santo M, Umansky M, Shirin H, Degani Y, Revivo M, Halpern Z, Arber N (2006) The prevalence rate and anatomic location of colorectal adenoma and cancer detected by colonoscopy in average-risk individuals aged 40-80 years. Am J Gastroenterol 101(2):255–262

  16. 16.

    Rundle AG, Lebwohl B, Vogel R, Levine S, Neugut AI (2008) Colonoscopic screening in average-risk individuals ages 40 to 49 vs 50 to 59 years. Gastroenterology. 134(5):1311–1315

  17. 17.

    Chung SJ, Kim YS, Yang SY, Song JH, Park MJ, Kim JS, Jung HC, Song IS (2010) Prevalence and risk of colorectal adenoma in asymptomatic Koreans aged 40-49 years undergoing screening colonoscopy. J Gastroenterol Hepatol 25(3):519–525

  18. 18.

    Imperiale TF, Wagner DR, Lin CY, Larkin GN, Rogge JD, Ransohoff DF (2002) Results of screening colonoscopy among persons 40 to 49 years of age. N E J Med 346(23):1781–1785

  19. 19.

    Koo JE, Kim K-J, Park HW, Kim H-K, Choe JW, Chang H-S, Lee JY, Myung S-J, Yang S-K, Kim J-H (2017) Prevalence and risk factors of advanced colorectal neoplasms in asymptomatic Korean people between 40 and 49 years of age. J Gastroenterol Hepatol 32(1):98–105

  20. 20.

    Leshno A, Moshkowitz M, David M, Galazan L, Neugut AI, Arber N, Santo E (2016) Prevalence of colorectal neoplasms in young, average risk individuals: a turning tide between east and west. World J Gastroenterol 22:7365–7372

  21. 21.

    Chouhan H, Ferrandon S, DeVecchio J, Kalady MF, Church JM (2019) A changing spectrum of colorectal cancer biology with age: implications for the young patient. Dis Colon Rectum 62(1):21–26

  22. 22.

    Kim KM, Lee EJ, Ha S, Kang SY, Jang KT, Park CK, Kim JY, Kim YH, Chang DK, Odze RD (2011) Molecular features of colorectal hyperplastic polyps and sessile serrated adenoma/polyps from Korea. Am J Surg Pathol 35:1274–1286

  23. 23.

    Gupta A, Samadder J, Elliott E, Sethi S, Schoenfeld P (2012) Prevalence of adenomas and advanced adenomas in patients in the 40- to 49-year age group undergoing screening colonoscopy because of a family history of adenoma/polyp in a first-degree relative. Gastrointest Endosc 75:705–711

  24. 24.

    Grover S, Kastrinos F, Steyerberg EW, Cook EF, Dewanwala A, Burbidge LA, Wenstrup RJ, Syngal S (2012) Prevalence and phenotypes of APC and MUTYH mutations in patients with multiple colorectal adenomas. JAMA. 308:485–492

  25. 25.

    Kalady MF, Kravochuck SE, Heald B, Burke CA, Church JM (2015) Defining the adenoma burden in Lynch syndrome. Dis Colon Rectum 58:388–392

  26. 26.

    Rodriguez-Bigas MA, Boland CR, Hamilton SR, Henson DE, Jass JR, Khan PM, Lynch H, Perucho M, Smyrk T, Sobin L, Srivastava S (1997) A National Cancer Institute Workshop on Hereditary Nonpolyposis Colorectal Cancer Syndrome: meeting highlights and Bethesda guidelines. J Natl Cancer Inst 89:1758–1762

  27. 27.

    Tomasetti C, Durrett R, Kimmel M, Lambert A, Parmigiani G, Zauber A, Vogelstein B (2017) Role of stem-cell divisions in cancer risk. Nature 548:E13–E14

  28. 28.

    Tomasetti C, Vogelstein B (2015) Cancer etiology. Variation in cancer risk among tissues can be explained by the number of stem cell divisions. Science. 347:78–81

  29. 29.

    Holme Ø, Løberg M, Kalager M, Bretthauer M, Hernán MA, Aas E, Eide TJ, Skovlund E, Schneede J, Tveit KM, Hoff G (2014) Screening on colorectal cancer incidence and mortality: a randomized clinical trial. JAMA. 312:606–615

  30. 30.

    Atkin W, Wooldrage K, Parkin DM, Kralj-Hans I, MacRae E, Shah U, Duffy S, Cross AJ (2017) Long term effects of once-only flexible sigmoidoscopy screening after 17 years of follow-up: the UK Flexible Sigmoidoscopy Screening randomized controlled trial. Lancet. 389:1299–1311

  31. 31.

    Schoen RE, Pinsky PF, Weissfeld JL, Yokochi LA, Church T, Laiyemo AO, Bresalier R, Andriole GL, Buys SS, Crawford ED, Fouad MN, Isaacs C, Johnson CC, Reding DJ, O’Brien B, Carrick DM, Wright P, Riley TL, Purdue MP, Izmirlian G, Kramer BS, Miller AB, Gohagan JK, Prorok PC, Berg CD, PLCO Project Team (2012) Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy. N Engl J Med 366:2345–2357

Download references

Author information

Correspondence to Lior Segev.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Segev, L., Kalady, M.F., Plesec, T. et al. The location of premalignant colorectal polyps under age 50: a further rationale for screening sigmoidoscopy. Int J Colorectal Dis (2020).

Download citation


  • Colorectal polyps
  • Colorectal cancer
  • Colonoscopy
  • Screening