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Clinical and demographic analysis of patients with colorectal cancer screened at a reference hospital in Southern Brazil: comparative study based on age (Retrospective cohort study)

BMC Gastroenterology volume 25, Article number: 91 (2025) Cite this article

Abstract

Background

Colorectal cancer (CRC) is a prevalent and lethal malignancy. This study examines differences in clinical and prognostic characteristics of CRC between patients under 50 years and those aged 50 and above, treated at a reference hospital in Southern Brazil.

Methods

A retrospective cohort study was conducted, analyzing data from the Cancer Hospital Registry in Porto Alegre, RS. Patients diagnosed with colon or rectal adenocarcinoma between January 2013 and December 2017 were included. Variables analyzed included family history, alcoholism, smoking status, clinical staging, tumor laterality, clinical presentation, CEA levels at diagnosis, adjuvant chemotherapy, and neutrophil-to-lymphocyte ratio.

Results

The study cohort included 1,121 patients, with 85% aged 50 years or older, and 15% younger than 50 years. Significant differences were observed in smoking status and clinical presentation, with younger patients presenting with a higher prevalence of obstruction/subocclusion at diagnosis, which may reflect differences in clinical presentation due to delayed diagnosis.

Conclusions

Age and lifestyle factors, particularly smoking, significantly influenced the clinical presentation and management of colorectal cancer. These findings underscore the importance of targeted prevention strategies and personalized treatment approaches for younger CRC patients.

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Background

Colorectal cancer (CRC) ranks among the most prevalent and lethal neoplasms globally, being the third most common cancer in both sexes in the United States of America and many other parts of the world [1,2,3]. Understanding the characteristics of CRC is crucial for effective prevention and early treatment.

Numerous risk factors, including genetic, environmental, and lifestyle factors, influence the development of CRC. Greater knowledge about modifiable risk factors is essential for public awareness and lifestyle changes that can aid in CRC prevention [4,5,6,7,8,9,10]. In recent decades, an alarming increase in CRC incidence among young adults has been documented, particularly in developed countries, prompting discussions on the causes of this epidemiological shift [11,12,13,14,15,16,17]. Lifestyle changes, such as increased consumption of ultra-processed foods, saturated fats, simple sugars, and sugary drinks, as well as physical inactivity and rising obesity rates, are key factors in this trend [4,5,6,7,8, 10].

Furthermore, younger patients often present more aggressive clinical features compared to older patients, raising concerns about the need for changes in screening policies and public education on lifestyle modifications to prevent CRC [16, 17]. This study aims to evaluate the differences in clinical and prognostic characteristics of CRC in patients aged under 50 years old compared to those aged 50 years old and above at a philanthropic reference hospital in Southern Brazil.

Methods

Study design and setting

This retrospective cohort study analyzed clinical and demographic data from the Cancer Hospital Registry (CHR) of a Philanthropic Reference Hospital in Porto Alegre, RS. Patients who were diagnosed with colon or rectal adenocarcinoma between January 2013 and December 2017 were included.

Participants

Patients diagnosed with colorectal adenocarcinoma confirmed by pathological examination and who had at least one medical appointment at this hospital were included in the study. Those with other histological subtypes were excluded.

Data collection

Data were retrieved from medical records and included variables such as family history, alcohol consumption (classified as never, former, or current consumer), smoking status (classified as never, former, or current smoker), clinical staging, tumor laterality, clinical presentation, CEA levels at diagnosis, adjuvant chemotherapy, and neutrophil-to-lymphocyte ratio.

Tumor laterality was defined as proximal (cecum to transverse colon) or distal (descending colon to rectum).

Statistical analysis

Results were presented as absolute and relative frequencies, and the neutrophil-to-lymphocyte ratio (NLR) was presented as median and interquartile range (IQR). Normality was assessed using the Kolmogorov- Smirnov (K-S) test. To assess the association between age group and the variables, Chi-Square tests with adjusted standardized residuals and Mann- Whitney tests were applied. The significance level adopted was 0.05, and analyses were performed using the SPSS statistical software (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.).

Ethical statement

The present study utilized anonymized data from the Hospital-Based Cancer Registry (RHC) database, which routinely and systematically collects information on oncology patients treated at the institution. These data are stored to support scientific research, epidemiological monitoring, and the improvement of healthcare services. The study involved only the retrospective analysis of existing data, with no direct interventions with participants, thereby minimizing any risk to the individuals integrity and privacy rights. Ethical approval was obtained from the Research Ethics Committee of Santa Casa de Misericórdia de Porto Alegre (Approval No. 4.488.237, January 4, 2021), and given the retrospective design and use of anonymized data, the requirement for informed consent was waived by the ethics committee.

All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author (OA) on reasonable request. Neither the patients nor the general public were involved in the design, conduct, reporting, or dissemination of the study plan.

Results

The cohort included 1,121 patients, of whom 85% were aged 50 or older and 15% younger than 50. Among patients aged 50 or older, 50.6% were male, while among younger patients, 47.6% were male and 52.4% were female.

A statistically significant difference was observed in the smoking status between the two age groups, as we can see in Fig. 1. Among patients younger than 50 years, 40.4% were active smokers, compared to 16.5% in those aged 50 or older (p < 0.001).

Fig. 1
figure 1

Smoking status by age group

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Regarding clinical staging among patients aged 50 or older, as shown in Fig. 2, the stages were distributed as follows: stage I at 5.2%, stage II at 27.5%, stage III at 31.3%, and stage IV at 36.1%. For patients younger than age 50, the distribution was: stage I at 5.4%, stage II at 22.2%, stage III at 28.7%, and stage IV at 43.7%.

Fig. 2
figure 2

Clinical Stage by Age Group

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Table 1 Demographic data on CRC patients
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Table 1 shows the demographic data of the patients included in the study. It indicates that the majority of patients were aged 50 or older, and there were no significant differences in sex or ethnic group distribution between the age groups.

Tumor laterality showed that among patients aged 50 or older, 23.1% had right-sided colon cancer and 76.9% had left-sided colon cancer. Among those under 50 years old, 19.3% had right-sided colon cancer and 80.7% had left-sided colon cancer.

The clinical presentation varies by age. Among patients aged 50 or older, 92.1% presented with bleeding, 2.3% presented with obstruction/subocclusion, and 5.6% reported pain. Among patients younger than 50 years, 85.3% presented with bleeding, and 14.7% presented with obstruction/subocclusion. This difference was statistically significant (p < 0.001) and is shown in Fig. 3.

Fig. 3
figure 3

Clinical Presentation: Obstruction/Subocclusion by Age Group

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Table 2 Clinical Data
Full size table

Table 2 summarizes the clinical data of the patients, highlighting the differences in clinical presentation and tumor laterality between the age groups.

Baseline CEA levels in patients aged 50 or older showed that 51.3% had values greater than 10, while 48.7% had values less than 10. Among patients younger than 50, 41.1% had values greater than 10, and 58.9% had values less than 10.

Regarding adjuvant chemotherapy among patients aged 50 or older, 40% received treatment, and 53.3% did not. Among patients younger than 50, 51.1% were treated with adjuvant chemotherapy, while 48.9% were not.

The neutrophil-to-lymphocyte ratio showed that among patients aged 50 or older, 49.6% had a ratio of 3 or higher, while 50.4% had a ratio of less than 3. Among patients younger than 50 years, 56% had a ratio of 3 or higher, while 49.4% had a ratio of less than 3. This result is shown in Fig. 4.

Fig. 4
figure 4

Neutrophil/Lymphocyte Ratio by Age Group

Full size image

Discussion

This study evaluated the influence of multiple variables, including age, sex, race, smoking status, alcoholism, clinical staging, tumor laterality, clinical presentation, CEA levels, adjuvant chemotherapy, and the neutrophil-to- lymphocyte ratio in 1,121 patients diagnosed with colorectal cancer. The analyses revealed significant statistical differences, especially concerning smoking and clinical presentation, providing important insights into the pathogenesis and management of the disease in young patients.

Our study showed that a larger portion of young patients (< 50 years) are active smokers (40.4%) compared to older patients (16.5%). This finding confirms the information that smoking is a particularly relevant risk factor for the early development of colorectal cancer. This aligns with the literature indicating smoking as a significant modifiable risk factor for colorectal carcinogenesis [4].

A significant difference in clinical presentation between age groups was observed. Younger patients had a higher incidence of obstructive or subocclusive disease at diagnosis (14.7%) compared to older patients (2.3%). This difference suggests that the disease presents itself more aggressively in younger patients. Previous studies have also reported similar findings, indicating that younger patients often present with more advanced stages and aggressive forms of colorectal cancer [16, 17].

Other variables provided important insights, despite not showing significant differences. The clinical staging distribution showed a slightly higher proportion of younger patients diagnosed at stage IV, similar to findings in previous studies [18]. Additionally, no significant differences were observed in terms of sex, ethnicity, or tumor laterality that would alter current approaches to colorectal cancer [12]. Although not statistically significant, the numerical differences observed in tumor laterality align with previous reports, which also identified a predominance of left-sided tumors in young-onset CRC patients in Brazil [19]. This similarity highlights the potential influence of regional and genetic factors on tumor distribution and underscores the need for targeted screening and earlier diagnostic strategies for younger populations in Brazil.

One observed limitation in this study was the significant loss of data, a common challenge in retrospective cohort studies relying on medical records. Additionally, the inability to perform survival analysis, due to many patients not completing diagnosis and following the treatment to an end within the institution, represented another major constraint of this study. Another important limitation is the lack of quantitative data on smoking exposure (pack-years) and alcohol consumption (grams/day), which could provide a more precise assessment of risk. Similarly, the absence of data on tumor grade, lymphovascular invasion, and perineural invasion limited the assessment of biological aggressiveness. Furthermore, it was not possible to perform subgroup analyses of CEA levels by smoking status, stage of disease, or clinical presentation due to limited data availability. Future studies with access to such data may provide a more comprehensive understanding of the role of CEA in these subgroups.

Conclusions

The results of this study reinforce the importance of considering variables such as age and lifestyle habits, like smoking, in the diagnosis and treatment of colorectal cancer. The increased prevalence of obstructive symptoms in younger patients suggests the need for a differentiated diagnostic approach for this group. Additionally, differences in tumor laterality highlight the need for population-specific approaches to screening and diagnosis. These findings provide a foundation for future research and targeted public health strategies. Moreover, these insights may guide future research to explore personalized treatments and prevention strategies focused on high-risk populations. Additionally, longitudinal studies can be useful in better understanding disease progression in different population subgroups.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author (OA) on reasonable request. Neither the patients nor the general public were involved in the design, conduct, reporting, or dissemination of the study plan.

Abbreviations

CRC:

Colorectal Cancer

CEA:

Carcinoembryonic Antigen

NLR:

Neutrophil-to-Lymphocyte Ratio

IQR:

Interquartile Range

K-S Test:

Kolmogorov-Smirnov Test

SPSS:

Statistical Package for the Social Sciences

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Acknowledgements

We would like to thank the Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) and the Santa Casa de Misericórdia de Porto Alegre for their support in conducting this study. This work is dedicated to all patients who endure the challenges of colorectal cancer, whose strength and resilience inspire our continued research and efforts in the fight against this disease.

Funding

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Graduate Program in Pathology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil

    Otavio de Carvalho Modaffar Al-Alam & Claudia Giuliano Bica

  2. Department of Internal Medicine, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil

    Rafael Jose Vargas Alves

  3. Postdoctoral Research Fellow, Johns Hopkins University, Baltimore, USA

    Otavio de Carvalho Modaffar Al-Alam

  4. Clinical Oncology Department, Hospital Santa Rita, Santa Casa Hospital, Porto Alegre, Brazil

    Rafael Jose Vargas Alves, Jamille Rizzardi Lava & Julia Signori

  5. Undergraduate Medicine Program, Lutheran University of Brazil (ULBRA), Canoas, Brazil

    Adele Lanziani Fae, Camile Neves Cardoso, Joanna Palmeira Castro, Larissa Grazziotin Claudino, Tales Barros Cassal Wandscheer & Victor Viecceli Villarinho

  6. Undergraduate Medicine Program, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil

    Affoue Prisca Michelle S. Yao

  7. Department of Basic Health Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil

    Claudia Giuliano Bica

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  1. Otavio de Carvalho Modaffar Al-Alam
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Contributions

O. C. M. A. wrote the entire manuscript and was responsible for creating all the tables and figures included in the article. R. J. V. A. and C. G. B. served as the study’s supervisors. They developed the initial research idea and provided technical assistance and guidance throughout the writing process of the manuscript. J. P. C., A. P. M. S. Y., C. N. C., J. S., J. R. L., V. V. V., T. B. C. W., A. L. F. and L. G. C. contributed by assisting in the collection of data for the study.

Corresponding author

Correspondence to Otavio de Carvalho Modaffar Al-Alam.

Ethics declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Research Ethics Committee of Santa Casa de Misericórdia de Porto Alegre (Approval No. 4.488.237, January 4, 2021). Given the retrospective design and use of anonymized data, the requirement for informed consent was waived by the ethics committee.

Consent for publication

Not applicable. No identifying images or personal or clinical details of participants are presented that compromise anonymity.

Competing interests

The authors declare no competing interests.

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Al-Alam, O.d.C.M., Alves, R.J.V., Fae, A.L. et al. Clinical and demographic analysis of patients with colorectal cancer screened at a reference hospital in Southern Brazil: comparative study based on age (Retrospective cohort study). BMC Gastroenterol 25, 91 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12876-025-03607-6

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BMC Gastroenterology

ISSN: 1471-230X

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