Breaking: Colon Cancer Isn't Just for Seniors Anymore - Insights from the Innersight Podcast #27

Understanding Colorectal Cancer: Why Awareness Matters Now More Than Ever

At Innersight, we often explore topics that affect both our physical and emotional health, and today’s focus is a crucial one: colorectal cancer. This form of cancer doesn’t get nearly as much attention as others like breast or prostate cancer, but it should. Not only is it one of the few cancers we can currently screen for, but it’s also increasingly affecting younger people, and the outcomes can be devastating if not caught early.

To unpack this topic, we’re joined by Dr. Jaco Botes, a specialist colorectal surgeon based at Durbanville Mediclinic in Cape Town. His insights from clinical experience are both eye-opening and important for anyone concerned about their long-term health.

Why Colorectal Cancer Deserves Our Attention

Colorectal cancer is still one of the most feared diagnoses out there, and for good reason. While other cancers have become more manageable thanks to better screening and early detection, colorectal cancer often goes unnoticed until it’s progressed. The cancer landscape is shifting, and this form of cancer is no longer just an "older person’s disease." It’s showing up more frequently in younger individuals, often in more aggressive and advanced forms.

Statistically speaking, colorectal cancer is among the top cancer risks for both men and women, second only to breast or prostate cancer depending on gender. Yet, it remains one of the most overlooked. Many people simply don’t talk about it or think about getting screened, particularly if they’re under 50.

While colorectal cancer has always been a concern for older adults, the increase in younger patients is what’s causing a spike in overall cases; the older group hasn’t declined, it's that younger people are now entering the picture at a growing rate and that shift is what's driving the numbers up.

What Exactly Is Colorectal Cancer?

At its core, colorectal cancer is the result of genetic mutations in the cells lining the colon. These cells divide rapidly, and when they make a mistake during that division, they can form growths called polyps. These polyps, much like a skin tag or mole on the skin, can evolve into cancer over time through a predictable sequence known as the adenoma-carcinoma progression.

Most polyps don’t turn into cancer right away. In fact, there can be a lead time of 5–10 years from the first genetic mutation to the development of a malignant tumor. But once that change begins, it often follows a stepwise process, first forming a benign adenoma, then progressing into a high-grade adenoma, and eventually transforming into a carcinoma.

The scary part? You won't feel or see anything happening, because it's all happening inside your colon. And once the cancer has passed through the colon's single-cell-thick lining, it becomes invasive. The deeper it goes and the more it grows, the higher the likelihood of it spreading.

Should We Be Screening Earlier for Colorectal Cancer?

At Innersight, while we don’t conduct screenings ourselves, we often guide patients toward further evaluation when red flags appear. Increasingly, the conversation around when to start screening for colorectal cancer is changing. The old benchmark of starting at age 50 is being reconsidered globally, and rightly so.

Up until about a decade ago, U.S. guidelines recommended colorectal screening from age 50. Over time, however, researchers noticed a troubling trend: rising mortality rates in people aged 45 to 50. In response, the U.S. has now lowered its official screening age to 45, after confirming that earlier screening improves survival outcomes.

In Dr. Botes’ private practice, based in a relatively affluent area of Cape Town, the pattern is already clear: younger patients, some even in their 20s, are being diagnosed with colorectal cancer. And notably, many of these aren’t inherited or familial cases, they're sporadic, occurring with no clear genetic link.

In South Africa, particularly in the private sector where patients often pay out-of-pocket or rely on medical aid, the age threshold is still largely stuck at 50, though some schemes are beginning to acknowledge 45 as reasonable. Based on international data and clinical experience, 45 is already a well-justified starting point, and this number might keep moving downward.

Who Should Be Concerned Earlier?

While age is a major factor, it’s not the only one. There are clear warning signs and risk factors that may justify earlier screening, even well before 45.

3 Big Red Flags to Watch For:

1. A Change in Bowel Habits.

   If you’ve had regular bowel movements your whole life and suddenly experience unexplained constipation, diarrhea or other changes, take notice.

2. New Rectal Bleeding

   It’s tempting to blame blood in the stool on hemorrhoids, but that should be a diagnosis of exclusion, not the first assumption.

3. Unexplained Iron Deficiency Anemia

   Chronic blood loss from a hidden tumor in the colon can cause iron deficiency long before any obvious symptoms appear.

   
   

If you have a family member who had colorectal cancer, that places you in a high-risk category. The general guideline?

Start screening 10 years earlier than the age at which your family member was diagnosed.

For example, if your father had colon cancer at 50, you should start screening at 40.

Other inherited conditions like Lynch syndrome or familial adenomatous polyposis (FAP) also significantly increase your risk, and most GPs will recognize these factors and refer you for early screening or genetic counseling.

Screening vs. Prevention: What’s the Difference and Why It Matters

In a previous episode, Professor Louw highlighted a key point: even in young women with mild menstrual bleeding, unexplained iron deficiency may actually signal something more sinister in the bowel. This brings us to a critical question: is it worth screening for blood in the stool?

When Is It Screening, and When Is It Diagnosis?

First, it’s important to distinguish between two types of patients:

• Symptomatic: These patients already have signs like visible blood in the stool. For them, screening is no longer relevant, they need diagnostic investigation, typically a colonoscopy.

• Asymptomatic: These patients feel fine but are being tested just in case. That’s where screening or prevention comes in.

And here’s where the nuance matters. Screening aims to catch cancer early, while prevention aims to stop it from ever developing. This distinction often gets lost in public discussions, but it’s essential to understanding your options.

While stool tests for hidden (occult) blood or DNA can be useful tools, Dr. Botes encourages you to do the test you’re willing to do.

Each test has limitations:

• Stool tests can be inconvenient or missed by patients.

• Blood tests (for cancer DNA) aren’t always sensitive enough.

• But all positive tests ultimately require a colonoscopy for confirmation.

So why not skip the intermediate step?

Why Colonoscopy Remains the Gold Standard

A colonoscopy doesn’t just diagnose, it can actually prevent cancer. During the procedure, the doctor can detect and remove polyps, which are abnormal growths that can become cancerous over time.

Colonoscopy offers two key advantages:

1. Diagnostic accuracy: It’s over 99% accurate at detecting existing cancer.

2. Preventative power: By removing polyps early, it stops cancer from forming at all.

Dr. Botes strongly recommends that if you're able, go straight to a colonoscopy, especially in South Africa, where access to scopes in the private sector is relatively straightforward.

Why Screening Tests Can Miss Early Warning Signs

Screening tools like blood or stool DNA tests work only when the disease has progressed enough to shed cells or blood. That’s why prevention, removing the threat before it gets to that point, is so much more powerful.

If you're serious about prevention and peace of mind, a colonoscopy is the most effective route.

What the Numbers Tell Us

Dr. Botes recently reviewed his own data and confirmed a startling statistic: about 33% of screening colonoscopies reveal polyps. But not all polyps are equal. Some will never become cancer, and others have a higher risk based on:

• Size

• Grade

• Type (morphology)

The problem? It's nearly impossible to determine a polyp's danger level by sight alone.

So, You’re 45 and Ready to Be Screened - What Now?

Let’s say you're one of our listeners or readers who's just turned 45, and you're thinking, “It’s time to get screened for colorectal cancer.” You have no symptoms, but you’re aware of the rising risk and want to be proactive. What’s the next step? Do you just call and book a colonoscopy? According to Dr. Botes, not quite.

“My personal feeling is that you should probably be seen by a clinician first,” he says. “And the reason for that is actually the worst part about the colonoscopy: the prep.”

The Colonoscopy Prep: More Than Just an Inconvenience

Before a colonoscopy, you'll undergo bowel preparation using a solution like sodium picosulfate. This flushes out your system so the colon can be properly examined. It sounds simple, but the reality is often uncomfortable:

• Dehydration

• Nausea

• Electrolyte imbalance

This is why a medical professional, whether a GP or a surgeon, should first evaluate whether you're medically fit to go through the prep process.

“In our practice, even if I don’t see all the patients personally before the scope, they’ve at least been cleared by a GP I trust.”

So, if you're 45 and thinking about getting screened, your best starting point is still your general practitioner. They can assess your overall health, clear you for the prep, and then refer you for the colonoscopy itself.

What About Alternatives to Colonoscopy?

While colonoscopy is the gold standard, it’s not the only method. Some patients ask about:

• CT colonography (also called virtual colonoscopy)

• Video capsule endoscopy

• Stool-based tests

Each of these has its pros and cons.

CT Colonography: A Safer but Less Sensitive Option

CT colonography is a good tool for some patients. It’s non-invasive, has a low risk of perforation, and gives a 3D image of the colon. But it comes with limitations:

• It misses flat polyps, which are often the most dangerous.

• It can produce false positives, meaning you might still need a standard colonoscopy.

• It doesn’t allow for biopsy or polyp removal.

  
  

  “My rule of thumb is that anything larger than a centimeter might show up on a CT,” says Dr. Botes. “But for smaller or flat polyps, the risk of missing them is high.”

That’s why CT colonography is often reserved for patients who are at higher procedural risk, such as those with severe diverticulosis or extensive abdominal adhesions.

In Short: Colonoscopy Is Still King

Colonoscopy is unique in that it:

• Diagnoses cancer

• Detects and removes polyps (prevention)

• Offers real-time treatment during the same procedure

But it’s also a technical procedure. It requires:

• Skilled, mentored training

• A trusted system of clinicians and endoscopists

• A focus on quality metrics like:

  • Cecal intubation rate (reaching the end of the colon)

  • Ileal intubation rate (optional but tracked)

  • Polyp detection rate

  • Post-colonoscopy cancer rate

    
    

    “You want a trusted endoscopist,” says Dr. Botes. “Someone who’s trained, mentored, and confident in their detection and removal skills.”

And this is not something AI or automation can replace. The nuances of the procedure, and the judgement calls made during it, require real-world expertise.

What Happens If You Wait Too Long?

As doctors, we understand where this journey can end if colon cancer isn't caught early. But it's vital to paint a picture for those who don’t see what happens after a cancer is missed.

Colon cancer is slow-growing compared to other cancers; that gives us an opportunity. Even in stage 3 or 4, surgery and modern treatments can still offer meaningful survival, especially with good liver and thoracic surgeons.

Still, it's not a path you want to take if you can help it. When caught late, many patients require a colostomy, a surgical opening that diverts the bowel to an external bag.

“It’s not the end of the world, but it is life-changing,” says Dr. Botes. “And the thing is, all of this could often have been avoided with one early colonoscopy.”

Yes, the prep is unpleasant. Yes, the idea of the procedure can be intimidating. But the colonoscopy itself is typically simple and painless.

“The actual scope is the easy part, the worst bit is the bowel prep the day before. You’re sedated during the scope, and most patients wake up saying, ‘Was that it?’”

After Your First Scope: What Then?

If your colonoscopy comes back normal, you may not need another one for 10 years. That’s the current guideline for average-risk individuals in many health systems.

In the private healthcare system in South Africa, a 10-year interval is achievable. But in public healthcare, screening is rarely available at all. It’s “wait for symptoms, then act”, and that’s where preventable cancers slip through the cracks.

The First Colonoscopy Is the Most Important

“The first scope is the one that decides your risk,” Dr. Botes emphasizes. “It helps stratify your future: are you high-risk or can you relax a little?”

Some people discover they have polyposis syndromes, inherited conditions where the colon produces dozens or even hundreds of polyps. These carry a near-100% lifetime cancer risk but without screening, you’d never know.

That first colonoscopy doesn't just detect or prevent cancer, it also sets the pace for your follow-up. If polyps are found, the interval between future scopes is shortened. If none are found, it can be extended. Much like pap smears or mammograms, colonoscopy is the first step toward peace of mind.

Why Are We Seeing More Young People with Colon Cancer?

This rise in early-onset colon cancer is no longer just a theory, it’s a trend. So why is it happening?

“It likely comes down to the microbiome, the bacteria that live in your colon,” says Dr. Botes. “The balance of that ecosystem depends on diet, lifestyle, inflammation and more.”

Our modern, processed diet is likely to blame. Highly processed foods:

• Lack fiber, which keeps the bowel moving

• Are harder to digest, slowing transit time

• May introduce carcinogens, especially processed meats

Combine that with physical inactivity, high BMI, alcohol use and increasing rates of metabolic syndrome, and you have the perfect storm.

“We are in a processed food epidemic, and if you think about how much processed meat the average person eats today, the picture becomes clear.” ” says Dr. Botes.

The American Cancer Society has now classified processed meat as a Group 1 carcinogen, the same category as tobacco. Red meat is Group 2. It’s not just about genetics anymore, it’s also about how we live and what we eat.

So, What’s the Takeaway?

If you’re 45 or if you’re younger but have risk factors like family history, diabetes or obesity, it’s time to talk to your doctor.

✅ Screen early

✅ Screen once

✅ Stratify your risk

✅ Prevent what you can

Because the truth is, one colonoscopy could save your life, or at least save you from major surgery, a colostomy, or years of uncertainty.

In Conclusion:

Colon cancer isn’t just a disease of the elderly anymore. As we’ve discussed, lifestyle factors, diet, and even the microbiome are shifting the risk younger, often before symptoms ever appear. That’s why early screening isn’t optional; it’s essential. A single colonoscopy can not only detect cancer early when it’s still treatable, but also remove precancerous polyps and prevent the disease entirely. The prep might be unpleasant, but the peace of mind is worth it. Whether you’re 45 and healthy, or have a family history, take this seriously: the first step to preventing colon cancer is booking that first scope. It could literally save your life.

If you would like to get in touch with Dr. Botes, you can contact him through the following website: 🔗 https://colorectalsurgery.co.za

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