For decades, colorectal cancer was commonly seen as a disease mostly affecting older adults in their 60s and 70s. However, it is increasingly affecting younger, healthier people who are often in the prime of life. With three out of four patients under age 50 now diagnosed at a late stage, researchers and clinicians are racing to understand why this group is being hit so hard and so quickly.
To address this urgent public health crisis, City of Hope recently held a virtual media briefing featuring a multidisciplinary panel of internationally recognized gastrointestinal experts and a patient living through the statistics.
The discussion asked an important question: why are otherwise healthy adults—like Gabby Zappia, an Orange County mother of three whose Stage 4 symptoms were initially dismissed as pregnancy-related—becoming the epicenter of a modern epidemic?
The briefing was led by a distinguished panel of City of Hope experts dedicated to reversing this trend through research, surgery, and precision medicine:
- Marwan G. Fakih, M.D., Deputy Director, City of Hope Comprehensive Cancer Center and Division Head of GI Medical Oncology.
- Ajay Goel, Ph.D., AGAF, Professor and Chair, Department of Molecular Diagnostics and Experimental Therapeutics, who is pioneering a “game-changer” blood test for early detection.
- Pashtoon Kasi, M.D., M.S., Medical Director of GI Medical Oncology, City of Hope Orange County, an expert in liquid biopsies and immunotherapy.
- Laleh Melstrom, M.D., M.S., Chief, Division of Surgical Oncology, focusing on advanced surgical interventions for young patients.
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The Mystery of “Why?”
A primary concern raised by Dr. Marwan Fakih and Dr. Ajay Goel is the “diagnostic gap.” Because standard screening guidelines generally do not apply to those under age 45, most young patients only seek help once they become symptomatic.
Misdiagnosis in younger adults is a major issue. Both patients and primary care providers often dismiss symptoms such as rectal bleeding or fatigue as benign conditions like hemorrhoids, IBS, or pregnancy-related exhaustion.
As Dr. Fakih noted, it is common for young patients to have symptoms for a full year before receiving a definitive diagnosis, by which time the cancer has often progressed to Stage 3 or 4.
While many assume early-onset cancer is purely hereditary, the panel clarified that genetics—including conditions like Lynch Syndrome—account for only about 20 percent of cases. The remaining 80 percent are “sporadic,” likely driven by environmental and lifestyle factors.
The experts flagged several emerging risks:
- High consumption of ultra-processed foods.
- Early-life exposure to antibiotics and microplastics.
- Changes in the microbiome (the “good and bad bugs” in the gut).
- Behaviors such as binge drinking at a young age.
The “Healthy” Patient
One of the most troubling trends discussed was the rise of the “healthy” patient. Unlike historical cases often linked to obesity or uncontrolled diabetes, clinicians are increasingly seeing patients who are fit, active, and health-conscious.
Early-onset colorectal cancer is a biologically distinct disease, according to Dr. Goel. About 90 percent of these cases manifest as rectal cancer or on the left side of the colon. This suggests that the neurological and biological origins of this cancer differ from those typically observed in older adults.
In the second half of the briefing, the panel shifted from the “why” to the “how”—specifically, how City of Hope is pioneering new ways to detect, track, and treat colorectal cancer through high-tech diagnostics and precision medicine.
A “Game-Changer” Blood Test for Early Detection
Dr. Goel shared groundbreaking news regarding the development of a liquid biopsy specifically designed to catch colorectal cancer in younger populations. His lab has developed a blood-based test that is 90-95 percent accurate in detecting young-onset colorectal cancer to provide an inexpensive, non-invasive tool that can be used during routine check-ups to identify at-risk young adults before they develop advanced symptoms.
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Harnessing the Immune System: The 95% Challenge
Dr. Kasi and Dr. Fakih addressed the “unmet need” in advanced colorectal cancer: the 95 percent of patients with Microsatellite Stable (MSS) tumors, which typically do not respond to standard immunotherapy.
City of Hope is leading trials using bi-specific antibodies and novel drug combinations to “turn on” the immune system so it can recognize and kill MSS cancer cells.
Dr. Kasi highlighted a revolutionary approach of giving immunotherapy before surgery. In early trials, this has shown the potential to achieve a “complete response,” where the cancer is eradicated without the need for traditional, invasive surgery.
Precision Surgery and “Organ Preservation”
For young patients, the long-term side effects of treatment—such as impacts on fertility, sexual function, and bowel control—are a major concern. Dr. Laleh Melstrom and Dr. Fakih highlighted the move toward precision surgery. By utilizing minimally invasive techniques and “total neoadjuvant therapy” (chemotherapy and radiation before surgery), doctors can shrink rectal tumors so significantly that many patients can avoid permanent colostomies and preserve their quality of life.
Circulating tumor DNA (ctDNA) tests look for “tumor trash,” as Dr. Kasi calls it, right in the patient’s blood. This high-tech approach lets doctors figure out very accurately if the surgery really got all the cancer or if the patient still needs some “clean-up” chemotherapy.
Patient Perspective: Gabby’s Journey
The clinical data presented by the experts found its human heartbeat in the story of Gabby Zappia, a 36-year-old mother of three from Orange County. Her journey serves as a sobering cautionary tale about the dangers of the “too young for cancer” narrative that persists in both the public and medical communities.
While pregnant with her third child, Gabby began experiencing symptoms that felt “off.” She was plagued by profound exhaustion and noticed blood in her stool. However, because she was young, fit, and pregnant, these red flags were dismissed by medical professionals as common, benign pregnancy side effects—specifically pregnancy-related hemorrhoids. “I trusted it,” Gabby shared, “I really wanted it to make sense.”
It wasn’t until after her son was born and the symptoms persisted that Gabby pushed for deeper answers. What was thought to be a routine post-pregnancy issue was revealed to be a large mass in her colon. She went from a healthy young mother to a patient with Stage 4 colorectal cancer that had already metastasized to her liver overnight. The nine-month delay between her initial symptoms and her eventual diagnosis highlights the “diagnostic gap” that many young adults face.
After undergoing intensive treatment—including 15 rounds of chemotherapy, immunotherapy, and a liver resection with the implantation of a hepatic artery infusion (HAI) pump—Gabby was declared to have “No Evidence of Disease” (NED) and celebrated by ringing the survivor bell in September 2025.
However, in late 2025, while her scans were still clear, her ctDNA levels began to rise, signaling a molecular recurrence. A subsequent PET scan in December confirmed new activity in her liver.
In January 2026, Gabby underwent an additional liver surgery. As her ctDNA remains detectable following this procedure, she is currently working with her City of Hope team to explore novel clinical trials, representing the “next generation” of precision medicine for refractory disease.
Her story is a powerful reminder to others to trust their intuition.
“If something feels off in your body… don’t ignore it and advocate for yourself,” Gabby urged. “Ask for that colonoscopy. We need more awareness… I’m just one of the many young faces of colon cancer.”
The City of Hope briefing concluded with a unified message from both the medical experts and Gabby: the rising tide of early-onset colorectal cancer requires a fundamental shift in how the disease is viewed.
In the absence of population-wide screening for those under 45, the most powerful tool for survival is symptom awareness. They urged young adults not to ignore:
- Persistent Rectal Bleeding: Often, the most dismissed symptom in young adults.
- Changes in Bowel Habits: Any lasting deviation from your “normal” function.
- Unexplained Weight Loss: Drastic changes not tied to intentional diet or exercise.
- Profound Fatigue: Exhaustion that persists beyond normal daily stress.
- Abdominal Pain: Persistent discomfort or a feeling that “something isn’t right.”
