Treatment Delays in Early Age–Onset Colorectal Cancer

Importance: Incidence of early age-onset colorectal cancer (EOCRC) is increasing. Delays in initiation of definitive therapy are associated with worse outcomes in colorectal cancer (CRC), but their impact on EOCRC has not been comprehensively characterized. Objective: To evaluate incidence of EOCRC, identify patients affected by treatment delays, and determine targetable factors contributing to delayed therapy. Design, Setting, and Participants: This retrospective, population-based cross-sectional study analyzed data from patients diagnosed with CRC from January 1, 2004, to December 31, 2019, using the Texas Cancer Registry. Patients were classified as having either EOCRC (diagnosed age <50 years) or average age-onset colorectal cancer (AOCRC; diagnosed age ≥50 years). The data analysis was performed between August 2024 and November 2025. Main Outcomes and Measures: The main outcomes were EOCRC status and treatment delays, defined as more than 6 weeks from tissue diagnosis to initiation of definitive therapy. Overall survival (OS), prevalence, impact of treatment delays, and patient-level and system-level factors associated with delayed treatment were also assessed. Results: Among 112 672 patients with CRC (overall mean [SD] age, 65.4 [13.5] years; 61 570 [54.6%] male), 12 079 (11%) had EOCRC, and 100 593 (89%) had AOCRC. The cohort comprised 3111 Asian and Pacific Islander individuals (2.8%), 14 517 Black individuals (12.9%), 23 372 Hispanic individuals (20.7%), and 71 672 White individuals (63.6%). Mean (SD) age for the EOCRC cohort was younger (41.6 [5.9] years) compared to the AOCRC cohort (68.2 [11.2] years; P < .001). Compared to patients with AOCRC, patients with EOCRC were less likely to be of White race (6421 [53.2%] vs 65 251 [64.9%]; P < .001) and more likely to be of Hispanic ethnicity (3389 [28.1%] vs 19 983 [19.9%]; P < .001). Median OS for patients with EOCRC was not reached compared to patients with AOCRC at 80 months (hazard ratio [HR], 0.56; 95% CI, 0.56-0.60; P < .001). In multivariable analysis, higher Social Vulnerability Index (HR, 1.22; 95% CI, 1.19-1.26; P < .001) and treatment delays (HR, 1.29; 95% CI, 1.26-1.32; P < .001) were associated with worse OS. Median OS for patients with EOCRC was not reached in patients with or without treatment delay; however, it remained significant (HR, 1.35; 95% CI, 1.32-1.38; P < .001). After controlling for demographic and clinical factors, language barriers were associated with treatment delay in EOCRC (odds ratio, 1.45; 95% CI, 1.18-1.79; P < .001). Conclusions and Relevance: In this cross-sectional study, EOCRC was associated with improved OS compared with AOCRC; however, treatment delays were independently associated with worse survival among patients with EOCRC. Language barriers could be a potentially modifiable risk factor associated with delayed treatment and may provide an opportunity to improve timely care and outcomes in EOCRC.