Nearly half of new colorectal cancer cases now occur in adults under 65. The epidemiologic shift is real and it's not subtle. Organized screening drove incidence down in the 65+ population. That was the success story. But the age-incidence curve is now moving in the wrong direction for younger cohorts. The generational gradient is striking. Someone born in 1990 carries roughly twice the colon cancer risk and four times the rectal cancer risk of someone born in 1950. What I keep coming back to clinically is stage distribution. Three out of four patients under 50 present with stage III or IV disease. We're seeing these patients after nodal involvement, after peritoneal seeding, after liver mets — not because the patient ignored symptoms, but because their providers did. Iron deficiency anemia in a 38-year-old gets worked up differently than in a 68-year-old. It shouldn't. I see this in clinic every week. The patients getting diagnosed at 40 with synchronous liver metastases who were symptomatic for months before anyone scoped them. The biology of early-onset CRC may also be different — higher rates of signet ring histology, left-sided predominance, distinct molecular profiles. We're still learning what that means therapeutically. The demographics of this disease have already changed. The question is whether our diagnostic reflexes are keeping pace. @TheGutOncLab nytimes.com/2026/03/02/well/…