Colorectal cancer (CRC) is the third most frequently diagnosed malignancy and the second leading cause of cancer-related death worldwide, accounting for approximately 9.2% of cancer mortality and projected to increase substantially in low- and middle-income countries by 2035.¹,² CRC arises from the malignant transformation of glandular epithelium of the colon or rectum and is driven by an accumulation of genetic and epigenetic alterations modulated by age, dietary patterns, lifestyle, chronic inflammation, and inherited predisposition.³,⁴

Although high-income settings have demonstrated marked declines in CRC mortality through population-based screening and improvements in multidisciplinary management, much of Southeast Asia continues to report rising incidence rates and a disproportionate burden of locally advanced disease at presentation.⁵–⁷ In Indonesia, CRC ranks among the four most common malignancies, with a notable proportion of patients diagnosed below the age of 50 years – the so-called early-onset phenotype.⁴,⁸

Successful CRC management hinges on early detection, accurate staging and stage-appropriate surgical resection, increasingly delivered alongside neoadjuvant or adjuvant chemoradiotherapy.⁹–¹¹ However, the case mix presenting to peripheral tertiary referral hospitals in Indonesia is shaped by local awareness, access to colonoscopy, and surgical capacity – factors that vary substantially across provinces.¹²,¹³ Aceh province in northern Sumatra is served by a single tertiary referral centre, Dr. Zainoel Abidin General Hospital (RSUDZA), yet contemporary descriptions of its CRC caseload are scarce. Robust local epidemiological data are a prerequisite for service planning, audit, and the design of region-specific screening interventions.

This study therefore describes the demographic, anatomical, pathological and surgical profile of patients with CRC managed at RSUDZA in 2024, providing a quantitatively benchmarked baseline against published Indonesian and international data.

A total of 57 patients with histopathologically confirmed CRC met inclusion criteria during the study period.

This single-centre audit of 57 consecutive CRC patients managed at RSUDZA in 2024 provides four observations of programmatic relevance. First, the mean age at presentation (49.37 ± 12.4 years) was significantly younger than the 60-year benchmark commonly reported in high-income registries (p < 0.001), and one-third of the cohort was aged 45 years or less. This finding is concordant with reports from other Indonesian centres, including Widya et al.,³³ Asmaul Husnah et al.,³⁴ and Pratama et al.,³⁵ who similarly identified a downward shift in CRC age distribution. The early-onset phenotype is increasingly recognised as a global epidemiological trend driven by dietary westernisation, rising obesity prevalence, sedentary lifestyles, and possibly gut-microbiome alterations.²,⁴ Its statistical prominence in the present cohort underscores the limitations of using age 50 years as the sole threshold for CRC screening eligibility in the Indonesian context.

Second, male predominance was modest and did not differ statistically from parity (54.4% vs 50%, p = 0.508), consistent with Aritrina et al.³⁶ (58.6% male) and Yasri et al.³⁷ (59.4% male). The biological basis for the small but consistent excess in men is multifactorial and includes differences in visceral adiposity distribution, lifestyle exposures, and the putative protective effect of endogenous oestrogen on colonic epithelium.³⁶–³⁸

Third, the rectum dominated the anatomical distribution (56.1%), a pattern that mirrors several Indonesian and Chinese reports³⁹–⁴² yet is the opposite of patterns described in many Western registries where colonic and right-sided tumours have become relatively more frequent. The non-uniformity of the seven-site distribution was unequivocal (p < 0.001), although the dichotomous rectal-versus-colonic comparison did not reach significance, reflecting the moderate sample size. The rectal preponderance carries operational implications: rectal cancers demand multidisciplinary input, magnetic-resonance staging, neoadjuvant chemoradiotherapy in selected patients, and total mesorectal excision performed by appropriately trained surgeons. Late presentation with bulky low rectal tumours typically narrows the technical window for sphincter preservation.

Fourth, the stage distribution was non-uniform (p = 0.013), with stage III as the modal category, and 52.6% of patients presenting with locally advanced (III) or metastatic (IV) disease. This profile is consistent with that of Widya et al.³³ (stage III: 41.0%), Indarti et al.⁴⁴ (stage III: 38.2%) and Birch et al.⁴⁵ (stage III: 29.2%), and reflects a well-documented diagnostic delay in low- and middle-income settings driven by limited symptom literacy, reluctance to undergo per-rectal examination or colonoscopy, and constrained access to specialist diagnostic services.³³,⁴⁴,⁴⁵ Adenocarcinoma overwhelmingly dominated the histological mix (91.2%; p < 0.001 vs equal split), in agreement with global figures of approximately 85–90%.³⁹,⁴⁰,⁴⁶ The histogenetic basis lies in the abundance of mucin-secreting goblet cells in the colorectal mucosa and their susceptibility to malignant transformation under sustained carcinogen exposure.⁴¹,⁴⁷

The procedural pattern – with 70.2% of cases managed by open laparotomy with tumour resection and no laparoscopic colorectal resections recorded – mirrors the experience of Salmiah et al.⁴⁸ at a comparable Sumatran centre and Breekveldt et al.⁴⁹ in the pre-screening Dutch period. The procedural distribution was highly non-uniform (p < 0.001), reflecting the dominance of one pathway. The relative under-utilisation of LAR among rectal cancers in this descriptive denominator (18.8%) is consistent with the high proportion of low rectal tumours presenting at advanced stage, in whom abdominoperineal resection or palliative diversion remains the most defensible option. Expanding minimally invasive capability and embedding structured neoadjuvant pathways – with downstaging assessment and pelvic MRI – would be the most plausible single intervention to shift this procedural mix towards sphincter-preserving and laparoscopic options over the next planning cycle.⁴⁸–⁵⁰

Among 57 patients with colorectal cancer managed at RSUDZA in 2024, presentation was dominated by middle-aged adults (mean 49.4 years), with rectal cancer (56.1%), stage III disease (40.4%), and adenocarcinoma histology (91.2%) as the modal categories, and open laparotomy as the principal surgical approach (70.2%). All categorical distributions departed significantly from a uniform null (p ≤ 0.013 throughout), and over half of the cohort presented with locally advanced or metastatic disease. These data justify (i) lowering the operational age threshold for opportunistic CRC screening in Aceh, (ii) strengthening symptom-based public health messaging targeting rectal red-flag symptoms, and (iii) investing in laparoscopic and sphincter-preserving capacity within the regional referral network. Multicentre, prospective registries with linked outcome data are required to consolidate these findings and to evaluate the impact of future service-level interventions.

The authors thank the staff of the Department of Surgery and the Medical Records Installation of Dr. Zainoel Abidin General Hospital for their assistance with data retrieval.

The authors declare no conflict of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Approved by the Research Ethics Committee, Faculty of Medicine, Universitas Syiah Kuala / RSUDZA. Individual informed consent was waived for the use of de-identified secondary data.

SSW conceived the study, collected and analysed the data, and drafted the manuscript. KR supervised the work, contributed to interpretation, and revised the manuscript critically. Both authors approved the final version.