>> From the famous to the ordinary.

It seems that more young people are being diagnosed with colorectal cancer.

Is this a real trend or are we just paying attention because it's affecting a younger population?

Stay with us as we talk to colon and rectal surgeon Doctor Sandy Kavalukas about the changing demographics of colon and rectal cancer.

Next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> Cancer of the Colon and rectum, or colorectal cancer, is the second most common cause of death due to cancer for men and women combined.

The good news is that the number of people diagnosed with colorectal cancer has decreased.

The bad news is that it remains one of the most common cancers in the United States, with 4.5% of the population, or one out of every 24 people expected to be diagnosed with colorectal cancer in their lifetime.

Though the overall frequency has decreased, there are some disturbing trends in the past years.

Those diagnosed with colorectal cancer were 65 years of age or older.

Unfortunately, now 1 in 10 people who are diagnosed with colorectal cancer are under the age of 50.

A more troubling statistic is that the rate of diagnosis in those 20 to 39 years of age is increasing by 2% per year.

There are many reasons for this change in the demographics of those affected with colorectal cancer, and for the lowering of the mortality rates.

To discuss these with us, we have as our guest today, doctor Sandy Kavalukas.

Doctor Kavalukas graduated with a master of Science in Physician Assistants at Duquesne University in Pennsylvania, and then earned her medical degree from the Penn State College of Medicine.

She then did a residency in general surgery at Vanderbilt University in Nashville, followed by a fellowship in colon and rectal surgery at the Cleveland Clinic Foundation at the Florida campus.

Doctor Kavalukas is now an assistant professor in the Division of Colon and Rectal Surgery in the Department of Surgery at the University of Louisville.

Doctor Kavalukas Sandy, thanks for being with us today.

>> Thanks for inviting me.

It's a pleasure to be here.

>> So tell me, somewhere out there, there's a young lady who's interested in getting into colon and rectal surgery.

So I've got to ask the question, why colorectal surgery?

And how did you get here?

>> Yeah, it's one of the few professions, I feel like, where we get to do a multitude of different operations.

They can range from small procedures that are hemorrhoidectomy based or colonoscopy based to anything as large as a rectal cancer or Crohn's disease.

So for me, it was really the variety of the different procedures that we do and kind of the lifestyle of of really having to think about every thing that you have and what options you can present to the patient.

And particularly, you know, a lot of the Crohn's disease patients really need somebody that understands them and listens.

And that kind of drew me to the profession in the beginning.

>> Yeah, but it's pu.

>> It is.

But you know what?

I always tell people my job when done correctly, is actually don't see stool because you've done your bowel prep before you show up for my surgery.

>> If you do it right, you don't have to look at.

>> It, correct?

>> Yes.

No look.

No touch, no see, no smell.

Exactly.

Gotcha.

So when we're talking about the colon and rectum, what are what are these parts and where are they located?

>> So the colon is it's basically a long tube that goes around your GI tract.

And I tell patients it goes around your, your belly like a picture frame or a question mark.

And basically your entire GI tract is one long tube.

And I also try to tell patients, you know, Shelbyville Road becomes Frankfort Road becomes something else.

And so different areas throughout this tube, it's just the same tube.

It's just named something different.

And we'll have different functions throughout that tube.

So the colon is about 80 to 90% of the the tube that goes around your body like a question mark.

And then the rectum is the very last 15cm of that same tube just has a different name.

>> So what are the functions of the colon and the rectum as opposed to the small intestines.

>> Yeah, the colon and rectum really the only job is to absorb water.

It has.

You can definitely live without your entire colon.

Not a lot of people want to and I understand that.

But the small intestine is really your powerhouse for absorbing nutrients.

And, you know, all your stomach digests the food.

The small bowel kind of breaks it down and absorbs the nutrients out of it.

And then you get a huge liquid load into your right colon.

And as that load kind of goes around your body, your colon is drawing out the water in order to make a solid stool at the end to excrete whatever your body doesn't need.

>> Storage function.

>> Well, the rectum is is really the powerhouse for that.

The colon doesn't have a lot of storage, but the rectum is kind of a bigger swelling.

If you have a two lane road, it visualizes going to maybe a four lane road and gets a little bit bigger down there, and that allows you to kind of store it to when it's a good time for you.

>> I'm never going to look at highways and city streets the same, by the way.

>> It's easy.

It's easy.

>> So when we talk about colon and rectal cancer, what exactly are we referring to?

>> So colon rectal cancer is a it's an ongoing problem.

It's it's the end stage of small mutations that happen in the colon.

So the innermost lining of the colon can form polyps.

Or you just get a little clump of cells that kind of overgrows.

And there are a variety of different polyps out there.

And they all have different risks of turning into cancer.

But over time, these little cells that kind of start to build up, if those cells undergo a mutation and then they keep growing and undergo another mutation and keep growing, that's how it turns into a colon cancer.

>> So I guess the million dollar question is what causes these mutations to cause a normal cell to become abnormal or develop into a polyp and or cancer?

>> Sure.

We don't have one specific answer for that.

There's a lot of things.

The one thing that a lot of people talk about is genetics, right?

Family history.

There's a lot of genetic syndromes out there.

Believe it or not, genetics only makes up 5% of colorectal cancer cases, 95% of colon cancer cases.

Patients have no family history.

They don't have a history of polyps.

Like there's we we can't just blame it all on genes.

But certainly if you have a family history, then yeah, there's something about how your body works and how it repairs processes that make it more prone to mistakes.

And those mistakes is what causes a cancer.

The other 30 to 40% of the time, we say it's due to modifiable risk factors.

And a lot of the evidence that's coming out now is obesity is really a big player of that.

Obesity kind of puts your body in a state of chronic inflammation, and you can and it predisposes you to getting polyps and cancers, smoking of course, like everything else, you're inhaling carcinogens.

Those get in your saliva.

And as that saliva turns down your GI tract, those carcinogens, those substances that cause cancer can lead to it.

We're starting to find that processed meats and foods.

There's been a huge article that just came out in the past year, maybe showing that there is a markedly if you remove all of the other factors age, race, sex, body habitus, obesity, lifestyle, all those things.

Even if you eat the same foods, if you're eating those foods from an industrial process, place like a fast food restaurant or something like that, your chances of getting colon cancer are higher.

So again, we have to try to I can't say it's this one thing.

Eliminate it.

You're not going to have cancer, but there are a lot of different factors that we keep in mind about what might increase your risk.

And unfortunately, there's still quite a lot of people that have none of these risk factors.

And it still happens.

And then it's just bad luck.

>> You know, sometimes we hear that since you mentioned about the processed foods, what are some of the dietary things that have been at least recognized as increasing our risk for cancer, besides preserved foods?

And what are some of the things that 1st May take that may minimize the risk of developing?

>> Certainly one, we always say it's kind of a balance of the the whole colon cancer related to food is deleting the deleting the good and adding the bad.

So deleting the good is whenever you're having less dietary fiber, when you're having, you know, less fruits and vegetables and all the things that we actually used to eat a lot of in the 50s and 60s.

And now whenever you kind of replace that, adding the bad or the a lot of the, the meats that are processed have a lot of nitrates, hot dogs, hamburgers, things that come from, from big factories that have to put these things in their foods.

They don't go bad by the time they reach you.

Right?

Like when you have a McDonald's cheeseburger, better taste like a McDonald's cheeseburger.

So they can't make that.

They can't make those burgers in house.

>> And you're not saying McDonald's is a primary Coke.

Yes.

>> Correct.

Yeah.

And you have when you go to a restaurant, you're going for that taste.

Yeah.

You know, and so that has to reach you from their plant so that it tastes the same everywhere you go.

Sure.

And so there's a lot of chemicals and things that are added into that, that end up being bad for you.

A long time ago, there's a big craze about pink slime.

And Jamie Oliver was the famous chef that kind of brought this out, about how they have to process this with ammonium hydroxide and all these crazy things.

Luckily, I think the food industry did respond favorably to that, and they've really diminished it from their foods.

But those are kind of the the processed things that we look out for.

>> You did mention there's some other things which we can't seem to identify.

I seem to notice every now and then we see clusters of colon cancer in certain neighborhoods or areas in which we're living in.

It suggests that there may be some environmental or pollution related.

What have you found about that?

>> We have found we're doing a lot of really interesting stuff, especially through the University of Louisville Envirome Institute, where we've been able to look at wastewater in these certain areas.

So we have found particularly, you know, in West Louisville and in parts of Appalachia and certain clusters throughout, certainly even the state of Kentucky in general.

Kentucky has the second highest rate of colon cancer in the country, really, and we have a really good screening rates.

Our patients are getting screened at that 70 percentile, which is the national average.

So it's not that people aren't getting tested, and they have these polyps that grow and they find that at the last minute we just have higher, higher cancer rates.

And on top of that, in certain areas like you're discussing, the rates are even higher.

So at least in urban Louisville, where we have found kind of west Louisville has a much higher incidence.

We have found that some of the ambient exposures to toxins or things that are in the air, they're at higher levels.

In our Louisville Metro EPA report, we have measured it in the wastewater and it's higher in there.

And then we have ongoing studies where we've been able to also identify these patients in blood or urine of patients that have colon cancer.

So we haven't really nailed down exactly what it is.

The other theory that's out there nationally is also like kind of what your mother may have been exposed to, so that it's what you were exposed to in utero while you were developing baby.

That may have also contributed to it.

And I think that, you know, as time goes on, we're that's the the exposome or the environment that that is around you is a factor that I think nobody really took into account.

But we're going to have to start paying attention.

>> Who's the typical patient?

Is there a typical age group sex that has developing colon rectal cancer, and how has that changing?

>> I think in general, it used to be 50, 60 year olds, you know, just a function of age and having more time to develop these mutations or these polyps is what we used to screen for.

As you had alluded to in the beginning of the episode, that is markedly decreased to a much that population, actually, their incidence of colon cancer is decreasing and alarmingly and younger people that it's almost a public health crisis at this point.

Colon cancer is now the leading cause of cancer death in men under the age of 50.

>> Really.

>> And it's the leading cause of cancer death in women under the age of 53rd leading cause under the age of 50.

So I think that, you know, it's every opportunity for research and grant funding and everything that the NIH is after is after trying to figure out this early onset colon cancer.

So honestly, it's mostly I think the risk is higher in men that are under the age of 50, more so than women.

A lot of the studies that are out there will show, you know, obese males or smoking male like it really.

They really seem to hit harder on the male population.

It's not to say I haven't seen women that are early onset colon cancer, but it is.

Men are slightly more affected.

Certainly the African American population is also more affected.

I think they're considering dropping the screening rate specifically for African American males, but they haven't made that move yet.

And those are the kinds of, you know, we really are at a race to sort of see how early do we screen.

And, you know, the guidelines can only change so many so often.

>> Yeah.

Any particular things that might explain why we're seeing young people?

>> I think that those modifiable risk factors that we had talked about are actually seem to be, in my mind, kind of more present in that in that age group, the sedentary lifestyle, maybe not so much.

You know, we aren't walking and biking as much as we did in the 60s or 70s, but I wouldn't blame it all on that.

I think the obesity rates really the speak to us as far as what's going on in the country, the amount of DoorDash and Uber Eats and like the just the convenience of being able to eat out more that that that generation basically between 15 and 40, actually get 40% of their weekly calories from ordering out DoorDash and UberEats.

And that's the generation that will pay for convenience.

Right?

And they grew up tech savvy, and it's easy for them to pull it up on their phone.

So that's kind of something we're paying attention.

>> It looks like the mortality rate from colon and rectal cancer has decreased.

And I would guess you'd have to say that screening, as you talked about how Kentucky is doing a pretty good job, what is screening really all about and how is it done.

>> So screening really has the mainstay of doing any screening test is that you want to be able to find the disease in a state where earlier treatment would have made a difference, and it has to be reasonable and it has to be something that everybody can do.

So a lot of people are like, oh, well, there's no screening for pancreatic cancer.

It's a really bad one.

It's like there isn't, but there's really not an easy test to do that, that with a high enough incidence rate that it's going to be reasonable.

So the purpose of a screening test is to is to identify cancer.

And so that's where all of the screening tests that we're going to talk about all will fit that role.

The additional part though of a screening test that we have, particularly colonoscopy, is that it can remove polyps and therefore become a preventative test.

And so that's kind of going to be the bias of a lot of people who do colonoscopies.

Yes, we can do whatever you want to detect colon cancer.

But the only thing that will prevent colon cancer is getting your scheduled colonoscopy.

>> So there are things like we see on TV, the little box that's talking to us.

Cologuard I guess that's using blood and immunohistochemical analysis.

Yes.

And then there's the old stool sample on the card that.

>> People do, and they also have CT colonography.

Okay.

So that's something you still have to do a bowel prep for it.

So that's usually the worst part of doing a colonoscopy is people don't want to do the bowel prep.

You can do a CT colonography where it's like this cool virtual CT machine that will make a 3D model and find polyps in your colon.

But you have to have a bowel prep.

So if you're going to do the work of that as well, just show up and be able to have something that.

>> What about a blood test?

>> The blood tests right now are not recommended.

The blood tests are not sensitive enough at finding it.

They certainly won't find polyps.

And they'll really if you have some indicators of cancer in your blood, your tumor is pretty far gone.

You're at least a stage three at that point.

>> So with colonoscopy, you're standing over a patient and you have a little tube that you're passing up.

Is that right?

>> Yes.

>> And you go to a separate little place to do this.

>> Yeah.

You usually go to an endoscopy suite of either a hospital or surgery center or something.

You can do it awake.

I would highly recommend against that.

It's not very comfortable.

But they get you know, nowadays almost everybody uses propofol.

It's quick on quick off.

You completely go to sleep and then you just navigate the scope all the way through the colon and look at look for polyps and take any out that you see.

>> So I guess you mentioned about polyps and that's what you're hoping to find.

And if you find them what you can remove them at the same time.

>> If they're.

Yeah, depending on the size.

Sometimes they're really big.

If they're really big because it either had just grown that much over time or if it's a cancer, you'll at least get some biopsies to see kind of what it is.

And then your provider can talk about the next steps of how they're going to either remove it or treat it.

>> So screening is done for somebody that doesn't have any symptoms.

Correct.

Because it then becomes diet.

What are some of the symptoms of colon and rectal cancer.

>> So the biggest symptoms a lot of because of how we discussed the colon kind of works if it's on the right side, a lot of times you don't have any symptoms.

Your your primary care doctor.

It's liquid.

Liquid can pass through something that's the size of a straw.

So while your colon may be, you know, three 4cm or 2in in diameter, you won't know that there's really a problem there until, like, liquid can get through something very small.

So a lot of times the right side, if there's a cancer over there, a lot of times you don't know it, you might have some pain eventually if it's a pretty late stage.

But a lot of times if your doctor will say, hey, I did a blood test and you're anemic, your your red blood cell count is low.

That would be on the list of right sided colon cancer that can cause anemia.

The left side is a little bit easier of a towel because the stool is a little bit more solid.

So when people are constipated, they have abdominal pain and feel like they can't go to the bathroom and they need to.

And of course, any sort of visible rectal bleeding is really the biggest, most reliable indicator that we need to do a colonoscopy and make sure that you're not having bleeding from a cancer.

>> What about distension, belly getting all protuberant and all that sort of thing?

>> Yeah, that's it's tough.

>> Distension is definitely a symptom, but it's also a symptom of so many things.

People can have gastroparesis, they can have irritable bowel syndrome.

They can, you know, like there's it's abdominal distension and bloating.

You can't rule it out.

But it's it's I feel like that's a much more vague.

It's kind of like nausea.

Right.

Like nausea could be from so many things.

>> You mentioned blood.

And I'm always amazed that people will see blood and will come up with any number of reasons why.

If I'm not mistaken, when you talked about things moving through the intestinal tract, I don't hear I don't remember you saying blood is one of those components of stool being so blood.

If you see blood, what.

>> Should we do?

>> That's I mean, I think that everybody's, you know, knee jerk reaction is, oh, I probably have hemorrhoids.

Yeah.

And and 90% of the time they might be right.

But the 10% of the time that they're incorrect.

Or you can we always you know, when I was going through training, one of my teachers would say, you can have as many diseases as you please, right?

So you can have hemorrhoids, but you may also have a colon cancer.

And I think that if you have any sort of rectal bleeding and you haven't had a colonoscopy, then I would definitely start there.

And then you can write it off as hemorrhoids.

>> All right.

So you find a person who has these symptoms.

You've done the workup.

They have a cancer.

I think I'm sure that you probably here to think I don't want to have a colostomy.

>> Right.

Sure.

>> People still think, okay.

>> We're in the same boat.

>> So what's a colostomy and and what are the options?

So we don't have to have a colostomy.

>> A lot of unfortunately I would say that 85% of the time if you have a colostomy, it's only based off of location where in the colon your cancer was.

The other 15% of that has to deal with what stage it was when it was diagnosed and your overall general condition.

So when we take out a part of the colon, if we want to put it back together and not give a colostomy or a bag or whatever people want to call it, you have to be healthy enough to heal that.

Otherwise you're going to end up with that area where we connecting it leak, and then you get super sick and possibly have a really bad outcome.

If the further, the closer down to the very end in the rectum.

And that's where we start to worry a little bit more about bags and things like that.

The only thing really to avoid it, as I said, if it's a really late stage tumor where we're getting in there and we're like, okay, this person's obstructed, we need to remove this cancer, but the next thing they need is chemo.

Then you don't want to wait for that area to heal back together.

You don't want to take a risk that it's going to leak and delay chemo.

And in that case, a lot of people will wake up with temporary bags or ostomies so that they can get chemo.

I feel like most of the time, if you're coming in with a colon cancer that was found on a screening colonoscopy, you're not going to end up with a with a with a permanent bag most times.

>> And it's more likely you can treat this person to cure them of their disease.

Correct.

Surgery is still the primary treatment for colon.

>> Colon cancer.

It is rectal cancer is a whole other ballgame.

It is whenever it's kind of deeper down in the pelvis, it's protected by your pelvic bones.

And so a lot of times we can radiate that and or do chemotherapy and see if that totally goes away.

If the cancer goes away, we don't need to operate on it.

That happens about 30% of the time.

So it's not our it's it's something we always consider the whole way through their treatment.

But it's not something you can promise somebody upfront before they start their treatment.

>> Well, you're one of these people who's very facile at doing robotic surgery.

Yes.

That doesn't mean there's some AI surgeon AI doctor Kavalukas there.

So what is it and what are the advantages of doing it with the robot?

>> So robotic surgery is when the patient is on the operating room table, there's this big machine that kind of we drive up to the table.

And whenever you do laparoscopic surgery, which is it's it's literally the same thing.

When you do laparoscopic surgery, you will put a small sheath basically through the abdominal wall that you can pass instruments in and out of.

And if it's laparoscopic, then I stand there and I do all the stuff with the instruments.

If it's robotic, it's actually the same principle.

It's just that a robot is docked to the sheaths that are there, and I'm sitting down at a console controlling every single thing that that robot's doing.

The reason it has gained popularity is because when we used to do things laparoscopically, the instruments were straight.

We didn't have any technology to articulate them.

And when you're working down in the pelvis in particular, it's a confined space where you really want to be able to, like, move your wrists over bony prominences.

And so that's what the robot can, can do.

If I do this, the robot does this.

>> Do patients recover faster and with fewer complications during robotic as opposed to the old way of.

>> As opposed to open?

Absolutely.

Yeah.

It helps a lot of people to not have a lot of incisional pain and that there's plenty of data out there to show that the robotic approach is a lot less painful.

And with a quicker recovery.

>> We only have about a minute or so left.

So give me the two big things you want people to take home about colon and rectal cancer that we're getting wrong.

>> I think that I will number one, and this is only based off of patients that I see in the office.

If your doctor orders a cologuard for rectal bleeding, it is going to be positive.

That is one of the things that a cologuard picks up.

So if you have rectal bleeding, you need to have a colonoscopy because your cologuard immediately should be positive if it's doing its job.

Number two, any screening is better than no screening.

So if there's some reason, either from a general health standpoint or a scare to death to do a bowel prep, or you don't have a ride, then 100% do whatever screening you can cologuard fit testing whatever you want to make sure that you don't have colon cancer.

And then number three again, also, I've spoken to a lot of patients that were unaware that the colonoscopy, the, the, the poop in the box or some of these other testings that aren't colonoscopies will not detect polyps very well.

Even the cologuard will detect advanced polyps 40% of the time, which means 60% of the time they miss it.

And so your cologuard may be negative today, but you have a polyp there that's starting to mutate, and next year you're going to have a colon cancer.

And then they're like, how did this happen?

My cologuard was negative.

So just one of those things to think of.

All of these tests are awesome for detecting cancer, but it's really the the prevention part that is helpful.

>> And I'm going to assume that even if we're not married to a chef, we can all make some dietary changes that will keep us going strong.

>> Yes, sir.

>> Fruits and vegetables cut down on the fats.

>> Lots of dietary.

>> Fibers, lots of dietary fiber.

>> Stop smoking for lots of reasons.

>> Boy, you're cutting into everybody's lifestyle.

Doctor Kavalukas.

Well, I appreciate you being with us today, and you've given us some really, really good information.

And thank you for being with us.

I hope that you have a better understanding of how diet, certain pollutants and hereditary influence our risk factors for developing colon or rectal cancer.

Equally important, I hope that you can appreciate the importance of screening to prevent the development of colorectal cancer and facilitate early diagnosis and early treatment.

If you wish to watch this show again or watch an archived version of past shows, please go to ket.org Waterworks Museum.

If you have a question or comment about this or other shows, we can be reached at KY.

Health at ket.org.

I look forward to seeing you on the next Kentucky Health.

But in the meantime, please talk to your primary health care provider.

If you're over age 45, get screened what tool you use.

That's up to you, but please do get screened and follow up on that so we can see you again next week and in the future here on Kentucky Health.

Thank you.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.