(gentle bright music) - [Aaron] Colorectal cancer, usually reserved for older men and women, on the rise in people in their 40s and even 30s.

What to look for, and the screenings that could save your life.

That's next on "Health Matters."

(gentle bright music ending) Colorectal cancer is on the rise in younger people.

According to the American Cancer Society, in people under 55, the death rate has been increasing by about 1% per year since the mid-2000s.

What's causing that and how do we respond?

Good evening, I'm Aaron Luna.

Joining us tonight to explore these questions, Dr. Anjuli Kumar, vice chair of surgery for Washington State University College of Medicine.

And Dr. Brett Gourley, an oncologist with the MultiCare Cancer Institute, and Dr. David Johnson, a gastroenterologist with Kootenai Clinics.

Thank you all for joining us this evening.

This type of cancers on such an upswing that the recommended screening age was dropped from 50 to 45, is it normal for screening recommendations to be changed like that or is this something that we should really be alarmed by?

Dr. Johnson, let's start with you.

- So I definitely think that when you see a major screening recommendation change going from 50 to 45, there's a lot of data behind that.

That's not a new thing.

You know, they follow trends over time.

And as you pointed out, we're seeing this incremental increase year-over-year of colon cancer incidence in patients under 55.

We're actually seeing a decrease in patients over 65, historically, the group that's been screened over the last several decades.

And so when you see a guideline change moved by five years and across, you know, millions of patients, it means that there's a lot of data pointing in a particular direction.

- And as a gastroenterologist, what is your specific type of medicine?

- So in gastroenterology, we're really on the front lines of colorectal cancer screening.

We spend a significant amount of our time in training and in practice doing colonoscopies, which is, you know, one of the tests that has some stigma around it with regards to colorectal cancer screening.

So we're the scope doctors, we're the ones passing the instrument and looking for the polyps that can lead to cancer or we're diagnosing the cancers.

We're also the ones who do the follow-up colonoscopy if there's a noninvasive test for screening.

- And, Dr. Kumar, tell us a little bit about what you do.

- So I'm a practicing colorectal surgeon, and colorectal surgeons take up the patient from when cancers are diagnosed.

And we're usually able to offer patients what's called restorative surgery, which means that we remove the piece of the colon that's affected, and then reestablish their continuity or put them back together.

- And, Dr. Gourley, just a real quick synopsis of what your specific field is.

- Yeah, so I'm a medical oncologist.

So my job is to give people medicines and drugs to reduce the risk of recurrent cancer or, if they're in the metastatic setting, palliative treatment to help extend their lives.

- We're talking about these screenings and what do these screenings look like?

What can we expect for people when they go in for a screening?

What do they plan for?

- Well, I think there's a couple of different options for screening.

I think the gold standard is what was previously described as the colonoscopy.

Colonoscopy is where we take a camera that's on a long tube, and the gastroenterologist can insert that into the colon, look at the colon, look for any nodules or masses within the colon.

And then, they're able to sample those or remove them if those are found.

There are other screening modalities.

There's the CT enterogram.

The advantage of that is it's a CT scan.

You still have to do the prep.

So you don't get spared from the prep, which everybody hates.

And if they see something, then you still need to have a follow-up colonoscopy.

There's also stool tests, and the stool tests have improved.

When I was a medical student, there used to be blood testing where we just look for blood.

But now we actually look for DNA signatures, what we call FIT testing, and that can increase the sensitivity of these tests.

But, again, if we have an abnormal test, then we are going back to the colonoscopy.

- And, you know, we're talking about people who are younger and younger getting these types of cancers.

Is that the case for both men and women?

- Yeah, the decrease in incidence with age seems to be, or the incidence increasing in younger patients seems to be across both men and women.

Maybe a little bit more in men.

So when we talk about how common these cancers are, I think, you know, it's not always at the forefront of patient's minds, that actually colon rectal cancer, the second leading cause of cancer death in men and women of all ages, but it's the leading cause of cancer death in men under 50.

So if you're a man who's under 50, it's actually the most likely cancer to kill you.

So probably a little bit more for men, but we're definitely seeing it in women as well, even down into their 30s.

So it's sort of across a really broad spectrum of patients.

Some of the risk factors that we think are contributing to this are probably a little bit less powerful in women and more in men.

But it's not like it's just isolated to one sex or the other.

- But I'm glad that you asked about gender differences, because there are also racial differences.

And so what we're noticing is that people who are not Caucasian, so people from African American descent or Native American descent have higher incidence of colon cancer, especially at younger ages.

So, for them, screening is of utmost importance.

- And that kind of ties in with my next question.

What are some of the reasons someone might need to seek testing if they're younger than the recommended age of 45?

Are there also factors outside of an age that people should be alerted to?

- Yeah, so, you know, reasons to be getting earlier screening is because of you have a genetic predisposition.

So if you have something like Lynch syndrome or familial polyposis syndrome, these would be reasons why you should be getting earlier screenings.

Sometimes those screenings even start at the age of 20.

If you have a first-degree relative, you should be getting screenings 10 years earlier than the age that they got colon cancer.

So, for example, if you have a first-degree relative who got a colon cancer at the age of 50, you should start your screening at age 40, not 45.

And then, I don't know if I would call this a screening test, but if you're having any concerning symptoms, so if you're having blood in your stool, if you're having changes in the caliber of your stool, these might indicate the need for assessing that sooner than later.

- And a first-degree family member would be someone in your immediate, mother, father, sister, brother?

- Mhmm.

- So I usually refer to patients, it's mom, dad, brother, sisters, or kids.

And then, so, you know, we get some interesting questions of half siblings.

And they're siblings, nothing half about 'em.

So yeah, to Dr. Gourley's point, certainly if you have symptoms, that's an indication to talk to your doctor.

And then, if you have a first-degree family member who is under 60, we start at 40 or 10 years before their age, whichever is sooner.

So if you had a family member who is diagnosed at 47, you'd start at 37, and so that's how the guidelines sit currently.

- Great, and I was able to sit down with a Spokane man currently being treated for colorectal cancer, a diagnosis he never expected.

(screen whooshing) It's a conversation Andrew Keating never planned to have with his three children.

- I have had the dying conversation with my oldest son, Steve, and he actually took it really well.

He was like, "Okay, so you're sick, and you're gonna die, and you're gonna go to heaven."

And I was like, "Yeah."

- [Aaron] Andrew's oldest, Steve, is only seven.

- I don't think that the finality has set in for any of my kids, but they at least know what's happening.

- [Aaron] Difficult for his children to understand and challenging for his family to come to terms, that just four years ago, at the age of 31, Andrew was diagnosed with stage 4 colon cancer.

- [Andrew] Oh, that means I'm gonna die.

(chuckles) - [Aaron] The cancer has now spread to other parts of Andrew's body.

- So I've got tumors on my liver, I've got some small tumors in my lungs, some tumors in my lymph nodes.

- [Aaron] In 2009, Andrew served his first tour in Afghanistan with the Air Force, and would be deployed two more times.

- That was actually a really fun time.

One of the greatest leaders that I've encountered was my team leader.

So, Chris, that's you.

- [Aaron] His duties there put him in hazardous situations.

- Why I get VA disability is because my doctor wrote a letter saying that it was more likely than not that the burn pits caused my cancer.

- [Aaron] Medically retired, Andrew's life is basically divided into two parts, when he's on chemotherapy and when he's not.

- I visit with a doctor on Monday, they check my blood and they give me the green light to get chemo.

Tuesday I sit in a chair for four hours, and then they send me home with a chemo pump, which is a slow dose of chemo.

And I get that over Wednesday, and then I get the pump taken off on Thursday.

- [Aaron] Looking back on his diagnosis, Andrew says there weren't clear signs something was wrong, although he did have stomach pain before his diagnosis.

- Maybe a year before I got checked out.

And I did the manly thing of just grin and bear it, you know?

- [Aaron] He thought it was likely just gallstones, something a friend had recently experienced.

- By the time I felt the pain in my liver, I was already on stage 4 cancer, so there was really no warning.

- [Aaron] What he tells people now when something feels off in their bodies, "Go get checked."

- There's a lot of people out there that don't wanna create a fuss and everything like that.

And my message to them would be, "If you don't go, the worst that could happen is that you could die, so you should probably go get checked out."

- [Aaron] Andrew doesn't know how much time he has left with his wife and kids.

And while that's tough for him to think about, he's treating his cancer as a gift.

- God's gonna work through the best and the worst situations.

He's gonna use everything for his good.

And if anybody else is going through cancer, just take solace in the fact that, you know, God's gonna use it.

- For Andrew, it seems that his exposure to burn pits during his time in the service likely contributed to his diagnosis, but most people being diagnosed with this cancer aren't exposed to those same hazards.

Do we know what's causing this shift, and who is getting the cancer, and when?

- Well, I think we don't know exactly why people are getting cancer at a younger and younger age.

We know that there's some correlations, we know that people are becoming more and more obese in the United States and across the world, and that could be a factor.

We're eating processed foods more often, which have less fiber in them.

That could be a factor.

We are exposed to plastics.

And so many of these things could be contributing factors, and it may be all of these things that are contributing factors.

So it's tough to know what one specific thing is, but probably a combination of multiple things.

- And everything is kind of shifting around even as we speak, like we were talking beforehand, people are smoking less and it seems that they're drinking less, so you would think that'd be a positive, but we're actually seeing a shift in a different direction.

- Yeah, the classical risk factors, like smoking and alcohol use, are declining.

Yet, we're still seeing the rise of colorectal cancer, and so it seems a little paradoxical.

- And, Dr. Kumar, you've done some extensive research into this, and access to screening can play a significant role as well.

Can you walk us through what your research found?

- Yeah, absolutely.

I was able to team with the geospatial epidemiologists at Washington State University, and we took data from the Washington State Department of Health and correlated with the residents at mortality from colorectal cancer.

And we found these hotspots of premature cancer death from colorectal cancer, especially in Southeast Washington.

So working with my colleagues, we turned what we found into a collaborative and advocacy effort.

So we've been going to farmer's markets locally in the Richland and Yakima area, and health fairs, and trying to raise awareness through sometimes goofy methods, like dressing up as poop emojis, just to destigmatize what it's like to undergo the screening test that can save your life.

- How do you measure the effectiveness of something like that?

- That's a great question.

I think that's gonna take a long time.

But there are definitely organizations that are really focused on Washington State, like certain branches of the American Cancer Society that have really strong objectives and goals as to where they want these incident rates and prevalence rates to be in five years.

So I think we'll see the effect through that.

- And another theme that came up in Andrew's story, that we just watched, was the idea of wanting to tough it out, not wanting to make a fuss, as he said, and go to the doctor.

And what do you say to people who tend to ignore symptoms for the sake of being tough or maybe they might be afraid to inconvenience or possibly even alarm loved ones?

- So, I think, you know, from my perspective, something I always tell patients is that, you know, there's a lot of stigma around colorectal cancer.

People don't like colonoscopy, they don't like stool, but we talked about how common it is.

I also, you know, counsel patients, it's one of the most preventable cancers and that symptoms don't always mean that you do or don't have something.

So most polyps and early-stage cancers are actually completely asymptomatic, and that's the best time to intervene so we don't have to do, you know, extensive, long-term therapy for palliative purposes or to extend life.

We hope to get a cure.

But so, you know, we talked a little bit about all the different testing options, and patients say, "Oh, which one's the best test?"

It's whichever one you'll do, right?

And so don't be afraid to go talk to your doctor.

And then, you know, I'm obviously biased, I love colonoscopy, but it's not right for every patient.

And so toughing it out isn't gonna save your life, and, you know, doing some test is better than doing nothing, and talking to somebody is better than doing nothing as well.

- What do you find is the biggest reason people say they haven't done it?

Is it just they didn't wanna go through the process or they didn't think they need it?

You know, I know it's kind of an anecdotal question.

- Yeah, so lack of knowledge is definitely one.

I think most patients aren't familiar with how common colorectal cancer is.

They're not familiar with the concept of not having symptoms, doesn't mean you don't have anything.

Again, small tumors usually don't cause blood in the stool or any symptoms.

And then, it's a long list of other things, inconvenience, fear of the procedure, they don't like stool, they don't wanna take a day off work.

But, you know, it's an important health maintenance piece and so making time to do it, and so I'm sure we all have similar stories of what kind of barriers there are.

- Dr. Kumar, you must have seen this in your research and your outreach as well.

- Yeah, I think that one of the things that has struck me from meeting people in the community in the places where they live is that there is an intimidation with just seeking help from a physician.

But then when they get to know someone like me or Dr. Johnson, we're just very down to earth and we usually, you know, have a sense of humor, and can walk them through a very serious thing that they might be dealing with, but in a very compassionate way.

- While colon cancer is on the rise, there's also been some changes not only in how and when we test, like we've discussed so far, but also in how we treat colorectal cancer.

What's kind of the most exciting news that we're seeing in the treatment realm?

- Well, you know, I think some of the screening modalities is really cool.

I mean, the fact that we can detect abnormal DNA in people's stool and try to focus in on those people who have that for screening, I think is pretty remarkable.

That's in the screening realm.

And maybe one day everybody doesn't get a colonoscopy, maybe everyone gives a stool sample and we analyze that, and then decide who needs that.

There's a lot of talk about the microbiome of our gut, and what that means is the bacterial makeup of our gut.

And there may be people who have certain bacteria colonies that are overgrown that have a higher risk of colorectal cancer.

And that's one of the things we didn't talk about earlier, that this could be a cause for people to have increased colorectal cancer risk.

So, you know, I think in the screening there's a lot of really interesting modalities that are coming about.

In the treatment of colorectal cancer, there's also a lot of changes.

It used to be if you had lymph nodes involved, you'd have stage 3 disease and everyone got six months of chemotherapy.

And now we're starting to risk stratify people, and we have some people who actually do shorter amounts of chemotherapy.

In the palliative setting, or in the stage 4 setting, unfortunately, we're still not curing very many people.

We only cure about 5%, but we keep on pushing that a little bit further every year.

And, hopefully, we start curing more and more people, like Andrew, who have stage 4 colorectal cancer.

In addition, our science is getting really cool about what we can treat people with.

I have a lady who has stage 4 colorectal cancer and I saw her about seven years ago, and she did really poorly on chemotherapy and she came to me for a second opinion.

And, at that time, we had a new antibody that stimulates the immune system called pembrolizumab, also known as Keytruda.

We gave this to her and she went into complete remission.

Now, she tours around the country, and she stops in every six weeks to a different oncologist somewhere in the United States, gets her infusion of her therapy, and is in complete remission and has been so for seven years where at the time that I saw her, she should have passed away probably 12 months after I saw her.

So that's pretty remarkable.

- Remarkable and exciting.

And on this side of the table as well, what kind of gets you excited when you look forward to new things coming down the pipeline?

- I love the human aspect of it, the survivors, and there are so many, because colorectal cancer is a survivable condition, are very passionate about spreading the word and their personal stories among people whose lives they could save.

So a great message is, "I love you, get screened."

- Yeah, I agree with Dr. Gourley.

I think, you know, there's a lot of excitement around the chemotherapy, 'cause we see these patients on the front-end and, like, they may have bad disease, and some of these therapies are absolutely amazing and the responses from the tumors, biologically, is really pretty impressive.

I think something that maybe is a little bit underappreciated, is I feel like in the 10 years I've been in this clinical space, is that really social media, you know, that it can be leveraged in a lot of ways.

I think social media has brought a fair bit of colorectal cancer awareness and sort of is contributing to the fighting against the stigma and getting younger people aware of it as a problem, and then also that there are options for screening, and that it's an important thing to consider.

So I'd see, you know, again, advocacy, and sort of outreach, and survivorship is really kind of a big important thing.

- Like, one meme that stood with me was a smashed cell phone screen, and the caption said, "There are worse things than screening colonoscopy."

(everyone laughs) - So what you're saying is we should follow you guys on Instagram for all the latest-and-greatest reels and memes.

You know, just to really touch base on that outreach program.

Just in other settings we've found that, you know, different cultures and different ethnicities oftentimes have a little bit a tougher time reaching out to doctors.

There might be some mistrust there in that sense.

Do you see that when you're out there?

Like you said, you were kind of in Southeastern Washington.

And do you have those conversations with people?

- Yeah, I think just, again, humanizing that doctors are people, and people with relatives, and it goes a long ways.

And I think that being culturally sensitive also, for example, sometimes the concept of having an instrument inserted into your body when you're awake is not something that is palatable, but potentially a home test would be.

But we get questions like, "What do you do with the home test after I send it to you?

Will you send it back to me?"

You know, things like that.

So there are some cultural sensitivities around people's products.

- Yeah, I totally agree.

Again, we have to meet the patient where they're at with what kind of test they're willing to do, and the best test is the one that gets done.

And for a lot of folks, it's not a colonoscopy.

They don't wanna come see me with the, you know, get sedated and have a camera inserted through their colon.

But, again, there's different disparities, and we have to figure out how to meet each individual group of patient's needs.

- Are there any systematic changes or changes to our medical system as a whole that could potentially impact outcomes and treatments?

I mean, as we get new technology and new treatments, is there something that stands out that you think is going to be productive in a systematic change?

- Well, I think all of the changes that are occurring are little steps.

So it's not very common where we see something that really moves the bar a whole bunch.

But we see a lot of little steps that just progressively move the bar.

And so that's what we're seeing in colorectal cancer and other types of cancers, that were slowly moving that bar and the outcomes now are significantly better than they were 20 years ago.

- And what about outreach?

You know, location is always kind of a big factor.

People in living in rural areas, especially in Eastern Washington.

Is it, do you run into, and, Dr. Kumar, you might be able to speak to this, just being able to go into a clinic or being able to drive there?

- Yeah, definitely geographic distance is a big impact on patients and their ability to get screened, and the Covid pandemic did not help things.

It really pushed those wait lists to even longer, and it doesn't account for people who develop symptoms while they're on a waiting list.

So we're really excited about home testing.

And then, also even blood biomarkers are really just on the precipice of being approved for detection of colorectal cancer, and that'll bring care a lot closer to patients' homes.

- I have you here in somewhat of a platform, is there something you would want, if, you know, talking to someone out there that you may or may not know, what do you want to tell them in just like a brief amount of time when it comes to this topic?

We'll start with you, Dr. Kumar.

- Well, I would say that anyone who gets screened is brave and should be complimented.

And when they go through it, to share their story with those that they know haven't gotten screened yet, and to just let them know it was not that bad.

I've had three screenings myself, so I can tell you that it's not that bad.

- Yeah, I agree with Dr. Kumar.

I think, you know, the high points for patients in the community are that this is a prevalent cancer, it's a preventable cancer.

We have a test that can work for you, and it's something that you don't have to suffer through and die from.

It's really one of the most, if not the most, preventable cancer, particularly in men.

You know, we can do noninvasive tests, lead to a colonoscopy, remove precancerous polyps, and actually prevent the cancer from ever happening, and so taking that first step.

And the feedback I get from patients very frequently is they were so afraid of their first colonoscopy, then they come get an anesthesia nap, they meet the doctor in person, they wake up, they get told that, "Everything is okay, we might have taken out some polyps," and they get to go have breakfast or brunch.

And then, they're like, "Oh, that wasn't so bad.

Like, why did I wait so long to do that?"

That's the overwhelming majority of folks that we see.

So taking that first step and getting your first screening is really kind of the big thing to do.

- Dr. Gourley, does that sound about right for you?

- Yeah, I would say an ounce of prevention is a pound of cure.

You know, I just had my screening colonoscopy last month, and, you know, I got to have a day of Jell-O.

And then, followed by, I had a late consult, so I got home at 9:00 PM, and I started drinking that MiraLAX and got cleaned out for the next morning.

And so, you know, for me, it wasn't horrible.

On a personal note, my father-in-law, who I never got to meet, he passed away from colorectal cancer.

My wife, as a result, got screened earlier than normal, and they found a 1.5 centimeter polyp at her screening colonoscopy at the age of 40, that, at the time, was 10 years before she would've ever been screened.

Given another 10 years, she might've met the same fate as her father.

And so we would much rather have everybody find these cancers early before they have to come see me and be in a situation like we saw with Andrew.

- So it sounds like a lot of it, you know, doesn't come down to just taking responsibility for yourself, but possibly going out there and being an advocate for people that you know, people that you love.

What was it that you said?

"I love you"?

- "I love you, get screened."

- "Get screened."

- Yeah.

- And it's as simple as that.

Again, thank you for joining us this evening.

If you'd like to share this episode with someone you love, you can find it on ksps.org.

I'm Aaron Luna, goodnight.

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