Screening is important; diet, genetics can play a role

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Cases of colorectal cancer in people under age 50 have increased by more than 50% over the last two decades, and it's one of the deadliest cancers in this age group. For help understanding why and what can be done about it, I'm talking with Dr. Jeffrey Albright. He's an associate professor of surgery at Upstate, specializing in colorectal surgery.

Welcome to "The Informed Patient," Dr. Albright.

Jeffrey Albright, MD: Thank you for having me, Amber.

Host Amber Smith: The American Cancer Society recommends colon cancer screening to people beginning at age 45. How often do you see patients that are that young?

Jeffrey Albright, MD: With cancer specifically, we definitely have been seeing an uptick over the course of the last 10 years, and I'm seeing more and more patients who largely are not informed of the change in the screening age. And, for that reason, I sometimes will surprise them by saying, you do meet screening age, and a number of those people we will pick up having polyps or even cancers in them.

Host Amber Smith: So even people in their 20s and 30s, you sometimes have to have the conversation with?

Jeffrey Albright, MD: Yes, we do. Typically, the way that we try to approach things with people that are a bit younger, especially ones under the age of 45, is, it really depends on their overall symptoms.

And we know that somebody, if they're in their 20s, and they don't have a family history of having cancer of specifically the colon or the rectum, that the likelihood of having a little bit of bleeding on the toilet paper, something like that, is unlikely to be colon cancer. But as we start to see people as they get into their 20s or 30s, or if they start having more warning signs as far as blood or changes in their bowels or pain that we can't really explain in any other way, we will often start to recommend doing a colonoscopy or some other type of study to evaluate the colon, just to make sure that we're not dealing with a young person who does have a colon cancer.

Host Amber Smith: How are these colon cancers that you find in younger people distinguished from the colon cancers you find in older people?

Is there any difference that you've noticed?

Jeffrey Albright, MD: Well, much of that really comes down to family history, and there are some genetic syndromes, so things that people carry in their genes that put people at a much, much higher risk of developing cancer of a younger age. We think of one condition called Lynch syndrome, which we often will see colon cancer, cancer associated with the gynecologic organs, so ovaries and the lining of the uterus and a number of other cancers that all kind of cluster together. And it's related to having gene problems where people don't repair damage to the genes as effectively, and so they develop cancer at a younger age and more rapidly.

There's another one called familial adenomatous polyposis. The name doesn't matter so much, but it's just, really, these genetic syndromes probably make up less than 10% of overall colon cancers that we see. And so the majority of them are going to be more of what we call sporadic, or just kind of the random thing that pops up that develops through a typical, pathway that we see with colon cancers, and for the most part, we think that the ones that we see in younger people, people in their 30s and 40s, are mostly the same type of cancers we see in older people. It's just they're developing it at a younger age.

Host Amber Smith: So some of the reason that we're seeing more young people being diagnosed has to do with these genetic reasons.

But a lot of it is, like you said, sporadic?

Jeffrey Albright, MD: Yes, that's correct. It's really probably the sporadic ones that we are really identifying more and more. That's probably the bulk of what we're seeing. There's not an outbreak of more people with genetic problems because that's probably been there at, kind of hanging out at, its baseline level, for decades and decades.

So it's mostly just younger people, getting it through the pathways that the older people would normally get It from.

Host Amber Smith: As a colorectal surgeon, what are the symptoms you wish people would pay attention to that might signal cancer?

Jeffrey Albright, MD: So people that experience bleeding would be one thing. Usually if somebody has a cancer or tumor that's further down, it's more likely to cause bleeding that they can see. If people have unexplained anemia. most cancers are larger polyps that occur further up in the colon, so further away from the anal area, tend to just cause slow blood loss over the course of time. And it's maybe anemia that gets identified by their primary doctor, that needs an explanation.

Anemia for most people is not a disease, it's just a sign of something else going on, so that's something we also want to be very sensitive to.

People that have changes in their bowel function, so if they're having worsening constipation that they can't explain over the course of a few months, or if their stools are coming out narrower, or if they've got unexplained diarrhea, if they've got bowel crampiness or abdominal pain that can't be explained, those can be signs of colon cancer. They can also be signs of a number of other things, but those can be signs of colon cancer.

And then probably the other thing that we think about as well is just knowing your family history, knowing if you've got a parent who's younger who developed colon cancer, if you've got a number of different first- and second-degree relatives who have had colon or rectal cancer, then there may be some underlying issue related to your genes, even though it doesn't fit some of these specific genetic syndromes like Lynch syndrome, there could just be some type of a predisposition to developing cancers at a younger age.

Host Amber Smith: Let's talk about how colorectal cancer is diagnosed. Do primary care providers send patients to colorectal surgeons like yourself to be diagnosed? Or do they already know the patient has cancer and is going to need surgery before they come to you?

Jeffrey Albright, MD: What I'd say is there's a mix. Our primary care doctors do an excellent job of trying to get their patients to do the screening types of tests. And so colonoscopy is just one of the types of tests that we use in order to be able to identify colon cancer, as I discussed before.

People with colon cancers or bigger polyps will often have some bleeding into the intestine, into the colon. And so one of the things that we do is, we actually look for signs of blood in the stool. And there are certain tests that can be done from the stool to try to identify any blood that you may not recognize, because you just can't see it. You're losing in small enough amounts, you don't see bloody-looking stools.

There are newer tests. One that's commonly seen, people may see commercials for, is one called Cologuard, which is testing for DNA that can be spilled by cancer cells into the stool.

And so if somebody has a positive testing for that, that usually is a sign then, OK, we need to go and do the gold-standard test, which is to go in with colonoscopy and to look for what could be the cause for the blood loss or for the DNA that they're seeing in the stool.

Less commonly, we'll see people that are being sent over because they know with certainty they've got colon cancer, and colorectal surgeons, we're a relatively small group of doctors. Really, a lot of the colonoscopies are being done by gastroenterologists, or even general surgeons out in the community are doing colonoscopies in order to help, because there's too many colonoscopies to go around for it just to be done by one group or another, which is appropriate for public health, to make sure that everybody's getting the screening that they need.

Unfortunately, for people that are offered colonoscopy, it's the minority of people who actually act on it and really proceed to get the testing done.

And so that's why it's important, if screening is offered, that people go for it.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with colorectal surgeon Dr. Jeffrey Albright about rates of colon cancer that are showing up in higher numbers in younger people.

Now, treatment for colorectal cancer usually involves some sort of surgery, is that right?

Jeffrey Albright, MD: Most commonly, yes.

Host Amber Smith: And how do you remove early colon cancers or polyps?

Jeffrey Albright, MD: One of the things that differentiates the way we tell a difference between a polyp and a cancer is that a polyp is a precursor, what comes before the development of colon cancer.

And what it is, is just kind of a grouping, or cluster, of abnormal cells from the lining of the colon that starts to mound up and create kind of a growth on the inside of the colon. When we see something like that, we can go in and do a colonoscopy, and usually it's a matter of using a special thing to remove it, to pluck a piece of it off or to use kind of a little electric lasso to what we call "snare off" some of these polyps in order to take them out.

In that situation, we're removing the polyp, which prevents somebody from going on to develop a cancer from that polyp, typically, and it also gives us the ability to send that tissue off to the pathologist to confirm we're not just seeing a very early colon cancer.

Now a cancer starts to invade where it's not supposed to be, so it starts to penetrate deeper into the wall of the colon. And so if we go in, and we see something that looks like it's penetrating more deeply, we may not be able to remove it. And those are the people that tend to require an operation.

A small percentage of people can have a very, very small cancer in a polyp and have enough of what we call margin, or healthy tissue, surrounding the little tiny cancer that can just be removed with colonoscopy.

But that's definitely the minority.

Host Amber Smith: If you end up having to have a more extensive surgery, does that usually happen before or after chemotherapy or radiation? Do most colon cancer patients end up needing one or the other, or both?

Jeffrey Albright, MD: We kind of look at colon cancer and rectal cancer in a slightly different way.

The rectum is really about the last six inches of the colon, and it's down deep in the pelvis. And because of the way in which we have to do an operation for people typically for rectal cancer, if it appears that somebody's got a cancer that invades pretty deeply into the wall of the colon, or if there's evidence that there's cancer that's already spread to the lymph nodes -- and the lymph nodes are just like little filters for our body, for viruses, for cancer cells -- if we see that in our testing before the operation, that group of people may get chemotherapy and potentially radiation therapy before we do an operation, OK?

For people that have colon cancer, because of a number of differences between the way we treat them, we usually will go ahead and do the operation first. And then if there's evidence of cancer spread to lymph nodes, and the way I kind of describe this is, if your cancer's learned how to travel, it's gone from being local, in the wall of the colon, and it's figured out how to go from one place to another and start to grow and has spread to the lymph nodes, then we have to presume that it may have learned how to travel to other places further away, like the liver or the lungs, where if somebody has Stage IV, or metastatic, colon cancer, that's when people's lifespan really gets limited by colon cancer.

And so we use those as markers for people who should get chemotherapy.

And chemotherapy, I'd like to describe it as poison with a purpose. It's a poison that's intended to kill off cancer cells that may have gone elsewhere, outside of where we would normally remove a cancer when we're doing an operation. And so if you've got cancer cells that have spread to the liver, we hope by giving the chemotherapy, we can kill off those cancer cells before they have a chance to start to grow, and potentially lead to a more difficult problem to treat.

Host Amber Smith: Can surgery for colorectal cancer be curative in some cases?

Jeffrey Albright, MD: Absolutely. In order to make sure we're giving people the best type of therapy but not overtreating them, we do staging. And so when you hear about Stage I, Stage II, Stage III, Stage IV colon cancer or rectal cancer, that's the way that we as doctors kind of talk about, OK, what's somebody's risk of having cancer come back?

If somebody has a Stage I colon cancer, which is not deeply penetrating into the wall of the colon, hasn't learned how to spread to lymph nodes, that group of people, if we go and just do surgery with no chemotherapy, the likelihood that they'll be around, cancer-free, five years down the road is typically in the 90% to 95% range. And so the vast majority of people with Stage I colon cancer are going to be cured by surgery.

For people that are Stage II, so those are ones that invade more deeply, but the cancer still hasn't figured out how to spread to the lymph nodes, that's probably more in the 70% to 80% around five years, cancer-free. And so you can see as a more advanced cancer, it starts to be a much higher risk.

For Stage III, those are ones that have learned how to spread to other locations without chemotherapy. Those people are at best a coin flip as far as whether they'll be around cancer-free five years down the road.

And so for that group, that's one where we are going to be much more aggressive about treating them with chemotherapy afterwards, to try to really boost their odds of being around in the future, cancer-free.

Host Amber Smith: What can you tell us about the success of immunotherapy in colorectal cancer?

Does that ever get used alongside surgery?

Jeffrey Albright, MD: It does, it does. It's a newer therapy, and so we've got less experience with it, but there's certain types of cancers, like the one I described before, the one with Lynch syndrome, where just because of the mechanisms that lead to that type of cancer, the pathways that the things go through to get to it, that type of cancer tends not to respond to our normal chemotherapy very well. And there are even some people who can have something that looks like Lynch syndrome, that really have a similar type of problem, and those won't respond as well to standard chemotherapy. And we found that for that group of people, the immunotherapy tends to be much more effective. And so if somebody looks like they've got a reason to get chemotherapy, and we think that they're not going to do as well with the standard stuff because they fall into that grouping of type of cancer, that's when immunotherapy tends to be used, at least in the non-research world, at this point.

Host Amber Smith: How often do colorectal cancer survivors get follow-up colonoscopies, and what else is involved in their after-care?

Jeffrey Albright, MD: Once somebody's developed a colon cancer, we really worry about a couple different things. The first thing is, we already know they've got that one cancer. What's their likelihood of having, identifying down the road that, they've got a cancer coming back in their liver or their lungs?

That would be a group of people where we do all of our staging ahead of time to try to determine chance for spread. And when we do our CAT scans and stuff like that, something has to be big enough to be able to see on a CAT scan, otherwise we may not see it. So if somebody has very tiny spread to the liver or the lungs, we may not see it, initially.

And so for that group of people, we typically will follow every three months for the first couple years, and then every six months for three more years, knowing that if somebody's going to have cancer come back, most of that risk is in the first couple years. And so that's why we do more intensive surveillance, or watching, after we initially treat the patient.

And so usually what our surveillance means is getting a blood test during each of those visits, usually getting a CAT scan every year to look for any chance of spread and then, above and beyond having their original cancer be identified in a new location, if somebody has a colon cancer, they're at a higher risk of developing a second colon cancer, so a brand new one in a different portion of the colon.

And so, those people, we typically will say, OK, we'll go back and do your first colonoscopy to check the remaining colon, usually a year down the road. And then if that one is OK and doesn't have much pre-cancerous growth, then we'll go back again three years later. And if that still is OK, we'll go back five years later.

And so then they'll be on this kind of surveillance program for getting the repeat colonoscopies, looking for new cancers, at most five years apart, but part of it also depends on what we find on each individual colonoscopy.

Host Amber Smith: Before we wrap up, I want to ask you for your advice for what people can do to reduce the risk of colorectal cancer.

And I imagine it has a lot to do with what we eat, right?

Jeffrey Albright, MD: Absolutely. There are a number of things we think are probably the contributing factors for why people are getting colon cancer at a younger age. And, there's an interesting link between obesity, so being overweight, and developing cancer at a younger age, and it is for a range of cancers, and colon cancer is just one of them.

And so maintaining healthy weight is a very important thing for people to try to do, for a number of different reasons, not just colon cancer, but overall health. We know that diabetes is associated with both developing colon cancer as well as being overweight. And so, if you're diabetic because of being overweight, that probably also contributes, and so that's kind of a double whammy.

Third thing has to do with diet. And we know that there's some things like eating lots of red meat, especially grilled or fried food, food with a lot of preservatives in it, also are damaging to the lining of the colon and can set off a cascade leading to precancerous changes or cancer. (Likewise), having a diet that's low in fiber.

People talk more and more about the microbiome. So that's the different bacteria and yeast and other things that live on our skin, in our GI (gastrointestinal, or digestive) tract, wherever, that just coexist with us. And what we eat is going to feed the bacteria in our intestine. And if we eat things that cause more inflammation in the lining of the colon, then that's going to make people more prone to developing colon cancer.

And so there's actually been some interesting studies where if you compare people that are on a high-fiber diet, which decreases the inflammation on the colon, and you switch them over to a diet where they eat more of an American type of diet, that causes a lot more inflammation and a change in the microbiome to bacteria that contribute to inflammation and can contribute to cancer.

And so, eating a diet that's high in fiber, high in fruits and vegetables, more limited on things like grilled meats, can definitely impact somebody's potential for getting colon cancer. The other thing I'd say for people, aside from diet, is, listen to your doctor. Take these things seriously.

It's a whole lot easier to go through the screening tests, even though doing a bowel prep to clean out your intestine for a colonoscopy is not fun, it's not that bad. And it sure beats living with a colostomy or not living because of advanced colon cancer.

Host Amber Smith: Now you mentioned fiber, from whole grains and green leafy vegetables and all of that.

What about fiber supplements? Do they do as good a job at protecting us as natural fiber from a diet would?

Jeffrey Albright, MD: So the short answer is yes. Really, when we talk about giving people fiber supplements, it's trying to put back into our diet what we normally should be getting. But because American diets have so much processed food, where a lot of that fiber is really taken out, it's tougher to get it just with a normal diet. And so, taking a supplement can put everything back in that we should otherwise be getting. People can start on that in their 20s and 30s and probably have that long-term benefit. There's no harm in taking it for the vast majority of people, so it can be a preventative thing, especially if you're prone to it, and it just helps to keep the colon healthy and happy.

Host Amber Smith: Now some of these symptoms we talked about earlier with the change in, dramatic change in, bowel habits and blood in the stool, those can be kind of scary, and I want to let people know, I mean, how often do you find out that that's being caused by something that's not colon cancer?

Jeffrey Albright, MD: I would say most of the time it's not colon cancer. Most of the time it can be constipation or people can have bleeding from hemorrhoids or have blood loss from other things like heavy periods and stuff like that, that people can get anemic from. Or they can have irritation in their stomach that can cause them, like ulcers or whatever, they can cause them to lose blood.

That being said, we can't really differentiate effectively between somebody with symptoms because of their colon cancer versus symptoms from something else, which is why we say, OK, if you're symptomatic, let's do further evaluation, further testing, to determine what's driving these changes.

If you're like the majority of people, where it's nothing bad, then you can have both the peace of mind that it's nothing else, and we can also try to address what the cause is. If you don't know and you don't go looking, then you're just in a way of rolling the dice and hoping you have a benign cause for it.

So it's important for us to kind of keep that in mind, that usually when people do start having symptoms, if it's because of colon cancer, it's often because it's more advanced. And so, even with people with more advanced cancer, it's better if we're picking it up at Stage III instead of Stage IV.

Host Amber Smith: I also wonder, I think a lot of people might not be aware that they have a family history of any kind of cancer or colon cancer until they're diagnosed with it and start asking.

Jeffrey Albright, MD: I agree.

Host Amber Smith: Well, thank you so much Dr. Albright, for your time. I appreciate you addressing this subject with us.

Jeffrey Albright, MD: Thank you very much.

Host Amber Smith: My guest has been Upstate colorectal surgeon Dr. Jeffrey Albright.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.