Dr Bob Underwood (Host): Welcome to Check-Up Chat with EvergreenHealth. I'm your host, Dr. Bob Underwood. Early detection of colorectal cancer allows you and your care team to access more effective treatment options. One way to screen for colorectal cancer is through a colonoscopy. We're here with EvergreenHealth primary care physician, Jeremiah Pamer, to discuss some of the risks for colorectal cancer and when screening for colorectal cancer is appropriate. Dr. Pamer, thank you for joining us today.

Dr Jeremiah Pamer: My pleasure. Thank you for having me.

Host: Absolutely. Well, so let's start with the basics. What is colorectal cancer and who's at risk?

Dr Jeremiah Pamer: Now, the cancer itself mostly that we find in this colorectal anatomy and that, again, what we're talking about today, it's actually called an adenocarcinoma. Again, no quiz after this, you don't have to remember this. But it's worthwhile to know that this type of cancer arises from glandular tissue. In this case, it's the glands in the walls of the large intestine that manufacture mucus. This mucus helps move the stool on the way to, well, I guess it's final destination we can say. And this is the type of cancer that generally is found in the intestine. I think that's good to know. And this cell in the wall of the intestine this glandular cell, it wants to live and it's going to continue to grow and it's potentially going to make itself into a polyp, which then can eventually turn into cancer. And so after all of that, to answer your question directly, this is the process of colorectal cancer.

And then to speak briefly about the next question, who is at risk of getting colorectal cancer? Well, all of us, but the risk factors do change depending on who you are, where you live and perhaps, most importantly, how old you are, of course. Here in the US according to NIH in 2023, breast cancer, lung, and then prostate cancer are predicted to be diagnosed the most of all cancer. And then, fourth on that list is colorectal. It's predicted there'll be over about 150,000 diagnosis and, of that, nearly 53,000 deaths again from colorectal cancer.

Generally after the age of 50, the rates of colorectal cancer increase. That said, and it's one of the reasons I'm glad we're doing this podcast, is there is an increase in younger patients being diagnosed with colorectal cancer. Briefly, and we're going to talk about this in a little more detail later in 2021, the screening age for most people was changed from 50 to 45, and that speaks to the increased incidence in younger patients.

Host: Yeah, absolutely. And you talked a little bit about the neoplastic part of colon cancer in terms of the DNA. And really, it's kind of the whole idea of cellular growth becomes unregulated. And that's where you got into the apoptosis conversation as well. And the decreasing age really is one of those things that It's kind of a confounder these days and something that everybody, especially we physicians, are very interested in. So when should individuals begin to screen for colorectal cancer?

Dr Jeremiah Pamer: Yes. As mentioned earlier, but definitely worth talking about, in 2021, the recommendations went from age 50 to 45. There's a couple other caveats here I think are worth mentioning. General guidelines say that if a patient has a first-degree family member who has a diagnosis of colorectal cancer, what we do is we subtract 10 years from the diagnosis of that first-degree family member. And if that's younger than the age of 40, then we would start screening at that age. So for example, somebody has their parent who has a diagnosis of colon cancer at 45, that patient should then be screened at 35. If that age is above 45, then we would start at 40. So, that's something that's worthwhile. And a person who does find themselves with a family member who has a diagnosis of colorectal cancer should have this discussion with their physician and try and get this process underway. I have this discussion on a regular basis in my clinic. As a primary care physician, I can see just about anything under the sun, but a lot of my day is spent with preventative aspects of colorectal cancer and all the other stuff out there.

People who need to be screened earlier, definitely include those with certain genetic syndromes. They need to be monitored very closely, as do patients with Crohn's disease or ulcerative colitis or people who have had surgeries where pieces of their colon have been removed, that will increase the risk as well. These people should be referred to gastroenterology for screening, whether it's colonoscopy or whatever needs to be done. Yeah. And so, that's in a nutshell who needs to be screened for colon cancer.

Host: So if I'm a patient and I'm worried about it, what kind of symptoms should I be looking out for?

Dr Jeremiah Pamer: That's a great question. And it's a challenge. It definitely is a challenge. I think as we go, it'll become apparent that one of the reasons why this is so dangerous in the younger population is these symptoms that can come up can have a wide variety of reasons that are outside of colorectal cancer where they come on. Obviously, one of the reasons is just the lack of screening for those people, generally speaking. And so, I think this question is really asking if there's the symptoms in these patients, but I think the symptoms, as far as I know, really aren't different from an older patient from a younger patient. So, let's just talk about the symptoms in general here. I think we should just address that.

Running through some of these symptoms that a patient should probably pay attention to, and then that lasts for more than a few days, I oftentimes tell patients a week or two, even more than a few days, but diarrhea, constipation, often something that we call pencil stools or narrowing of the stool, meaning that the course of the intestine is narrower, you know, that's something to pay attention to. If a person has a feeling that they need to have a bowel movement, but then that sensation is not relieved by having one, that should be checked out. Rectal bleeding with bright red blood should absolutely be checked out. You know, colorectal cancer in no way is the most common reason for this. We have hemorrhoids and this and that, but it should be checked out. Blood in the stool, and if there's bleeding higher up in the intestinal tract, this can make the stool look dark brown or black; cramping or abdominal pain, weakness and fatigue, unintended weight loss, all of these things have so many other reasons that they can happen, but colorectal cancer needs to be on that radar, so to speak. And so, it should trigger a visit to the doctor, a discussion and a plan should be put together in terms of what needs to be done next.

Host: Yeah, absolutely. And that's why we talk about screening. A lot of these symptoms can be caused by other things or they can be asymptomatic completely. And you already mentioned that sometimes by the time somebody is having symptoms, the disease has already kind of advanced and it's harder to treat at that time. So, that's why we talk about colonoscopy. And so, exactly how does colonoscopy detect colorectal cancer?

Dr Jeremiah Pamer: As I did with the first question, let's take a step back and think about just other ways in terms of how do we even get to the colonoscopy and what are the kind of screening availabilities or options are out there, I should say. So, let's take the picture that a patient comes to see me. He has symptoms which prompted the concern for colorectal cancer in either in the patient's mind or in my mind when we're talking about this. I didn't mention this in the symptoms specifically, but the fatigue and the exhaustion, right? That can also be something that comes from anemia, which is a low hemoglobin count. And colon cancer can absolutely have this slow but regular bleed, which leads to anemia. And so, one way that we have found colorectal cancer processes is by getting just some standard blood work, like a complete blood count where the hemoglobin levels are low. There's indication that the red blood cells are being pushed out of this bone marrow a little earlier than they should.

And if there's no other reason found for this anemia, they need to be screened for colon cancer. And so, then what do I do? I don't necessarily send them for colonoscopy right away. The next thing I would probably do is get fecal occult blood test, or FOBT, there's some other names for it. But basically what it does is it's a test looking for microscopic blood in the stool. If positive, colon cancer is by no means a guarantee, my goodness. But a referral is put in by me, in this case, to get them for what the next step should be, colonoscopy.

So, basically, I think most people are aware, but let's talk about it. Basically, it is having a camera inserted into the anus to inspect the whole of the large colon. A little bit of air is pumped in there. So, the colon is inflated so you can see the walls of the intestine. The day before, the patient will need to drink a large container of laxative which may be the most unpleasant part of the whole process, essentially as the colon needs to be empty to properly visualize the walls of the intestine. During the procedure itself, most people have what we call a twilight anesthesia. They won't remember much of the actual process of the colonoscopy. But they are looking for tissue that looks abnormal. If there is something that's abnormal, a sample is taken and sent for testing. A doctor who's trained as a pathologist, they spend their days looking through microscopes and they're looking at this tissue to see is there evidence of pre-cancer or actual cancer. Depending on what's found, a patient could come back in 10 years or seven years, five years, three years, depending on how that goes.

As a primary care doctor, a large part of my role in healthcare is organizing and directing this preventative care. Other things, pancreatic cancer, a very lethal cancer, but relatively rare, thankfully. Difficult to screen for. There's not the resources, there's not the easy way to screen for it. Cervical cancer, prostate cancer, breast cancer, lung cancer, skin cancer, all these processes, while quite common, are also detectable at an early age, just like colorectal cancer or early stage, I should say. And these are the cancers that we screen for regularly. And colonoscopy, as I walk through that process with the listeners here, is a big part of what we're doing in that aspect.

Host: So, what risk factors have we just not discussed yet? Are there anything else that you'd want to bring up about risk factors?

Dr Jeremiah Pamer: There are. There are, and I think this is really important and oftentimes kind of an underlooked aspect. My day in the clinic oftentimes dictated, well, not often, always dictated by timing and lack of time, I would say. That's just the nature of the beast of modern healthcare. And I feel like I don't get enough time to talk about this, so I'm thankful to have a little, few minutes here to bring this up.

So heralding back to the very beginning of our talk when we were discussing the basis of how some of these cancers develop. Some of that same dynamic is at play here. We discussed some of the genetic or inflammatory bowel diseases and the risks thereof. But there are a lot of things that we can do in terms of lifestyle management. Things that we can actually control. We can't control our genetics. Somebody who has Crohn's disease, they didn't ask for this, they didn't do something wrong to get that disease. But we manage those risks.

So let's talk about those. First, let's talk about lifestyle stuff that can increase our risk of colorectal cancers. And this will in turn Inform many of the things we can do to decrease the risk. So, a lack of physical activity. This is just kind of a no-brainer in my mind. But somebody who is sedentary, the risks are higher. A diet low in fruits and vegetables, and by extension a diet low in fiber, or high in fat content or processed meats. Think cold cuts and salami and some of those things that I really enjoy on a charcuterie plate, not good in too high of doses. Being obese elevates the risks, alcohol consumption, tobacco use, nearly all of these behaviors or depending on your perspective, a lack of behavior, you know, they're all associated with increased risk of all kinds of cancers. A decent paper recently published demonstrated an increase in nearly all cancers in the obese population. And while it may seem clear when looking at the risk factors that we are able to most modify, let's run through some of this stuff real quickly and then some of the dietary stuff that can be beneficial.

So, of course, not surprisingly, increased exercise. Again, not surprising. It's helpful, not only just for so many things, everything from mental health, sleep, but decreased cancer rates, of course. Fiber supplement. Dietary fiber, also important, but there is some studies showing that actual fiber supplementation can be quite helpful.

Vitamin B6. There's some decent evidence that show that higher levels of blood B6 has been shown to be associated with lower incidence of colorectal cancer. Dairy intake and calcium supplementation, same thing. This is actually officially recommended as a supplement by the American Gastroenterology Association to decrease the risk of colorectal cancer.

Vitamin D. I think the past few years with COVID, there were a couple of studies that showed extremely low levels of vitamin D left people more at risk for all kinds of upper respiratory infections. Of course, in the world of COVID, that kind of made a splash a little bit. I oftentimes don't think of vitamin D supplementation as a way to help prevent against colorectal cancer, but here we are again, vitamin D. Up here in the Pacific Northwest, you know, I'm born and bred Pacific Northwest. And here we are into this part of the season where the sun goes away. So, vitamin D supplementation is a good idea. Same with magnesium supplementation. There's somewhat limited data, but one thing about magnesium is that it helps the absorption of the vitamin D. So even if it's not healthy by itself, it can help the vitamin D absorption. Garlic intake, interesting as somebody who loves some garlic. I love to cook with garlic. There was an international cancer institute in Europe that said we're going to endorse garlic as an anti-colorectal cancer. Interestingly enough, in my reading this past week, the FDA did not come to these same conclusions. But unless you're worried about some bad breath, I think garlic is safe. Fish consumption and, by extension, omega-3 fatty acid supplementation is going to be very helpful.

Out of all of these, I've saved, well, in my probably biased opinion the best for last coffee, I've spent years working as a coffee roaster. I met my wife at a coffee shop. I continue to depend on coffee for many of my simpler functions. And I'm glad to spread the news of coffee and its protective aspects for colorectal cancer. So, I saved that one for last. That was a personal favorite.

Host: Absolutely. And lot of those things were the heart of the Mediterranean diet. So, that's cardiovascular protective and rectal cancer protective. I like that.

Dr Jeremiah Pamer: Yeah. Agreed.

Host: All right. So as we're finishing up, anything else that you'd like to add?

Dr Jeremiah Pamer: Yeah. We went through a lot of kind of, I threw some numbers out there. I threw some, "Take some B6. Take some vitamin D. Do this. Do that. Don't do that, " kinds of things. But I think taking a high level picture here, I'm speaking for myself, but I'm also speaking from my experience the past handful of years as a physician. I think this might be the human condition in a way, but I think that so many times, all of us, we can get stuck in a rut where we begin to worry about the things that we can't control. Family history, this and that, and that should be addressed, and you should talk about it with your physician, absolutely. But really focusing on the last part of our talk there, when we were talking about, yes, the Mediterranean diet, some exercise, you know, efforting not to be obese, maybe some supplementations of this and that, some fish in your diet. These are things that we can control. And I think I mentioned this earlier, I would like a larger portion of my practice to be focused on that aspect. Of course, you have to hit the important things, and sometimes there's just not time for that. And I guess the old adage that we should control the things we can and have peace with the things we can't control or, you know, however that goes.

If the listener is going to take anything away from our little discussion today, it's doing what you can with the things that you have influence over. That lifestyle, that diet stuff. It's very important. And yeah, go ahead and get into that primary care doctor and talk about the next steps for what kind of screening stuff needs to happen.

Host: That's awesome. Thanks for being with us today. Really do appreciate it.

Dr Jeremiah Pamer: Oh, my pleasure, as always.

Host: Dr. Pamer really underscored the crucial importance of early screening for colorectal cancer. Understanding the risk factors, screening guidelines, and the significance of early detection will really help us make strides in preventing and treating this all too common disease.

 That wraps up this episode of Check-Up Chat with EvergreenHealth. Head on over to our website at evergreenhealth.com for more information and to get connected with one of our providers. I'm your host, Dr. Bob Underwood. Please remember to subscribe, rate and review this podcast and all of our other EvergreenHealth podcasts. And for more health tips and updates, follow us on your social channels.