Michael Smith, MD (Host): Welcome to Meaningful Medicine, a podcast by Novant Health. I'm your host, Dr. Mike. And joining me today is Dr. Sarah Fox, a colorectal surgeon affiliated with Novant Health Colon and Rectal Surgery in Wilmington. Today, we're going to be discussing colon cancer prevention, the latest screening recommendations, and healthy dietary steps to reduce our risk. Dr. Fox, welcome to the show.

Sarah Fox, MD: Thanks for having me.

Host: So, one of the things I wanted to start off with, it seems to be very concerning, colon cancer in younger adults. We're starting to see some cases, right? What's going on here?

Sarah Fox, MD: I agree with you. The rise in young-onset colorectal cancer is pretty alarming. And actually, the data show that, for people who are born in the '90s, they've got double the risk of developing colon cancer and four times the risk of developing rectal cancer compared to adults born in the 1950s. So, it's pretty significant.

What we know is it's caused by both things that you inherit from your parents and then some lifestyle factors. And while it's not an exact science for everyone, we know that those two factors work together and have been linked to the earlier onset of colorectal cancer.

Host: So with that in mind, you know, what you see in these younger cases and stuff, let's dive into diet, that's kind of the thing that really jumps out in front of me now, what's possibly going on here? And we know the standard American diet has not been great for many years. It seems to be maybe getting worse with all the processed foods. So, let's start there. How important is diet then to overall risk of colon cancer?

Sarah Fox, MD: It's a great question. Like you mentioned, the western diet's high in fat, red and processed meats, refined grains and processed sugars. And all of these things together have been linked to both high risk colon polyps, which eventually turn into cancer and colorectal cancer itself.

We also know that the western diet's linked with the rise in obesity rates, and particularly in childhood obesity. And what we've seen is that there's some evidence that links childhood obesity as well as the high consumption of sugar-sweetened energy drinks in childhood and the early teenage years with early-onset colorectal cancer.

And then, one thing that I find super interesting and patients ask me about all the time, because I think it's gotten a lot more pressed recently, is this whole concept of the gut microbiome. What we've learned is that diet really impacts this. So, our gut microbiome is made up of good gut bugs and they interact with our immune system to influence kind of how your body works.

And one of these functions is actually how well can this prevent tumor growth, and we've seen that the Western diet promotes these less favorable gut bugs with low diversity. So, the lower the diversity, the higher your risk for developing colon and rectal cancer. And these unfavorable gut bugs cause inflammation in the lining of the gut, which then increases the risk for colon polyps and for cancers.

Host: The gut microbiome, like you, I find very interesting too, because I've seen a lot about the importance of the diversity of the gut bugs, like you say. And so, not only now linked to obesity, colon cancer, but we've even seen low diversity maybe even impact longevity. Like, there's a lot I think we're still learning about that. So if I were to do this, put this together-- and I'm not trying to oversimplify the problem here with younger people getting colon cancer-- but it's like we had this obesity issue, the sugary drinks, and all this kind of stuff, and we saw childhood obesity. That was the big thing. And now, that's translated maybe into colon cancer as they're going in adulthood and somehow the microbiome's playing a role there too. Is that kind of a safe way of thinking about it?

Sarah Fox, MD: It is. And I think as we learn more and more about the gut microbiome, I think we will be able to link more definitively how these things are correlated. But for certain, I think you hit the nail on the head.

Host: What about alcohol? How does that affect risk?

Sarah Fox, MD: it seems to be dose-dependent. And so, what that means is that the more you drink, the higher your risk. And what we've seen is that people who drink more than three alcoholic drinks per day are at substantially increased risk for colon and rectal cancer compared to people who either don't drink or who just drink occasionally. And interestingly, these effects seem to be greater in men compared to women. So, there's some evidence that shows that for every additional day that a man drinks per week, they can increase their risk of colorectal cancer by 5% per day. So, that's pretty significant. And that type of relationship has not been proven in women in the same way.

Host: And when you have those conversations with the younger people, who are now experiencing higher colon cancer rates, so we know diets playing a role, maybe childhood obesity, is alcohol involved there? Do you see that in these patients?

Sarah Fox, MD: It definitely is. And unfortunately with the COVID-19 pandemic, we saw just a general increase in alcohol consumption across the board in all ages. And we're really, I think, starting to see some of those downstream effects now in the way of colon and rectal cancer. Obviously not everyone, occasionally it's just pure bad luck. and we can't really say these are your risk factors and this is why you have this. But generally speaking, people have a handful of different factors that are playing into this, and affecting their risk for colon and rectal cancer.

Host: Obviously, I think a lot of people, well, maybe a lot of people don't know this, right? That colon cancer doesn't necessarily present with a lot of symptoms, right? So if we're going to talk about prevention, we have to talk about screening.

Sarah Fox, MD: So, you're right. Most of the time, people don't have any symptoms when they're diagnosed. The concept is that the vast majority of colorectal cancer develops from pre-cancerous polyps, which are little growths on the lining of the colon, that transition from a benign growth to a cancerous growth, if you leave it there for a long period of time. And during colonoscopy, we can see these growth and we can remove them. And what that does is remove the risk for that polyp becoming a cancer. So, that's why screening is really important because we can actually remove these growths before they have the opportunity to turn into cancers.

Host: It's really one of the few screening techniques where you can actually treat when you're screening, right? And that makes it so powerful.

Sarah Fox, MD: Absolutely. Absolutely.

Host: So, what are the recommendations now? Because I think they've been updated recently. What are the ages that we should start lining up for colonoscopies?

Sarah Fox, MD: For all-comers, the very first thing we want to do is kind of figure out what is your personal risk. So if no one in the family has any polyps, there's no family history of colon or rectal cancer and you're pretty healthy, then you should start screening at age 45. But anyone who has any type of elevated risk, so if mom, dad, brother, sister, have colon polyps, history of colon cancer, certain disease processes like Crohn's or ulcerative colitis run in the family, then you may need to start your screening at age 40 or sometimes even earlier, depending on your personal and family history. And it's really important that anyone who is at elevated risk have a complete colonoscopy and not choose to do one of the alternative screening methods, because they really need the highest sensitivity for that screening test.

Host: If somebody is not at elevated risk, they get their first colonoscopy around 45, when do they come back?

Sarah Fox, MD: So if it's clear and they don't have any polyps, they're good for 10 years. If they have some polyps, then the repeat is based on the number, size and type of polyps that they have. And it's usually somewhere between three and five years to come back.

Host: I would assume repeat for elevated risk, that's a different schedule.

Sarah Fox, MD: It's typically every five years. But again, it kind of depends on what your personal risk is.

Host: Let's talk about those at-home tests. Tell us, what do you think?

Sarah Fox, MD: I always say that the best screening test is the one that you'll actually do. For some people, the thought of a colonoscopy is a deal breaker, for any number of reasons. And so, if I can talk you into doing an at-home stool test, I'm satisfied with that. They are not as sensitive of a test compared to colonoscopy.

So when we look at screening tests, you know, there are some fancy statistics that we use to determine is this a good test and you know which one is the best when we're comparing them. And so, colonoscopy has been the gold standard for a long time. And it can detect colon polyps 92% of the time, and colon cancer is 99% of the time. So, it's very reliable. And like you mentioned before, it's both diagnostic, meaning we can see them, and therapeutic, meaning we can remove those polyps at the time of the test.

The stool-based studies, the kind of very best ones now, and they are quite good, they can detect blood and then they detect polyp or cancer DNA. They're sensitive, but they're less sensitive than the colonoscopy. And there are some size criteria based on the size of the polyps or the cancer. And so, you kind of have to have enough of the polyp or cancer DNA in the stool to be able to detect that there's a problem. And so, because of that, it can identify about 43% of patients who have polyps and 84% of patients who have cancer. So just purely based on the numbers, it's not as good, but like I said before, I would rather you do something than do nothing.

The other thing that people forget frequently is that, if you do have a positive study, at-home stool study, then you need a diagnostic colonoscopy to figure out exactly what's going on.

Host: And I would assume if you're elevated risk, the at-home's not for you.

Sarah Fox, MD: It's not.

Host: Do you think these are going to get better over time?

Sarah Fox, MD: I do, I do. I mean, the technology has already gotten much better, even just in the last like five to seven years. So, as things become more technologically advanced, I would anticipate that this technology will continue to improve.

Host: So, we know colon cancer when a diagnosis is made, often there's no symptoms. But I do want to talk about some symptoms because somebody might be experiencing something. Maybe they're seeing some blood or there's pain. What are symptoms that should warrant them to give you a call?

Sarah Fox, MD: I say this all day, every day. Blood in your stool is never normal, ever. It always needs to be checked out, and I can't tell you how many times people come to the office and say, "I have blood in my stool. It's just a hemorrhoid," and it's definitely something that always needs to be checked out.

When symptoms do start to happen, and are indicative of colon or rectal cancer, they're actually pretty nonspecific. And so, they're really easy to ignore. Things like, "Oh, I'm a little bit tired," or "I have some blood in my stool," "My belly's a little bit bloated," or "I'm having this kind of weird twingy pain that's not that bad," change in bowel habits, and then kind of as we go down the line and things get more advanced, you may start to lose your appetite or lose some weight without trying. It is not uncommon that, especially in young people, because these are so such vague symptoms, that they aren't diagnosed until things are fairly advanced, because it's very easy to talk some of these things up to, "Oh, I'm tired," "Oh, I have this life stressor going on," whatever it is,

Host: And that's always a shame because like most cancers today, if caught early, the chance of having a good outcome is pretty good.

Sarah Fox, MD: It is.

Host: Yeah. So, screening, keep an eye on some of those symptoms. Don't hesitate to go see somebody like you, right?

Sarah Fox, MD: Exactly, exactly.

Host: I always like to ask my guests like, why they chose the specialty they're in. Like, what made you go down the Colorectal Surgery route?

Sarah Fox, MD: I get asked this all the time. They're like, "Why in the world would you choose this?" I love what I do. I always thought that it was really interesting when I was a resident and then I had a call weekend, where I was up all night for like three days in a row and it was just all colorectal emergencies. And I was like, "Oh, this is where I go." I was so happy taking care of everyone. And I've honestly never looked back.

And then, the other big thing is that I grew up in Wilmington, so I always wanted to be able to come back here and take care of my community if the stars aligned. And for about four decades, there was only one colorectal surgeon in town. I knew that there was a need, especially as our population has grown so much, and I was very fortunate to be able to come back and practice here.

Host: That's great. Fantastic. I love hearing stories like that. We're so different. I'm a radiologist. I wanted to be in my dark little room. Leave me alone. That's what I did. Any last words, Dr. Fox, that you want to say to the listening audience?

Sarah Fox, MD: Get your colonoscopies. Don't ignore blood ever. And don't be afraid to talk about your bottom or poop because it's equally important to the rest of your body and your overall health.

Host: Perfect. Fantastic. Thank you so much. You're listening to Dr. Sarah Fox. She just shared some invaluable insights on colon cancer prevention. For more information or to find a physician, you can visit novanthealth.org. And if you liked this podcast, please share it on your social channels, and you can also also explore our library, which has tons more health and wellness topics. This has been Meaningful Medicine with Novant Health. Thanks for listening.