Evo Terra (Host): This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Colorectal cancer rates have been steadily increasing among adults under 50 and alarmingly more young people are dying from the disease. Why is that? Let's find out with Dr. Kenley Unruh, a Kenley R. Unruh colorectal surgeon at Skagit Regional Health. This is Be Well with Skagit Regional Health. I am Evo Terra. Dr. Unruh, thank you for joining me today to help demystify this troubling trend.

Kenley R. Unruh, MD: Happy to help.

Host: So let me start with asking you to quantify steadily increasing. How much has this incidence of rectal cancer in young adults increased recently?

Kenley R. Unruh, MD: Well, the funny thing is Evo, overall the rates of colon cancer are actually going down in the United States. It used to be somewhere around 3 - 4% of the population every year would get colon cancer back in the two thousands. It's actually down to 1% every year now in the last couple of years.

And that's because there's more overall screening and especially with colonoscopy being one of the most common ways of doing that. But the problem is, is that we used to start screening people at age 50. And so what we're finding now, is that the rates of colon cancer in people under that at less than 50 years old, has been going up almost one to 2% every year since the mid nineties, making that it went from around 11% in 1995 to now somewhere around 20% as recently as 2019 of all rectal cancers and colon cancers are in people less than 50 years old. So it's basically doubled over the last like 20, 25 years.

Host: Wow. That sounds like an increase. So, why, I assume part of it is now we are testing more people and according to someone I've heard of, if you test more, you get more responses. But are there other factors involved?

Kenley R. Unruh, MD: Absolutely. Yeah. We though, I will say we don't fully understand why this is happening. I mean we know one of the problems is that we're again, not screening people. So we're not looking for these cancers yet in people this young, before they start having symptoms. And so it can be hard to catch before it occurs.

And the reason is because it's still relatively uncommon yet becoming more common. So that's one of the reasons why we have now decreased our age of screening down to 45 from 50 to try to catch people a little sooner. But overall, you know, we don't have a great idea why this, this trend is getting worse and we know it's some combination of one, environmental factors, so things that you're exposed to, and genetics, some combination of those two.

For the environmental factors, one of them, a major one is smoking, or being exposed to secondhand smoke, but also alcohol use and obesity as well as a diet high in refined sugars or processed foods has also been attributed to this. So overall, just things that are associated with an unhealthy diet.

Host: Once again, being unhealthy leads to people being unhealthy. It seems like an obvious connection, but I know it's sometimes very difficult for people to understand that and really get past it. Let's talk about some of root causes. How well do we understand how colorectal cancer works, and are there any unanswered questions?

Kenley R. Unruh, MD: Yeah, so almost all, both colon and rectal cancers, they arise from what are called polyps. Now polyps are overgrowths of the normal cells that line our gut. And they just over the course of our lives develop some, what we call mutations or changes in the coding that tells them what to do. That allows them to start mounding up more than they should.

And when they're doing that, they're actually replicating. They're making copies of themselves more and more than they should. And each one of those copies that they're making has the potential to have other changes that eventually allow it to not only mound up and kind of bulk up in the area that it's not supposed to be, but start to invade into the wall of the bowel.

And that invasion is what changes these from what's a polyp into cancer. And so we know that one of the things that causes those changes is in any sort of inflammation in the body, which is why, again, those unhealthy lifestyle choices, they contribute to more inflammation in your gut, which can make cause these changes. Another thing that can, we know that can cause us are certain infections. And there's actually been a recent study that showed that some people with early colon and rectal cancer, they had exposure to a certain type of bacteria earlier in life that may have caused more inflammation.

We're still very early in trying to determine, ways that we might be able to use that to either help identify people that may be at more at risk for colon and rectal cancer or even preventing it be to with that knowledge. But it's a promising start in trying to figure out exactly what's causing this.

Host: You've mentioned some environmental factors, other issues like that, but what about, family history and genetics? How much does that play into the equation?

Kenley R. Unruh, MD: So the vast majority of people, about 70% of people under the age of 50 who get colon and rectal cancer, they just get it out of bad luck. It's hard to say exactly what caused them to get it. But we've found that only about 30% of people have a close relative, especially someone in their immediate family who's had colon and rectal cancer.

And so we think they have more of a genetic what we call predisposition to getting that cancer. And only actually about 15% of younger people especially who get colon and rectal cancer have a mutation that we can identify that put them at risk for that. So again, the vast majority of this is just bad luck.

Host: And bad luck happens to us all, I mean, we're speaking about young people and then this increase in amount of colorectal cancer they're seeing. So I'm thinking about specific risk factors for young people, because at least in my head as a 57-year-old man, I assume that the younger generation is, more healthy and aren't, the smoking is down significantly, so, but maybe I'm wrong about all that. What are the specific risk factors that are more prevalent in these young patients?

Kenley R. Unruh, MD: You'd actually be surprised, Evo, the rate of obesity in our country is only increasing and that's one of the, one of the major risk factors for this. And so yes, smoking is definitely way down, which is wonderful. But one of the things that we're uncertain about is how much things like vaping play into this, because there are still some causes of that inflammation that we know come from these other alternative ways to get nicotine. And so we're still trying to determine how, if, how much of a difference there is between vaping and smoking with regards to people's cancer risks. But again, it's the more sedentary, the more unhealthy lifestyles with obesity, eating more refined foods, especially those high in sugar, that is still incredibly common in young people. And so the more that we can start educating people, especially as children, as early as grade school, you know, and to be more active, to eat a more balanced diet with whole foods, and then showing them some of the risks that come with increasing their alcohol use as an adult or even starting alcohol use earlier in life and especially smoking too. Just showing them just some of the impacts they can have long term is going to be essential in helping to curb this trend.

Host: You brought up obesity and said that it's actually increasing, but at the same time, I know that we have these new GLP-1 agonists that are terribly expensive, but more people are getting on them all the time. Do you see a balance there?

Kenley R. Unruh, MD: You bring up a great point, Evo, that there are great ways that we're working to try and curb obesity. For a lot of people, these GLP-1 agonists are a game changer. Allowing them to be able to finally get those, that weight off that they've been struggling with for a long time. We don't know the long-term effects of these medications though, and we don't know how they play into the people's cancer risks. We do know that people who've lost weight over time, their cancer risk does go down. So we know that that helps. It's just needed to be balanced with the more knowledge about what the long-term effects of these medications might be.

But, for a lot of people, it's definitely, worth considering as part of a healthy lifestyle with exercise and a healthy diet to help with that weight loss.

Host: That's great. And as you say, these are relatively new. There's a new research as everybody, so I guess we'll find out in a few years what these studies are going to show just from population studies. Let's talk about public health for a moment and these risk factors for young people getting more of these types of cancers. How can we educate the public and promote preventative measures?

Kenley R. Unruh, MD: Well, one great way is educational programs just like this podcast, just people talking about it. We've been also working with primary care doctors, so you know, that see a lot more patients on a daily basis and trying to get ahead of this as well as other educational programs through schools.

Again, to start, you know, while people are young and just really trying to make it more of a normal part of conversation, especially because a lot of people don't talk about this as part of their health. They don't talk about, oh, it's time to go get my colonoscopy. You know, it's not something anyone looks forward to.

It's not, you know, a lot of people, almost sometimes feel shame about something like that, even though it's a very important part of their health and it's a very important step in preventing these diseases. And that's the other thing I'd like to point out is that there are a lot of different ways to screen for colon cancer.

Sorry, I just realized that's, that's probably our next question. So I can also just stop before that. Because I know you're probably going to bring that up.

Host: Yeah. That's exactly is where I am headed next about screening recommendations. You've already said that 45 is the new 50 for what we're recommending people. I say this as a 57-year-old who has had two different colonoscopies because they did find polyps in me. But just to clarify, that is 45 the right number for everyone?

Kenley R. Unruh, MD: So it's the right number for most people. If the majority of people that don't have any family history of colon cancer or colon polyps, especially in someone who's in your immediate family. So your mother, brother, father or sister and then, who've never had any symptoms either. And that's a key here, is that if you've ever had bleeding from your bottom, if you've had a major change in your bowel habits, if you have unexplained abdominal pain, it does not matter what your age is.

You should see a doctor and you should really consider getting a colonoscopy, especially if you're over the age of 35 and you have any of those symptoms. I tell every one of my patients at that age with any of those symptoms, you have to get a colonoscopy.

Host: So as we think about screening, and look, as you said, a lot of people are embarrassed to talk about this. They don't want to talk about it. But again, I've had two of these, and all of my friends made me feel like the prep was going to be the most miserable thing on the planet. And then it was so overblown. The whole, it was the, it was one of the easier procedures I've had done. So is it fun? No. But is it terrible? No. But what about new screening tests that are being explored for younger adults?

Kenley R. Unruh, MD: No, that's a great point. There are multiple ways that people can technically screen for colorectal cancer. There are multiple stool studies. The most common one people hear about is called the Cologuard test. And then there's also other tests that are looking for specific signs of bleeding in your stool.

There's also actually even a special CT scan that you can get that helps to look through your colon. But all in all, the one problem with all these other types of tests is that they're looking for either what's called an advanced polyp, so that precursor overgrowth that can lead to cancer, but it has to be pretty advanced.

It has to be pretty large to be able to identify it. Or a cancer that's already there. That's what both of these are looking for. So if you think about it, if you're doing any of these other types of tests, especially a stool-based test, you're kind of behind the eight ball, if it finds something, you might already have the cancer.

It's just going to help identify it earlier than you might have otherwise. The major difference with colonoscopy is that it can actually prevent cancer. And it truly is one of the only things that we know in all of medicine that can truly prevent cancer. There's a huge population studies that showed once colonoscopy screening became more common, and we go in there and we find polyps and we remove those polyps; the overall rate of colon and rectal cancer in the population went down. So we are truly preventing it, and that's one of the main things that is not brought across. People are just like, oh, well if I have to take this horrible prep, I have to get sedation, I have to take a whole day off of work. All these things.

I'd rather just do a stool test, but it's really not the same. It's apples and oranges and one prevents cancer, and the other one is just trying to catch it earlier after it's already formed.

Host: Yeah, and the earlier we can get in for anything, obviously, especially when we're dealing with cancer, is the better. So let's think about that for a second. When we do have a situation where we see rectal cancer, not just polyps, but rectal cancer in these younger patients, is there a change the treatment procedure as the young people as opposed to old dogs like me?

Kenley R. Unruh, MD: Not totally. There are different considerations, but the way that we treat it is usually the same. It really depends on when we catch the cancer, if it has started to spread anywhere, if it has, how far, things like that. But we do have some other considerations for younger patients. And main one is impacts on people's lifestyle because some of the different treatments that options that we have can have significant impacts on people's bowel habits, on their ability to do certain activities, things like that. So we definitely bring that into consideration. And then also a main one is people's fertility, their ability to have children. It can be greatly impacted by many of these treatments because we're treating a cancer that's right next to those reproductive organs, especially for women.

So it's something that we bring up and that we really try to work with patients to find a balance between the ability to have children long term, but also treating their cancer as best we can.

Host: And that's a decision, and then a conversation that's going to be different for everyone obviously. But long-term health consequences of cancer is not good. So we definitely want to make sure we're getting people screened. Dr. Unruh, thank you for the great information today and I hope the listeners, will take advantage of this and go get tested like now. Now's good.

Kenley R. Unruh, MD: Of course Evo. Yeah, happy to help spread the word and happy to help anyone that seems to have any of these issues crop up anytime in their lives.

Host: Once again, that was Dr. Kenley Unruh, a colorectal surgeon at Skagit Regional Health. For more information, please visit skagitregionalhealth.org. And if you found this podcast episode helpful, please share it on your social channels and check out the full library of episodes for topics of interest to you.

I'm Evo Terra and this has been Be Well with Skagit Regional Health. Thanks for listening.

Sources:

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1:27 - Siegel RL, Wagle NS, Cercek A, Smith RA, Jemal A. Colorectal cancer statistics, 2023. CA Cancer J Clin. 2023 May-Jun;73(3):233-254. doi: 10.3322/caac.21772. Epub 2023 Mar 1. PMID: 36856579.
 
5:27 - Sinicrope FA. Increasing Incidence of Early-Onset Colorectal Cancer. N Engl J Med. 2022 Apr 21;386(16):1547-1558. doi: 10.1056/NEJMra2200869. PMID: 35443109.
 
5:36 - Sinicrope FA. Increasing Incidence of Early-Onset Colorectal Cancer. N Engl J Med. 2022 Apr 21;386(16):1547-1558. doi: 10.1056/NEJMra2200869. PMID: 35443109.