Cheryl Martin (Host): Colorectal cancer is on the rise in young adults. Here to talk about why, the warning signs, the risks and more is Dr. David Blumberg, a Colorectal and General Surgeon at the Medical Group at Montefiore St. Luke's Cornwall.

 This is Doc Talk presented by Montefiore St. Luke's Cornwall. I'm Cheryl Martin. Dr. Blumberg, thanks for coming on.

David Blumberg, MD: Well, thank you for allowing me to be here, Cheryl. I'm very excited to answer all your questions regarding this problem.

Host: Great. So first of all, tell us more about yourself.

David Blumberg, MD: So I am a native New Yorker, born and raised. Did a number of years of training here and I just moved back from Baltimore, to the area. I'm a Colorectal Surgeon as well as a General Surgeon. I've been doing this for 35 years and my expertise is in treating patients with colon cancer and rectal cancer, and I'm an integral part of Montefiore Health's Cancer Center and network.

Host: So why did you decide to become a colorectal surgeon focused on treating colorectal cancer?

David Blumberg, MD: I took a real personal interest in cancer when I was in my first year of medical school. And unfortunately, my father was diagnosed at an early age with a advanced cancer. And I saw the patient's perspective and not having any real tools to help him. I was really his advocate, navigating the medical centers down in Manhattan, getting treatment.

And, since that time, those sort of formative years, as a medical school trainee and with those personal experiences, I elected to pursue a career in cancer surgery. Spent a couple of years at Memorial Sloan Kettering training in the 1990s, and I realized that many patients with colorectal cancer could be cured.

And so then I pursued a fellowship at the Ochsner Clinic in colorectal surgery. And then I was very fortunate to be recruited first right outta training to the University of Pittsburgh Medical Center and the Hillman Cancer Center where I spent approximately 15 years of my initial career.

Host: You have a broad range of experience and it's clear that you're passionate about what you do. So tell us what is colorectal cancer and how does it occur?

David Blumberg, MD: So simply, colorectal cancer is a cancer that occurs in the large intestine. And the large intestine is basically an organ that is six feet in length. It's primary function normally is to absorb water and store stool. The colon is divided into the colon, and the last portion being the rectum.

And the majority of colon cancers start as small polyps and polyps are benign initially until they undergo changes, and that period usually takes four or five years for the average person who has a colon polyp for it to become cancer. It's very significant to know that, you know, patients who develop a cancer really can be detected at an early stage when it's only a polyp. So screening can be preventative in patients, if you can diagnose patients at an early stage when they only have polyps.

Host: So how common is colorectal cancer?

David Blumberg, MD: So colorectal cancer is unfortunately very common. So if we look at the worldwide incidence, it's about 1.8 million cases annually. In the United States, it's roughly 150,000 cases. And, it's not too surprising because the average population with no risk factors, roughly 15 to 40% of people will develop colon polyps.

And so, unfortunately many of those patients develop cancers if they don't undergo screening. The other important aspect of this cancer is that it is the third most common cancer and also the second most common cause of death, despite the fact that screening has been around for many decades.

Host: So once again, just because a person gets polyps, it doesn't mean that those polyps will become cancerous.

David Blumberg, MD: Right, and thanks for clarifying that. So, there are several different types of polyps. So there are adenomatous polyps, there are hyperplastic polyps, and depending upon the type of polyp, some polyps will become a cancer ultimately. Some have a very low risk of becoming cancer, but the key is to identify them with some sort of tool, whether it's a colonoscopy or other tools that I'm sure we'll get into in this program, talking about, to detect those polyps so that they can be removed before they become a cancer.

Host: So after the colonoscopy, the doctor, the physician is able to look at the polyps and say, this one will never become cancerous. These possibly will?

David Blumberg, MD: So with all polyps that are removed, they're all submitted to the pathologist. The pathologist will then look under the microscope and he will determine if a polyp is a benign polyp or if it's a polyp that has cancer, the beginning of cancer, which we call dysplasia, or if it's truly a polyp that has cancer in it. And then we can define the risk of whether or not the patient needs additional colonoscopies in the future and what their risk of needing other surgeries are. If certainly if they have a cancer, they may need surgery after that colonoscopy as well.

Host: Now what is early age onset colorectal cancer?

David Blumberg, MD: So, you know, as you alluded to in the beginning of the program, we're here to talk about a subsegment of patients who have colorectal cancer, and this is the early age onset and in the past, most cancers were occurring after the age of 50. And so all of the screening guidelines for colonoscopy were really geared to that segment of the population.

And over the past 20, 30 years, we've noticed a dramatic increase in patients under the age of 50, what we call early age onset colorectal cancer. So these are patients that are getting cancers in their twenties, their thirties, and even in their forties. And right now, currently in the United States, there are approximately 15,000 patients that are just early age onset colorectal cancer, meaning, really millennials, in their thirties, forties that are getting these cancers.

Host: Why is that?

David Blumberg, MD: It's really tough to wrap our arms around why patients are getting them at such an early age, but clearly, there are changes, hereditary as well as environmental. And then there are certain risk factors that seem to be associated with that including obesity, a diet rich in meat and low in fiber, lack of exercise. We think the processed foods, alcohol and smoking. Certainly family history plays a part and then conditions such as Crohn's disease and colitis will play a part as well.

Host: Now, what are you finding in terms of how early age colorectal cancer may be different?

David Blumberg, MD: This is really the heart of the matter. It's not just that the kids are getting it earlier. And I call them kids because I'm sort of a later age onset, although I've never had polyps fortunately, but I'm over 50.

And so for the young patients, we're finding that they get more of the rectal cancer and with rectal cancer, compared to the older patients. And with rectal cancer, the treatment which we'll get into, I'm sure, is more complicated. And then there's always the threat that if the cancer is very advanced, you may need a colostomy. So you can only imagine a 20-year-old who gets diagnosed with a rectal cancer, and then you have to tell him he needs a colostomy.

And then on top of it, we're seeing patients with very advanced stage disease when they're younger, and it's not surprising because a young person who has, for instance, rectal bleeding, we used to assume it's just hemorrhoid bleeding, and they may be more dismissive of that bleeding, but it's crucial for patients and people who are younger age who have symptoms to really be evaluated by someone like myself to make sure that it is only hemorrhoids and not a cancer. Because by delaying diagnosis, then the tumor can grow locally and it can spread to other organs.

Host: So talk about the symptoms and warning signs, especially for young adults since they are not even thinking about getting a colonoscopy at their age.

David Blumberg, MD: Exactly, and such an important thing. So for a young person who has rectal bleeding, don't think hemorrhoids. If you're having constipation or diarrhea, don't think it's just your diet. Certainly if it persists, you need to seek out help. If there's any change in bowel habits, any abdominal pain, if the stool becomes narrow, these are all signs that you know, something's not right. And it may not just be something like hemorrhoids, so you really need to get to see a practitioner.

Host: Now is early age onset hereditary or environmental?

David Blumberg, MD: We think it's probably a combination of hereditary and environmental. However, with that said, if you look at the younger people who develop colon cancer, 30% of them, will have a hereditary component where in comparison, the older people who develop colon cancer, it's only about 5%. So hereditary and genetics really plays a very strong role in terms of those younger people developing cancers.

Host: So what do you say are the more common hereditary colorectal cancers?

David Blumberg, MD: Yeah, so there are two very distinct syndromes, if you will. One is called Lynch syndrome and one is called familial adenomatous polyposis. And the importance of identifying this is not just for the person who develops colon cancer, but it may also affect all family members. So it's very important to identify these syndromes. And so if patients, for instance, with Lynch syndrome, if they've had a colon cancer diagnosed, we always take a good history, want to know if they've had anyone in the family that might have uterine cancer, ovarian cancer, or gastric cancer. Because that signifies to us a red flag that they need further testing that they may have Lynch syndrome. For patients with familial adenomatous polyposis, a little less common than the Lynch syndrome. Those patients can have pancreatic cancers in their family, as well as also develop a pancreatic cancer within their lifetime.

Once again, important to then establish a pedigree, which is the family tree to see who in the family had other cancers, and then really to sit down with our geneticists at our cancer center to see what other tests may be useful.

Host: I'm glad you brought up genetic testing. Talk about what it is and whether it can be done. Talk about it being done at Montefiore St. Luke's Cornwall.

David Blumberg, MD: So first of all, many patients get scared when we hear genetic testing because we fear that if the genes are identified and that they may get discriminated and there's federal law protecting patients, and this information is all protected. And so the key is knowing that you are protected under the law and then going the next step to protect yourself and protect your family because this is a disease that is generational.

And so at the Cancer Center, what we do is we can test patients, based on, there are saliva tests. There are blood tests and then any polyps that are removed can also be tested and are routinely tested. And this is critical. So for instance, just to personalize this, we just had a patient who was 38 who had diagnosed with unfortunately a late stage colon cancer.

We think with a lot of therapy he will ultimately get cured. And, he didn't realize that all of his family members were probably connected, and had Lynch syndrome. He had a brother who he lost at a very young age to colon cancer. He had a parent who died of gastric cancer, and so all of the genetic testing is currently being done.

And will protect him and then protect his next generation because his children can be tested. And then guidelines for screening those people who have the gene can then be determined and we can treat not just him, but his whole family.

Host: That's great. Now, you mentioned before about lifestyle changes when I asked, you know, why. So what is the best way to prevent getting colorectal cancer?

David Blumberg, MD: So we think the best way of preventing is screening, screening and screening. And in the past it used to be 50, for the general population. And when I say screening, it means either getting a colonoscopy or other tests that we can certainly talk about. There are other alternatives to the colonoscopy, but a colonoscopy basically is we do a bowel prep to clean the stool out of the colon.

It's done with sedation and we're looking in the colon with a scope for those polyps at an early age. As I mentioned, age 50 used to be the guidelines for the general population. For someone who has no risk factors, no family history of colorectal cancer, screening guidelines have changed, so we screen patients at age 45 now. For those who have a first degree relative or risk factors, we screen them at age 40 or 10 years prior to when their relative may have been diagnosed with colon cancer. So just to give you a real example, so for the patient who I discussed with you who was just 38, 39 years of age being diagnosed with colon cancer, all of his first degree relatives would get screened at age 28, with colonoscopies. And then for certain syndromes such as FAP and Lynch, the guidelines are even much younger, in the twenties, to routinely get screened.

Host: So what if you don't want to get a colonoscopy? Are there other alternatives?

David Blumberg, MD: So not everyone wants a colonoscopy and it's important to get screened, one test or another, and so we should go through those tests. So a colonoscopy is a visual test. We're putting a scope in, we're looking. There are other tests that are just stool-based, where we're looking at the stool and we're trying to detect either blood or DNA that is abnormal.

And, DNA in the stool can be shed from tumor cells that are in the colon. And that can be detected. So the most well-known test is called the Cologuard, which is a stool-based test. It detects blood, it detects DNA, it's really only meant for the average risk patient, not a high risk patient.

So in other words, a patient who has first degree relative with colorectal cancer, it's not generally recommended for those patients, but for an average risk person with no risk factors, no family history; every three years, the Cologuard can be done and it's simply the stool that's tested.

Now the drawback though is that there are some high false positive and negative readings. So if the test is positive. You still need a colonoscopy. And the other drawback is that some insurances may not cover a colonoscopy after Cologuard, unfortunately. But it certainly, it is an alternative to think about.

There's also, just checking the stool for blood, which is called a FIT test. And basically it's similar to the Cologuard, but it just looks for blood and that can be done every year. And then for those people who they want a little bit more fidelity in terms of knowing if there's polyps or a cancer being detected, we can do what's called a virtual colonoscopy, and that's done with a CT scan. So the patient actually doesn't need physically to have a scope placed into the colon. And the CT colonography is very, very sensitive at looking for polyps and detecting them. It's done in the hospital and that's recommended every five years as an alternative to colonoscopy.

The drawback is that if the CT colonography or virtual colonoscopy, which we call it, detects something, then you still need a colonoscopy to remove that polyp. But it's, definitely a nice alternative to think about. And I would just once again advocate, you know, to the general public, that some form of screening, should be done on a routine basis because, 15 to 40% of people who have no risk factors will end up within their lifetime of having colon polyps. So we really have to keep up with our colon health.

Host: So doctor, what is the treatment if someone is diagnosed with colorectal cancer?

David Blumberg, MD: In general, the treatment is divided into those patients who have tumors of the colon and those patients who have tumors of the rectum. So the treatment for colon cancer is usually more straightforward in that most patients, after they undergo a staging. So a staging means, a physical examination, a CAT scan, and a blood test to make sure that the tumor hasn't spread anywhere.

If it hasn't spread anywhere, then surgery is usually indicated for those with colon cancer. For rectal cancer, it tends to be more complicated in that we tend to use a combination approach for more advanced rectal cancers that haven't spread to other organs where there's surgery, radiation, chemotherapy, and also immune therapy.

And so just to sort of give you various scenarios. So for early stage rectal cancer, after staging, once again, we would do a physical exam. We do a blood test called a CEA level, we get a CAT scan and in addition for rectal cancer, we also get an MRI of the pelvis to look at the tumor.

If the tumor looks like it's an early stage tumor where it's just localized to the rectum, it hasn't spread anywhere, surgery often can be done as a curative approach, and then we can check the pathology, and if the pathology shows that it truly was an early stage tumor, then no additional treatment is needed.

If it's more of a locally advanced tumor, meaning it goes into other organs, we generally try to shrink those tumors with radiation and chemotherapy. Sometimes we do have to have surgery after that, but there are times where radiation and chemotherapy alone can be curative. For patients who are Lynch syndrome patients, there is new immune therapy drugs that can be used in lieu of the radiation and chemotherapy, or sometimes with the radiation and chemotherapy and oftentimes can avoid surgery completely. And for those patients who have spread to other organs, a combination of chemotherapy and immunotherapy are used, and sometimes surgery as well.

And all of these decisions I will tell you are not made by a single individual. So we have a multidisciplinary tumor conference. If a patient comes to see me with either colon cancer or rectal cancer, we present that person, and their situation and all of their scans within a conference that's attended by a medical oncologist, a radiation oncologist, a pathologist with all of the tests. So everyone is there to weigh in on what the best treatment is and what the best sequence of those treatments are.

Host: Now, are any of these surgeries performed minimally invasively?

David Blumberg, MD: Yeah, so for colon cancer as well as rectal cancer, my specific expertise is for laparoscopic and robotic surgery. We do the surgeries at Montefiore St. Luke's, as well as Montefiore in the Bronx for more complex cases. Our colleagues and we participate with them in terms of our tumor board and some of those patients will go there for their surgery. And the great benefit is it's small incisions. The recovery's much easier. The surgery is very safe, and a number of us have spent our careers perfecting those techniques, including myself when I was at the University of Pittsburgh Medical Center, to make sure that those techniques are safe for patients.

And, all of the studies for colon cancer as well as rectal cancer have shown, that a minimally invasive approach is not only safe, but probably more beneficial than an open cut.

Host: So are all the treatments you're talking about available at Montefiore St. Luke's Cornwall Hospital?

David Blumberg, MD: So I will say with the caveat that we have our comprehensive cancer center, that's accredited from the Commission on Cancer. We do all the treatments, some of the more advanced surgery that requires patients who have a, for instance, a rectal cancer that might need other organs out or a portion of their liver removed. Our department is sort of interdisciplinary in terms of surgery. And so our colleagues at Montefiore in the Bronx, will then do their surgery. But the majority of treatments are available at Montefiore St. Luke's.

Host: That's great. Now, you mentioned before, colostomy. So if you get rectal cancer, does that mean you need one or what are the other options or alternatives?

David Blumberg, MD: I will tell you this is such an important topic because when patients come to our office, they are scared, right? They just have two questions in their minds. One is, am I going to get cured? And do I need to have a bag or a colostomy? And nobody wants a bag or a colostomy. And so the treatments, the techniques, whether they're surgery, radiation, chemotherapy, or immunotherapy, we're lucky to be in a state, and I don't mean New York state, but the state of the art is that things have advanced so much, that many patients who were ordinarily the only option was a colostomy in the past; we can save them a colostomy. So many patients can avoid surgery, many patients can avoid a colostomy. The techniques, there for removing sometimes tumors just through the anus. There are pull through techniques that we perform to allow patients to still have control of their bowels and not have a permanent bag.

The radiation techniques as well as the chemotherapy are now shrinking these tumors and curing them alone in many patients. And then there's dramatic results for those patients who fall into the Lynch syndrome, where the immunotherapy has had a remarkable track record of shrinking and curing them without any therapy other than immune therapy alone for many patients as well.

So, this is definitely good news for patients who are diagnosed with rectal cancer these days. Once again with the caveat that you gotta get screened early, detect those cancers early, because if it's locally advanced or if it's spread to other organs, then it makes things more complicated and there's a higher chance of needing a colostomy in those circumstances.

Host: Great, information. So just as we wrap up, any other advice you have for patients with a family history of cancer and also the advice that you may have for young adults? Anything else you want to add for them to prevent colorectal cancer?

David Blumberg, MD: So for patients with a family history of cancer, the key is to know your risk. And what I mean by that is to really sit down with either someone like myself or a genetic counselor and really know who in the family had cancer, what cancers they had, how many first degree relatives, is there potential that there is a genetic syndrome going on, such as Lynch or FAP, a familial adenomatous polyposis.

And then to determine not only should we be doing genetic testing, but after getting all of those results, figuring out a plan moving forward, not just for the individual, but the family in terms of screening. For young adults to prevent colorectal cancer, I think the key is if you have any symptoms, just get on the phone, make an appointment, and get checked out.

Don't assume it's hemorrhoids because unfortunately we're seeing a lot of patients, who have rectal cancer, when we thought or they thought that it was just hemorrhoids.

Host: And this is an important question, doctor, how can patients reach you for an appointment?

David Blumberg, MD: Yeah, so the best way to reach us we're located in Cornwell, and our offices are available, the telephone number, right on the website, on Montefiore Health St. Luke's. And you can find me there and make an appointment even if you're not sure, and we're happy to help out in any way.

Host: Dr. David Blumberg, thank you so much. You have shared such vital information about colorectal cancer. Thank you.

David Blumberg, MD: And thank you for inviting me, and I hope to be of service to the community in keeping people well.

Host: Well, you already have been. Thank you for being on this podcast. You can learn more about our colorectal and other primary and specialty services at SLCMedgroup.com and please remember to subscribe, rate, and review this podcast and share it on your social media. You can also check out our entire podcast library for other topics of interest to you.

Thanks for listening to Doc Talk presented by Montefiore St. Luke's Cornwall.