Joey Wahler (Host): It's the leading cause of cancer deaths in younger people. So, we're discussing early-age onset colorectal cancer. Our guest is Dr. David Blumberg. He's a colorectal and general surgeon at the medical group at Montefiore St. Luke's, Cornwall.

Joey Wahler (Host): This is Doc Talk, presented by Montefiore St. Luke's Cornwall. Thanks so much for joining us. I am Joey Wahler. Hi, Doctor. Welcome.

David Blumberg, MD: Hi, how are you?

Host: I'm good yourself?

David Blumberg, MD: I'm doing well. Thank you.

Host: Excellent. We appreciate the time, Doctor. So first, when we say early-age onset colorectal cancer, what age do we mean?

David Blumberg, MD: So, we're talking about people younger than the age of 50, and we're seeing an alarming trend in that more and more patients under the age of 50 are getting colorectal cancer. Alarmingly, survival appears to be worse in this age group.

Host: Why is that? Is that known?

David Blumberg, MD: Yeah, it appears that patients are presenting at a later stage. It's part and parcel that screening is generally not recommended in this group. And oftentimes, warning signs are dismissed.

Host: So, what are those warning signs?

David Blumberg, MD: So, there are five typical warning signs that should never be ignored, even in the young patient. And those include rectal bleeding, anemia, a change in bowel habits, abdominal pain, or cramps and weight loss. Oftentimes, rectal bleeding is assumed to be hemorrhoids in this group. It should never be assumed. Anemia is often written off, particularly in the young female who is having heavy menstrual periods. But if it's persistent, you need to see a doctor. If there's a change in bowel habits, sometimes it's felt to be due to a change in diet or seasonal changes, but we shouldn't assume that. And abdominal pain or weight loss that is prolonged or unexplained needs to be investigated.

Host: It is possible that someone could have no symptoms at all. Correct?

David Blumberg, MD: That's correct.

Host: And that's one of the things that makes this tricky, isn't it?

David Blumberg, MD: That makes it tricky, and that's why, you know, we try to screen patients. The screening has moved from the age 50 to now age 45 from the American Cancer Society.

Host: Before we talk about screening and colonoscopy, et cetera, can you give people an idea, Doctor, of just how much of a difference early detection can make here in terms of diagnosis as opposed to catching colorectal cancer in later stages when it could be life-threatening to say the least, right?

David Blumberg, MD: And that's a great point, Joey. So if we catch it early via screening, it saves lives. And that has been shown in the general population in the past.

Host: Typically—am I right doc? If someone has later stage colorectal cancer, it's usually because they're long overdue for a colonoscopy and perhaps they've never had one period, yes?

David Blumberg, MD: That's true. Many patients are not either getting a colonoscopy or other alternative tests that we certainly can talk about, and that we offer here at the cancer center.

Host: So, timely screening is therefore crucial, and the gold standard there is a colonoscopy. So, when should those start for most patients? And who's at high risk where they may need more frequent screenings. And you mentioned a moment ago, the minimum suggested age has changed in recent years.

David Blumberg, MD: Yes, exactly. So, the minimum age has now been moved to age 45. And as you point out, there are high-risk individuals. And those high-risk individuals are those who have a family history, a family history of polyps or family history of a colorectal cancer. Those patients who have families or personal history of inflammatory bowel disease or some genetic syndromes that we see in the community as well.

Host: So if you're the average person that's not high-risk, let's say you've gone for your first colonoscopy, when typically would you be due for another? And then, when might you be due sooner than that if you are considered high-risk?

David Blumberg, MD: Right. So for the average risk patient, the guidelines are generally, if the colonoscopy is negative, we do seven to 10 years from that colonoscopy. And then, for the average risk patient who then gets diagnosed with polyps, depending upon the size of the polyps, depending upon how many there are, and depending upon how aggressive the polyp is—in other words, was their pre-cancer in that polyp—will then determine their frequency. And the guidelines vary based on those factors.

Host: Gotcha. So colonoscopy, something I've had done multiple times, it gets a bad rap, doesn't it, doc? Because people fear it. They might be embarrassed to get one the first time around, but it's really nothing, isn't it?

David Blumberg, MD: All of the colonoscopies, we do under sedation, it's a very safe procedure, but yet there are a number of people that are squeamish about the procedure because it is certainly an invasive procedure. And that's why alternatives have been developed for those patients.

Host: And we'll talk about that in just a moment. But first, give people an idea of what a colonoscopy involves in terms of the prep and the procedure itself. Because I know personally, and I think I speak for most, the prep is more challenging for the patient than the procedure, isn't it?

David Blumberg, MD: Right. So, there are a number of more gentle preps. There are a variety of preps. A patient needs to take the day off from work the day before, because obviously you're going to be going to the bathroom quite often. So, it's to purge the colon of all the stool so we can visualize the colon well, the prep takes about a day. And then the next day, the patient will come into the endoscopy suite. We'll see our anesthesiologist or nurse anesthetist. We'll undergo conscious sedation. And the procedure usually lasts 30 minutes in which a flexible tube with a videoscope, a video monitor is used to visualize the inside of the colon. And what we're looking for is either early cancers or pre-cancerous, which we call polyps, so that we can remove them before they cause a problem.

Host: In terms of having the procedure done, once you get to the actual procedure, one moment you're awake; the next moment, you're put under. And the moment you know what's going on next, it's all over with, right?

David Blumberg, MD: it does seem that way, having been a patient myself. I'm over the age of four to five certainly, and I've had several colonoscopies. So, I can speak not just as a doctor, but I can also speak from the patient experience point of view. And I can tell you that I didn't feel anything. I woke up in recovery, just as you said, and it was over. So, it was very quick and I was happy that I had my colonoscopy, and everything was good.

Host: You touched on it, but just to elaborate a little bit, please, you mentioned a colonoscopy can reveal less serious things like a precancerous polyp. And so, this isn't just to detect cancer, it can ward off some other things too, right?

David Blumberg, MD: Exactly. And what we do know is by the age of 50, about one in four people will get polyps. And so, it is such a common problem that you really need to either get that colonoscopy or have an alternative to the colonoscopy to make sure you don't have polyps.

Host: Absolutely. Now, another thing you mentioned a moment ago, there is an alternative screening method to the colonoscopy, but not considered as accurate, right?

David Blumberg, MD: Correct. So, there are a number of tests that we can do, which are either invasive, similar to the colonoscopy or stool-based tests. And just to give you a quick rundown with the stool-based tests, the stool-based tests are perfect for that person who's gun-shy, who doesn't want to have an invasive procedure.

And what we're trying to detect is either microscopic blood or cancer cells in the stool. Our early detection program offers these stool-based tests. In addition, barium enema as well as a virtual colonoscopy is another alternative to visualize the colon in a less invasive matter. in other words, dye is either placed in and x-rays are taken of the colon to visualize the colon or dye is placed in And then a CAT scan is done. And once again, not as accurate as a colonoscopy, but a good alternative.

Host: And then, getting back to colonoscopies for just a moment. A colonoscopy can also reveal other conditions that are present, right, like colitis and some others. True?

David Blumberg, MD: Absolutely. So on a colonoscopy, we can see Crohn's disease. We can see colitis, we can see diverticulitis, we can see strictures of the colon, which are narrowings in the colon. You know, it is the gold standard because we're actually visualizing with our eyes the entire six feet of length of colon.

Host: Yeah. We should make sure that registers with those joining us. Think about it, folks, six feet that are kind of folded up in there. That's a lot of colon where there can be an issue, right?

David Blumberg, MD: But just remember, you'll be sedated. You won't feel the six feet.

Host: Yes. A good thing to keep in mind. Now, if someone is diagnosed with colorectal cancer, what surgical services do you offer?

David Blumberg, MD: So, we offer the full complement of services, including our cancer center, where we have medical oncologists, radiation oncologists, as well as immunotherapy. So for those patients who have colon cancer, surgery is the mainstay of treatment. So, we just take out the colon, where the cancer is, as well as the lymph nodes. And what we offer is specialty in minimally invasive surgery, which is either laparoscopically done or robotically done. And that basically allows us to perform the surgery with very small incisions. By doing this with small incisions, it's a quick recovery for the patient, and it does not compromise the results.

If it's a rectal cancer, what we have to be concerned about, and especially in the young patient, because one-third of those cancers in the young patient are actually in the rectum. So, the overriding concern is not just cure, but do you need a bag? Do you need a colostomy? And with the combination of radiation, chemotherapy, and sometimes immunotherapy, sometimes you don't even need surgery. And we offer all those services. And if surgery is needed, we can provide it in a minimally invasive fashion. In addition, we have specialized techniques to try to save the muscles or the sphincter muscles to avoid a colostomy or permanent colostomy or permanent bag.

Host: Obviously, that's something that many people have utmost in their minds in terms of results. Finally here, Doc, in summary, all of the above that you just mentioned, again, to reiterate, much, much less of a chance that any of that has to happen if you go for regular screening. So, what would you say to those joining us in conclusion here? Someone that may be putting this off, that may be thinking, "Ah, I feel fine. Leave it alone." That's the wrong way to go, right?

David Blumberg, MD: Yeah. So, it's very important once again to not discount any of those five key warning signs, and sometimes physicians will discount that also. Because we see a young, healthy, vibrant person who's having a little bit of rectal bleeding. So, you say, "Oh, it's just hemorrhoids." But if you are having rectal bleeding, if you're having anemia, if you have a change in bowel habits, if you have any constipation or if you have abdominal pain or weight loss, see someone like myself get checked out, get the colonoscopy, avoid a cancer.

Host: Very, very well said indeed. Well, folks, we trust you are now more familiar with early stage colorectal cancer. Doctor, keep up all your great work. Hopefully, those joining us heed your warning, and thanks so much again.

David Blumberg, MD: Thanks for the opportunity to speak.

Host: Absolutely. And to reach Dr. Blumberg for an appointment, please call the medical group at Montefiore St. Luke's Cornwall at 845-458-4847. Now, to learn more about colorectal and other primary and specialty services, please visit slcmedgroup.com. Please remember to subscribe, rate review this podcast and all the other Montefiore St. Luke's Cornwall podcasts as well. If you found this episode helpful, please do share it on your social media. And thanks so much again for being part of Doc Talk, presented by Montefiore St. Luke's Cornwall.