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Colorectal Cancer in Young Adults
Brian Ramnaraign, MD, discusses the clinical indications for screening colonoscopy in young adults. He touches on risk factors and treatment options available for young adults diagnosed with colorectal cancer.
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Learn more about Brian Ramnaraign, MD
Brian Ramnaraign, MD
Brian Ramnaraign, MD is an assistant professor of medicine in the division of hematology and oncology at the University of Florida College of Medicine.Learn more about Brian Ramnaraign, MD
Transcription:
Melanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole and join us as we examine colorectal cancer in young adults.
Joining me is Dr. Brian Ramnaraign. He's an Assistant Professor of Medicine in the Division of Medical Oncology at the University of Florida. Dr. Ramnaraign, it's a pleasure to have you join us today. Just start with by telling us a little bit about the prevalence of colon cancer in young adults. What do you see in the trends as far as that?
Brian Ramnaraign, MD (Guest): Sure Melanie and thanks for having me. So, colorectal cancer is actually much more common in older patients. However, since the 1990s at the very least, older patients have actually had decreasing rates of colon cancer. The numbers are actually going down, but in the younger population specifically in those under the age of 50, the rates are going up. And In fact, it is increasing at about 2% per year, the number of cases of colorectal cancer in this age group. So, it's definitely something we're very concerned about and something that we really want to shed more light onto.
Host: Why do you think that this is happening? And while you're telling us that, tell us some of the risk factors you can identify.
Dr. Ramnaraign: So, no one knows for sure exactly why the incidence of colorectal cancer is increasing in the under age 50 age group. But we do know that some of the risk factors for colorectal cancer have been getting worse, especially in younger patients. With regards to the risk factors for colorectal cancer, one of the big factors is genetic risk. However, that of course has been stable, over the decades, and that really only constitutes about 10 to 20% of the cases of early onset colorectal cancer. The most common genetic syndromes are Lynch syndrome or a FAP, familial adenomatous polyposis.
With regards to the actual risk factors that are, that are more common that we look out for; there are risks with regards to diet, risk with regards to weight, specifically a sedentary lifestyle. It gives you an increased risk of colorectal cancer and smoking. What we do see are increasing rates of obesity in this country, especially in younger patients, and a poor diet, a diet that lacks high fiber foods, a diet that is heavy in red meat are both risk factors that are going up and are seen in a younger patients, and may play a role in why these patients have higher rates of colorectal cancer.
Host: So, Doctor, we know that we have screening protocols from the US Preventative Services Task Force and other organizations, as far as screening for colorectal cancer in those 50 and older. I know myself, I've had many colonoscopies, but for young adults, what would indicate the need for screening? Are there symptoms that you've had patients come across? Is it just based on genetics? Tell us a little bit about clinical indications for screening colonoscopy in young adults.
Dr. Ramnaraign: Sure. So, anyone who's age 45, at average risk, should begin getting regular colonoscopies. Now the question is who should get a colonoscopy sooner.
Of course, if you do have some complaints, specifically blood in your stool, a change in your bowel movements, if you have abdominal pain; these could be symptoms of colorectal cancer and are definitely symptoms that you should bring up to your right primary care provider. However, these symptoms are very vague and non-specific, and could be you know for example, related more towards hemorrhoids, but they are definitely symptoms that shouldn't be ignored. And if these symptoms do persist, of course, a colonoscopy may be needed irrespective of how old the patient is. Of course, whenever a patient is seen in their primary clinic with their PCP, a thorough history, a family history, is needed. And if the patient has a first degree relative, so, that is you know mother or father, brother, sister, they should begin screening for colorectal cancer 10 years before that patient was diagnosed with their colorectal cancer or by age 40, whichever comes first.
With regards to the treatment for colorectal cancer, everyone is familiar with chemotherapy and the toxicities of chemotherapy, but here at the University of Florida Health Cancer Center, we're looking at other new options and investigational agents to tackle this disease. A lot of patients are interested in immunotherapy. And immunotherapy is actually a very good treatment option for patients. Right now, immunotherapy is approved by the FDA for the treatment of colorectal cancer, but that's only if a patient has a particular set of mutations that would predict a response. And we refer to these mutations as the microsatellite stability status or the mismatch repair deficiency status.
And patients who are microsatellite unstable or mismatch repair deficient, which really only account for 5% of these patients, are the ones who are eligible for immunotherapy. However, here at the University of Florida Health Cancer Center, we're looking at ways we can enhance the patient's immune system so that they can better benefit from immunotherapy. Studies are ongoing looking at clinical trials at this right now. We're also sending off patients' biopsies and tissues for next generation sequencing where we can look for specific targeted mutations that we can potentially target with specific drugs that bind to or block proteins from genes that may or may not be expressed in that particular patient, based on their genomic profile.
Host: So, now let's talk about treatments. Once you have diagnosed a younger person with colon cancer, what are some of the treatment options? Tell us a little bit about the difference that you might find between treating somebody younger versus treating someone older.
Dr. Ramnaraign: So, what we have noticed too, with younger patients with colorectal cancer is that a lot of them are presenting at more advanced stages. And this is probably because a lot of their symptoms are going ignored and are taken for more common things like hemorrhoids. With regards to treatment options, regardless of how old the patient is, it's usually a combination of surgery, chemotherapy or radiation therapy. When we discover that the patient has colorectal cancer, which is usually on biopsy of a tumor that's found in the colon or rectum, staging procedures are done. Staging images are done with CAT scans, commonly. If it is a very early tumor which is the whole point of getting screening colonoscopies; then surgery and only surgery is needed. However, if the tumor is more advanced, meaning that there's deeper invasion into the colorectal tract or if there's any suspicious lymph nodes that we see on imaging; the patient may need chemotherapy and radiation in addition to surgery.
And unfortunately, a lot of these patients are presenting with stage four disease and stage four means that the cancer has spread to distant organs or distant sites. If that is discovered, then the only treatment that we have is chemotherapy, and that's palliative chemotherapy. Chemotherapy meant to slow the growth of the tumor, of the cancer and to potentially give the patient more life expectancy than they otherwise would have. But once the tumor is stage four, chance of cure is low.
Host: Wow. That's quite a statistic. So, tell us a little bit about prognosis, if it's not stage four and also for some younger people as primary care providers and other gastroenterologists are working with these patients, fertility preservation may come up depending on the treatment regimen and how young they are. So, kind of tie a lot of this together for us as far as what you would like other providers to counsel their patients about when going through these kinds of treatments and diagnosis.
Dr. Ramnaraign: I think the most important thing for primary care providers and even gastroenterologists, when they see younger patients is to encourage healthy living, encourage your patients to have a diet that's rich in fresh fruits, vegetables, high fiber and of course limit the red meat intake. And for our patients who are overweight to encourage weight loss and even maybe refer them to a nutritionist or a dietician to help with such things. When it comes to treating the disease, and what the prognosis actually is; the lower the stage, the better the chances of cure and the better the chances of long-term remission. Staging in colorectal cancer, like other solid tumors, ranges from stage one, two, three, and four. Four, as I mentioned, I as someone who has a metastatic disease. Disease that has spread to other organs and distance sites.
Stage three is commonly when the tumor has spread to the lymph nodes and with rectal cancer, we can determine that based on getting a rectal MRI before surgery, however, with colon cancer, usually we have to wait until the patient has had their surgery in order to determine the lymph node involvement. And then stage one and two colorectal cancer is a tumor that is just limited to the gastrointestinal tract and it hasn't invaded into other lymph nodes or organs.
Host: So as a summary, Dr. Ramnaraign, tell other providers what you'd like them to know about patients, younger patients with colorectal cancer, and when you feel it's important that they refer to the specialists at UF Health Shands Hospital.
Dr. Ramnaraign: I think the most important thing for providers to know is that the incidence of colorectal cancer in this age group is increasing and is increasing at an incidence at about 2% increase per year. With regards, to the symptoms that could be explained by colorectal cancer, such as a blood in the stool, a change in bowel movements, abdominal pain or the discovery of iron deficiency anemia, shouldn't be ignored and these patients should be considered for a colonoscopy, if other more common things like hemorrhoids are excluded. Providers should also know that the recommendation to begin screening colonoscopies for the average risk patient is now at age 45, not at age 50 anymore.
So, your patients who are younger 45 should be considered for a screening colonoscopy. As well, it's always best to catch these cancers as soon as possible because the sooner we catch it, the more the likelihood of a cure is, and the better the outcomes with less need for potentially toxic therapy such as radiation therapy and chemotherapy. Providers of course, should always counsel their patients on living an active and healthy lifestyle. And as I mentioned, weight, diet, encouraging exercises are all very important things, right? In addition to smoking cessation if your patients are active smokers.
Host: What great advice in such an interesting topic that we examined here today. Thank you so much, Doctor, for joining us. And to refer your patient or to listen to more podcasts from our experts, please visit UFhealth.org/medmatters for more information, and to get connected with one of our providers. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.
Melanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole and join us as we examine colorectal cancer in young adults.
Joining me is Dr. Brian Ramnaraign. He's an Assistant Professor of Medicine in the Division of Medical Oncology at the University of Florida. Dr. Ramnaraign, it's a pleasure to have you join us today. Just start with by telling us a little bit about the prevalence of colon cancer in young adults. What do you see in the trends as far as that?
Brian Ramnaraign, MD (Guest): Sure Melanie and thanks for having me. So, colorectal cancer is actually much more common in older patients. However, since the 1990s at the very least, older patients have actually had decreasing rates of colon cancer. The numbers are actually going down, but in the younger population specifically in those under the age of 50, the rates are going up. And In fact, it is increasing at about 2% per year, the number of cases of colorectal cancer in this age group. So, it's definitely something we're very concerned about and something that we really want to shed more light onto.
Host: Why do you think that this is happening? And while you're telling us that, tell us some of the risk factors you can identify.
Dr. Ramnaraign: So, no one knows for sure exactly why the incidence of colorectal cancer is increasing in the under age 50 age group. But we do know that some of the risk factors for colorectal cancer have been getting worse, especially in younger patients. With regards to the risk factors for colorectal cancer, one of the big factors is genetic risk. However, that of course has been stable, over the decades, and that really only constitutes about 10 to 20% of the cases of early onset colorectal cancer. The most common genetic syndromes are Lynch syndrome or a FAP, familial adenomatous polyposis.
With regards to the actual risk factors that are, that are more common that we look out for; there are risks with regards to diet, risk with regards to weight, specifically a sedentary lifestyle. It gives you an increased risk of colorectal cancer and smoking. What we do see are increasing rates of obesity in this country, especially in younger patients, and a poor diet, a diet that lacks high fiber foods, a diet that is heavy in red meat are both risk factors that are going up and are seen in a younger patients, and may play a role in why these patients have higher rates of colorectal cancer.
Host: So, Doctor, we know that we have screening protocols from the US Preventative Services Task Force and other organizations, as far as screening for colorectal cancer in those 50 and older. I know myself, I've had many colonoscopies, but for young adults, what would indicate the need for screening? Are there symptoms that you've had patients come across? Is it just based on genetics? Tell us a little bit about clinical indications for screening colonoscopy in young adults.
Dr. Ramnaraign: Sure. So, anyone who's age 45, at average risk, should begin getting regular colonoscopies. Now the question is who should get a colonoscopy sooner.
Of course, if you do have some complaints, specifically blood in your stool, a change in your bowel movements, if you have abdominal pain; these could be symptoms of colorectal cancer and are definitely symptoms that you should bring up to your right primary care provider. However, these symptoms are very vague and non-specific, and could be you know for example, related more towards hemorrhoids, but they are definitely symptoms that shouldn't be ignored. And if these symptoms do persist, of course, a colonoscopy may be needed irrespective of how old the patient is. Of course, whenever a patient is seen in their primary clinic with their PCP, a thorough history, a family history, is needed. And if the patient has a first degree relative, so, that is you know mother or father, brother, sister, they should begin screening for colorectal cancer 10 years before that patient was diagnosed with their colorectal cancer or by age 40, whichever comes first.
With regards to the treatment for colorectal cancer, everyone is familiar with chemotherapy and the toxicities of chemotherapy, but here at the University of Florida Health Cancer Center, we're looking at other new options and investigational agents to tackle this disease. A lot of patients are interested in immunotherapy. And immunotherapy is actually a very good treatment option for patients. Right now, immunotherapy is approved by the FDA for the treatment of colorectal cancer, but that's only if a patient has a particular set of mutations that would predict a response. And we refer to these mutations as the microsatellite stability status or the mismatch repair deficiency status.
And patients who are microsatellite unstable or mismatch repair deficient, which really only account for 5% of these patients, are the ones who are eligible for immunotherapy. However, here at the University of Florida Health Cancer Center, we're looking at ways we can enhance the patient's immune system so that they can better benefit from immunotherapy. Studies are ongoing looking at clinical trials at this right now. We're also sending off patients' biopsies and tissues for next generation sequencing where we can look for specific targeted mutations that we can potentially target with specific drugs that bind to or block proteins from genes that may or may not be expressed in that particular patient, based on their genomic profile.
Host: So, now let's talk about treatments. Once you have diagnosed a younger person with colon cancer, what are some of the treatment options? Tell us a little bit about the difference that you might find between treating somebody younger versus treating someone older.
Dr. Ramnaraign: So, what we have noticed too, with younger patients with colorectal cancer is that a lot of them are presenting at more advanced stages. And this is probably because a lot of their symptoms are going ignored and are taken for more common things like hemorrhoids. With regards to treatment options, regardless of how old the patient is, it's usually a combination of surgery, chemotherapy or radiation therapy. When we discover that the patient has colorectal cancer, which is usually on biopsy of a tumor that's found in the colon or rectum, staging procedures are done. Staging images are done with CAT scans, commonly. If it is a very early tumor which is the whole point of getting screening colonoscopies; then surgery and only surgery is needed. However, if the tumor is more advanced, meaning that there's deeper invasion into the colorectal tract or if there's any suspicious lymph nodes that we see on imaging; the patient may need chemotherapy and radiation in addition to surgery.
And unfortunately, a lot of these patients are presenting with stage four disease and stage four means that the cancer has spread to distant organs or distant sites. If that is discovered, then the only treatment that we have is chemotherapy, and that's palliative chemotherapy. Chemotherapy meant to slow the growth of the tumor, of the cancer and to potentially give the patient more life expectancy than they otherwise would have. But once the tumor is stage four, chance of cure is low.
Host: Wow. That's quite a statistic. So, tell us a little bit about prognosis, if it's not stage four and also for some younger people as primary care providers and other gastroenterologists are working with these patients, fertility preservation may come up depending on the treatment regimen and how young they are. So, kind of tie a lot of this together for us as far as what you would like other providers to counsel their patients about when going through these kinds of treatments and diagnosis.
Dr. Ramnaraign: I think the most important thing for primary care providers and even gastroenterologists, when they see younger patients is to encourage healthy living, encourage your patients to have a diet that's rich in fresh fruits, vegetables, high fiber and of course limit the red meat intake. And for our patients who are overweight to encourage weight loss and even maybe refer them to a nutritionist or a dietician to help with such things. When it comes to treating the disease, and what the prognosis actually is; the lower the stage, the better the chances of cure and the better the chances of long-term remission. Staging in colorectal cancer, like other solid tumors, ranges from stage one, two, three, and four. Four, as I mentioned, I as someone who has a metastatic disease. Disease that has spread to other organs and distance sites.
Stage three is commonly when the tumor has spread to the lymph nodes and with rectal cancer, we can determine that based on getting a rectal MRI before surgery, however, with colon cancer, usually we have to wait until the patient has had their surgery in order to determine the lymph node involvement. And then stage one and two colorectal cancer is a tumor that is just limited to the gastrointestinal tract and it hasn't invaded into other lymph nodes or organs.
Host: So as a summary, Dr. Ramnaraign, tell other providers what you'd like them to know about patients, younger patients with colorectal cancer, and when you feel it's important that they refer to the specialists at UF Health Shands Hospital.
Dr. Ramnaraign: I think the most important thing for providers to know is that the incidence of colorectal cancer in this age group is increasing and is increasing at an incidence at about 2% increase per year. With regards, to the symptoms that could be explained by colorectal cancer, such as a blood in the stool, a change in bowel movements, abdominal pain or the discovery of iron deficiency anemia, shouldn't be ignored and these patients should be considered for a colonoscopy, if other more common things like hemorrhoids are excluded. Providers should also know that the recommendation to begin screening colonoscopies for the average risk patient is now at age 45, not at age 50 anymore.
So, your patients who are younger 45 should be considered for a screening colonoscopy. As well, it's always best to catch these cancers as soon as possible because the sooner we catch it, the more the likelihood of a cure is, and the better the outcomes with less need for potentially toxic therapy such as radiation therapy and chemotherapy. Providers of course, should always counsel their patients on living an active and healthy lifestyle. And as I mentioned, weight, diet, encouraging exercises are all very important things, right? In addition to smoking cessation if your patients are active smokers.
Host: What great advice in such an interesting topic that we examined here today. Thank you so much, Doctor, for joining us. And to refer your patient or to listen to more podcasts from our experts, please visit UFhealth.org/medmatters for more information, and to get connected with one of our providers. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.