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Colorectal cancer diagnoses have been rapidly increasing in younger individuals, even those in their 20s and 30s. While there's no clear answer as to why this is occurring, there are multiple factors to weigh. David Liska, MD joins Butts & Guts to discuss these considerations and how Cleveland Clinic is treating younger patients with this disease. Also, listen in for an update on this year's virtual VeloSano program, as well as insight into a new clinical trial made possible by funds raised through this annual event.

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Young Adults and Colorectal Cancer

Podcast Transcript

Automated voice:
Butts and Guts, A Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Scott:
Hi everybody and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to welcome appearance number two on Butts and Guts by Dr. David Liska, who is a colorectal surgeon here at the Cleveland Clinic and he is the Director of our Colorectal Cancer Multidisciplinary Tumor Board. David, welcome back to Butts and Guts.

David:
Thanks so much for having me back. Great to be here again.

Scott:
So we're going to talk a little bit about young adults and colorectal cancer today and some of the programs that you're putting together here at the Cleveland Clinic, but just as a reminder for those who did not listen to your last previous appearance in 2018, give us a little bit of background about yourself. Where you're from and how did it come to the point you're at the Cleveland Clinic?

David:
So, I'm originally from Vienna, Austria, but have lived here in the states now for over 20 years. I came here to the Cleveland Clinic in 2013 as a fellow and have stayed ever since. Like you said, I'm a colorectal surgeon and I have a special interest in minimally invasive treatment of patients with colorectal cancer, including hereditary, colorectal cancer syndromes. My research involves finding out better treatments for rectal cancer and also improving postoperative outcomes with enhanced recovery protocols.

Scott:
We are very lucky to have you here and David obviously our listeners can go to any of the back episodes, especially those during March, which is Colorectal Cancer Awareness Month and hear a little bit about more colorectal cancer. But just to start out for the new listeners here, can you give an overview about colorectal cancer? Maybe just some of the high points on it, how often it occurs, how it's typically treated.

David:
Right. So, colorectal cancer is the third most common cancer. It affects about 150,000 people in the United States each year. About 50,000 die from colorectal cancer every year and really the important message is that it's one of the few cancers that can be prevented by doing risk-appropriate colonoscopy. So when every person has a different age, when they should have their colonoscopy, but generally the recommendation now is at age 45 and colonoscopies can prevent colon cancer, which is one of the important messages to keep in mind. Importantly, even if you do develop colorectal cancer and the majority of people if colorectal cancer is caught early on in the course of the disease in most cases, it can be cured with surgery.

Scott:
So David, one of the more disturbing trends that we've been seeing is the earlier identification or diagnosis of a higher number of younger patients with colorectal cancer. Can you talk a little bit about this?

David:
Yeah. So, like you said, colorectal cancer was traditionally been thought of as a disease affecting older people. However, recently there have been emerging trends that have been seen on sort of a large looking at the entire population of the United States, showing that it is steadily and rapidly increasing in younger individuals. And when we talk about young-onset, colorectal cancer, or early-onset colorectal cancer, usually we refer to patients under the age of 50. We are now more frequently seeing patients with colorectal cancer in patients in their 40s and 30s and even in their 20s. So that obviously is an alarming trend to observe and it's important to number one, treat these people who develop colorectal cancer in their young age, in the appropriate way, but also for us to find out why is this happening.

Scott:
So kind of along those last set of lines, first, we're getting into the treatment of colorectal cancer in the young and the old, but I'm assuming here, you're talking about those patients that do not have a predisposition based on their genetics or runs in the family. Any ideas as to why this is occurring?

David:
This is really the key question that is still begging for a good answer. As mentioned, it has been clearly established that the incidence is rising, but there hasn't been a single convincing cause for this alarming trend identified. The most likely reason for why we haven't found out the cause for this is because it's probably not just one cause. It's probably a combination of different factors that's driving this. For one, it is probably not a coincidence that this trend of rising colorectal cancer in young is paralleling the obesity epidemic we're seeing here in the United States. There is good evidence showing that obesity and a sedentary lifestyle in general associated with an increased risk of colorectal cancer. So as we see more young people here in the United States and in other Western countries that are obese and sedentary, these are people who are also more likely to develop colorectal cancer.

However, this is likely not the only reason because there are many young patients with colorectal cancer who are fit, healthy, and active individuals. So obesity is not the only cause and there are theories about some unknown genetic causes and it might be contributing here, potential environmental exposures as well. Another emerging theory that has gotten a lot of attention recently is that it's potentially related to the microbiome and the microbiome of the millions of bacteria that live in our stool that goes through the colon and rectum. Some researchers are now finding that some of these bacteria could be the culprit for a rise of colorectal cancer in the young, but the bottom line is that we still don't fully understand it and there really is an urgent need for further research to answer this question.

Scott:
So let's take a step back or a step up from there and just talk about a little bit more high-level stuff before we dig into what you are doing there at the Cleveland Clinic. So first of all, what are some of the symptoms of colorectal cancer? How do we distinguish those from some of the more common symptoms that everyday patients who do not have colon cancer may get? Then the second part of this is you mentioned briefly about treatment for colorectal cancer and what does that encompass and does that encompass a difference between those who are older and those who are younger?

David:
Right. Those are really important questions. So starting with symptoms, this is really one of the most important things to keep in mind, especially when talking about colorectal cancer in young patients. A recent survey has shown that young patients will have symptoms for a much longer time before going to the doctor than older patients. In that survey found that a young patient that's diagnosed with colorectal cancer will have had symptoms for 270 days before going to the doctor on average versus a patient older than 50, only 30 days before going to the doctor. There are probably multiple reasons for that, but some of it is awareness and not only young patients but also their doctors. Colorectal cancer is usually not on top of their mind when they have these symptoms. So that's why it's important that we as doctors, but also everybody in general knows what some of these symptoms are and keep those in mind, even in younger patients. Those symptoms, the ones that are more concerning for colorectal cancer, there's some specific ones such as bleeding or blood coming out of the rectum, blood mixed in with the stool, blood in the toilet paper.

So in most people, when they have blood, it will not be due to colorectal cancer. However, when the symptoms persist, it is really important to discuss with your doctor and determine if further investigation needs to be done. Besides bleeding, a change in bowel habits. So if you notice a change in the caliber of your stool, or if you usually have sort of liquid stool or diarrhea, then it changes to constipation or the other way around. If these symptoms persist, it's also important to discuss that with your doctor. There are other more vague symptoms, such as weight loss, fatigue, and abdominal pain, and all these symptoms can also be a clue to colorectal cancer. Again, it's important not to be over alarmed because in the majority of cases, especially in the young, these are not due to colorectal cancer, but it is important to know that it could be and therefore to discuss it with your doctor early on.

Scott:
So David, one of the things that you're putting together at the Cleveland Clinic is just programs, multidisciplinary teams geared towards the young patient with colorectal cancer. Can you tell us a little bit more about that?

David:
Right. You were talking about how does treatment for colorectal cancer differ between young and old? It is similar but different. On the one hand, the actual tumor is treated very similarly, if you're a younger or older patient with colorectal cancer. In terms of meaning, they are a similar surgery, similar chemotherapy, if chemotherapy is needed. However, younger patients do have a set of different considerations that are really important to address when treating them for colorectal. This is what we're in the process of building here is a center that really caters specifically to these considerations we have to keep in mind when treating younger patients in a multidisciplinary way, in a coordinated way. So when I talk about these different considerations, for example, younger patients of colorectal cancer are much more likely to have an inherited condition that predisposes them to colorectal cancer.

In one study patients in their thirties who had colorectal cancer had about a 30% chance of having hereditary colorectal cancer syndrome. It is therefore really important that when an individual is diagnosed with colorectal cancer under the age of 50, that they have a meeting with a genetic counselor and then have testing for inherited colorectal conditions. Certain genetic conditions will significantly change what type of surgery the patient should have and also have important implications on what type of surveillance and follow up they should have. For example, a patient with Lynch syndrome, which is the most common hereditary colorectal cancer syndrome, will usually require more extensive surgery to prevent a second cancer from occurring and also need more frequent surveillance for colorectal cancer but also for other associated cancer than a patient who does not have Lynch syndrome.

In addition, somebody once they're diagnosed with Lynch syndrome it's important to determine their family members, their siblings, their children. If they have the genetic condition as well because that can then have huge implications in terms of when they should have their colonoscopy and other tests done to prevent cancers in any relatives from developing. But besides the genetic considerations, the other considerations to keep in mind when treating younger colorectal cancer patients, and this is related to the phase of life that these younger patients are in. Many of them are still in the process of having a family, having children. Sexual health is a bigger concern and other psychosocial considerations. Younger patients, many of them have jobs, are working full time, have childcare they need to take care of. So having surgery, chemotherapy, or radiation or whatever treatment that they might need can have significant implications on all these different concerns.

When we treat a patient with colorectal cancer, when we meet them for the first time even, these are all considerations we need to keep in mind and discuss with the patient in detail to address these concerns. When patients have colorectal cancer and we're worried about their fertility, we would refer them to one of our partner gynecologist or urologist for fertility preservation, and also to address any sexual health concerns. Psychologically, it can be very important for these people to meet with a mental health specialist or participate in support groups. So there are many different factors that come to play and different factors come to play in different patients. But when we deal with younger individuals of colorectal cancer, there's a whole different set of considerations and factors that need to be discussed and addressed.

Scott:
Well, that's fantastic stuff, David, and I'm so glad that you're leading this endeavor. Can you talk a little bit about what patients could experience when coming into the Cleveland Clinic for one of these types of multidisciplinary appointments? I, again, encourage listeners to revisit some of the recent episodes of Butts and Guts for more of this information, especially at the COVID area where we're recording this. We're doing everything possible to keep patients safe, but for those patients that may be experiencing some of these symptoms and a little bit hesitant to come in, walk them through what that experience might be like.

David:
With the COVID-19 situation, we've moved to have a lot of initial visits as virtual visits. So before a patient comes in, especially if they're hesitant to come in having an initial discussion with either one of us colorectal surgeons or a gastroenterologist or one of our other partners to discuss their new symptoms and see what testing would be indicated. When they do come in then for whatever tests they need, everybody who comes into our facilities now gets screened in terms of temperature, exposure, symptoms to really make sure that we don't expose anyone unnecessarily. All our caregivers here wear masks and all our facilities are really kept in a way that we don't spread any COVID infection. As far as the safety, all our patients undergoing procedures and surgeries for the last couple of weeks have gotten tested for COVID before they come in for their procedure. Obviously, if it's negative, we proceed and if it's positive, then it depends on the type of procedure they need if we will proceed with special precautions or defer.

Scott:
So one of the things that the Cleveland Clinic puts on every year is VeloSano. Can you talk a little bit about VeloSano's bike to cure, what this weekend is evolved into, the fundraising aspect of it? Obviously, this year is going to be a virtual fundraising experience, but it obviously is providing just an incredible experience for not only caregivers but cancer patients and their families and researchers and everybody into it, talk to us a little bit about this.

David:
VeloSano is really a fantastic fundraising endeavor and really experience for everyone involved. One of the amazing thing to me is really that 100% of all the funds that are being raised with VeloSano are going directly to research. And they're going to researchers here at the Cleveland Clinic and the Case Comprehensive Cancer Institute and directly for advancing treatment and our understanding of cancers that are affecting so many people. The event itself, this year it's virtual, but in the past, it's really an exciting event that really brings the community together. Both the caregivers, doctors, nurses, researchers, patients, survivors, their family members, and friends. I feel like the entire city comes together focused on cancer during that weekend and it's really inspiring.

Scott:
No, David, I know and I'm very proud to announce that you and your research group has been particularly affected by VeloSano, having some funding as a part of this process towards the exciting research that you're doing towards treating rectal cancer. Can you tell the listening audience a little bit about this?

David:
Right. So, one of the really exciting advances in cancer treatment, in general, has been immunotherapy. I'm sure a lot of listeners have heard about immunotherapy recently in the news over the last few years. The Nobel Prize for medicine recently went to those researchers who found immunotherapy. In colorectal cancer, immunotherapy is still not that commonly used. In rectal cancer, especially it has not been really used at all yet, at least not in the new adjuvant setting. What that means receiving immunotherapy before surgery. Right now, patients with more advanced rectal cancer will undergo standard chemotherapy and radiation before having surgery.
In some patients, the tumor really responds very well to this chemoradiation, but in most patients, the tumor persists, and then they have surgery. If we can get the treatment before surgery to really make the tumor disappear, those are the patients who have the best possible outcomes. So what my research has focused on that I was really lucky and privileged to receive a VeloSano award is to see if we can add immunotherapy to certain, not to all rectal cancer, but to some rectal cancer patients. If we can really make the tumor completely disappear or almost completely disappear before surgery and thereby improve outcomes in terms of survival, risk of cancer coming back, and also quality of life. That's an exciting project that hopefully we'll be able to start enrolling patients within the next few months.

Scott:
That's absolutely fantastic and congratulations on the work that you're doing, we look forward already to the results and I just encourage everybody to understand that VeloSano's bike to cure weekend is July 17th and 18th. For more information on this exciting virtual event taking place and for fundraising opportunities, please visit velosano.org. That's V-E-L-O-S-A-N-O.org. David, some final take-home message or messages for our listeners out there when considering this entire prospect of colorectal cancer and especially as it relates to the young.

David:
Right. So, colorectal cancer is common. It's a common cancer, and it's becoming more common in the young. Again, I can't stress this enough it's a cancer that can be prevented by doing colonoscopy especially. So it's important if you have symptoms or if you reach the age where you should have your colonoscopy to have that done, and we discussed some of the symptoms. If you have any of the symptoms, it's nothing to be embarrassed or shy about. Discuss it with your doctor, that's what we're here for and we need to figure out if it's something to be concerned about. Then take it from there because again, colorectal cancer can be prevented. If one were to develop colorectal cancer, it's very treatable and in most cases curable.

Scott:
Well, that's fantastic stuff and to learn more about colorectal cancer prevention and treatment, and to take a free colon cancer risk assessment, please visit clevelandclinic.org/coloncancer. That's clevelandclinic.org/coloncancer and for additional information or to speak with a specialist in Cleveland Clinic's Digestive Disease & Surgery Institute, please call (216) 444-7000. That's (216) 444-7000. And if I may add in times like these, it's important to keep up with your medical care. Just be rest assured that at Cleveland Clinic, we're taking all necessary precautions to sterilize our facilities and protect our patients. David, thanks so much for joining us on Butts and Guts.

David:
Thank you so much for having me.

Automated voice:
That wraps things up here at Cleveland Clinic until next time. Thanks for listening to Butts and Guts.

Butts & Guts
Butts & Guts

Butts & Guts

A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. You’ll learn how to have the best digestive health possible from your gall bladder to your liver and more from our host, Colorectal Surgery Chairman Scott Steele, MD.
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