ZACH MOORE: Welcome to On Health with Houston Methodist. I’m Zach Moore. I’m a photographer and editor here, and I’m also a long-time podcaster.

KIM RIVERA HUSTON-WEBER: I’m Kim Rivera Huston-Weber and I’m a copywriter here at Houston Methodist.

ZACH: And Kim, we’re talking about something pretty serious this time, colorectal cancer.

KIM: Yeah, it’s become quite an issue in people younger than 55, which, you know, I think, historically, the condition’s been thought of as being something that affects older populations but there’s a really scary trend that it’s getting diagnosed in people that are even as young as 20 years old.

ZACH: And colorectal cancer is something I associate with, I guess, older people ‘cause I know, like -- Like, my parents have gone and had colonoscopies and it’s always a thing they discuss and it’s something that I’m like “Oh, do I need to be getting these?” And, like, based off my own little research, not yet, I’m good. They’re always like, “You got a few years before you have to get these,” and so, I just -- That’s the way I look at it. But that’s how I associate it with an older age range.

KIM: Yeah. Colonoscopy isn’t recommended until you’re -- Until age 45 so you don’t think about it unless you’re a person that might have any digestive issues, which I know we’ve got an episode this season about them with Dr. Quigley. So, if you’re not having any experience with having GI problems, you’re probably not really thinking about your GI health. I think it’s 20% of all colorectal cancers are getting diagnosed in people that are younger than 55, which is a really staggering amount when you compare it to cancers of different parts of the body.

ZACH: Now, do you know anyone or have -- Has colorectal cancer?

KIM: I, kinda, through friends-in-law.

ZACH: Mhm. Friends-in-law.

KIM: You know, hearing about someone’s wife passing away when they’re in their early 40’s from it, and no really family history of cancer either. And I think, maybe that’s what’s so scary about it is I don’t really have a family history of cancer but there’s nothing to say that people don’t have genetic mutations and things along those lines that may make them more at risk.

ZACH: Yeah, I mean, I have some cancers that run in my family, not this one. And that’s how it is, right? There are some big, headline name cancers, and we all know what they are, and there’s some other lesser discussed ones, right? At least in the public sphere, and this is one of ‘em. And, who did we talk to about colorectal cancer today, Kim?

KIM: We talked to Dr. Tareq Kamal, colon and rectal surgeon with Houston Methodist.

ZACH: Alright, let’s get into it.

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KIM: Dr. Kamal, thank you so much for being with us today.

DR. TAREQ KAMAL: Thank you very much for having me on your podcast. It’s an absolute pleasure being here and talking about a very important subject today.

KIM: Of course. So, in early 2023, the American Cancer Society reported that 20% of colorectal cancer diagnoses in 2019 were in patients younger than 55, which is about double the rate from 1995. The rates of advanced disease increase by about 3% each year in people younger than 50. It predicted that in 2023, an estimated 19,550 diagnoses and 3,750 deaths would be in people younger than 50. Another report from the American Cancer Society published this year showed that two decades ago, colorectal cancer was the fourth leading cause of cancer death in both men and women under age 50. Now, it’s moved up to first in men and comes in second for women behind breast cancer. Have you noticed this trend in your practice, and what concerns you most about it?

DR. KAMAL: Yes, unfortunately, we’re seeing more patients with colorectal cancers in their 30’s, 40’s, and 50’s now. This is very concerning because even though majority of the cancer does occur in older patients above the age of 55, we’re seeing these cancers in the younger patient population, but most of these patients don’t even know that it can occur in their age group, so a lot of the times, we see patients with late diagnosis because of this misinformation.

KIM: Are there differences in the way this early onset cancer appears versus what’s seen in people who are diagnosed older, after 55?

DR. KAMAL: What we noticed most of the difference is with younger patients, a lot of the times, the cancers do present late because of the misdiagnosis or delay in diagnosis. So, patients can come in with more advanced disease or a more locally advanced disease whereas the older patients tend to have regular screening, so they’re detected earlier. But with regards to the symptoms, they’re pretty similar.

KIM: Do we know what’s causing this rise in early onset colorectal cancer?

DR. KAMAL: We still don’t know the exact reason why this rise and uptake in colorectal cancer in younger patients. Some believe it might be due to dietarian lifestyle, changes in environment, you know, being on a high fat diet that is lower in fiber, and sedentary lifestyle, obesity, alcohol intake as well can contribute. But the exact reason is still not understood. Genetics can also play a component of it as some of these cancers can be inherited form. But about 10-20% of these cancers in younger patients are inherited form, so the rest are not. I think there’s still a lot of studies need to be done to, kinda, identify what’s the exact reason because this increase.

KIM: That’s interesting. So, could you speak to the genetic component that could be happening here?

DR. KAMAL: Yeah, as I mentioned, you know, colorectal cancer starts as a polyp, and this polyp has abnormal cells with abnormal DNA, and starts to divide these cells, divides it regularly until they form a cancer. And some of these changes in DNA can happen either through by inherited form or can be acquired through your lifetime. The inherited form of colon cancer only accounts for about 5% of colorectal cancer and about 10-20% in the younger population. These are certain conditions like Lynch syndrome or what we call FAP. It’s important for our patients to understand their family history, especially, you know, if they have a history of first-degree relatives with colorectal cancer.

KIM: Is there any precedence with this with any other type of cancer that is having this strong increase with patients being diagnosed much younger than usual.

DR. KAMAL: What comes to my mind would be breast cancer. I think there is also a trend in breast cancer and seeing breast cancer in younger patients but it’s definitely more dramatic the increase intake in colorectal cancer and also other GI cancers.

KIM: Are the risk factors different for those diagnosed at younger ages or is it the same no matter your age?

DR. KAMAL: The risk factors are the same. We, kinda, think about them as either environmental or lifestyle risk factors, which we talked about the sedentary lifestyle , obesity, alcohol intake. And then you have the more inherited risk factors, that’s the family history or the personal history of polyps or colorectal cancer. So, this is pretty much the same for both colorectal cancer occurring older patients or younger patients. I think it’s important to understand for younger patients and knowing your family history can contribute part of it as well.

KIM: The Colorectal Cancer Alliance produces a survey report of young colorectal cancer patients and survivors. And in their most recent report, almost half of the respondents said that they didn’t know what the symptoms of colorectal cancer are. What are the symptoms and do they differ depending on your age?

DR. KAMAL: Majority of early colorectal cancer is silent, it’s asymptomatic. It’s only when the tumors gets larger, they cause symptoms, and the symptoms do not change between younger and older patients, and these are what we call the worrying signs or symptoms that patients should be concerned about. And some of these include rectal bleeding, seeing blood in your stool that’s persisting, persistent abdominal pain or pelvic pain that doesn’t go away, and a change in your bowel habits that’s also persisting, and weight loss. So, any of these symptoms or a combination of these symptoms should alert you to go seek attention from either your primary care or a specialist.

KIM: Talking about your GI health, especially going to the bathroom, your bowel habits can be really uncomfortable for some people. So, when you talk about these changes, what exactly do you mean?

DR. KAMAL: Obviously it’s not a topic everybody wants to bring, you know, on the dinner table but things to be aware of is a change in the pattern of your bowel habits. So, if you’re used to going once a day and that pattern all of a sudden change and being consistently changed or if you start getting a new onset constipation or diarrhea, or sometimes even the consistency and the shape of your stool makes a difference if the stools become more narrow, pencil shaped, that’s also a worrying sign. So, it’s just a combination of all these changes are important that you have that discussion with your doctor.

KIM: What screenings or tests exist to discover colorectal cancer at an early stage?

DR. KAMAL: So, there are different screening modalities but I think the gold standard still is a direct visualization of the colon and the rectum using a colonoscopy. Colonoscopy, it’s a flexible camera that we insert through the rectum and we look at the lining of the colon and the rectum to make sure there’s no polyps or tumors, and if there are polyps, then you can remove them right there and then during the same procedure, or if there are cancers or tumors, you can biopsy them and mark them. This is the recommended method and we usually start it at the age of 45, but there are other screening modalities if colonoscopy is not feasible or for medical reasons it cannot be obtained. And some of these include CT colonography, which is also known as virtual colonoscopy. This is done using a CT scan, a special kind of CT scan where they reconstruct, 3D reconstruct the colon to look at the lining and make sure they detect any polyps or tumors. It has its advantages and disadvantages because if you do have a polyp or a tumor, you still need to be referred for a colonoscopy, so you might end up getting both. You do need to prep for it as well. Obviously, it’s not as invasive as a colonoscopy procedure. The other methods of screening, and you’ll routinely now see in advertisement is the stool based testing. These can be, like, a stool -- Fecal occult blood or, you know, chemicals testing where you test for blood in the stool. This has to be done on a yearly basis because it has a lower sensitivity and specificity for detecting cancers, and the other, more common now that you see all over the news and advertisement is the stool DNA testing also known as Cologuard. This test is very useful, it had a higher sensitivity and specificity, or it can detect fecal DNA from the tumor cells, it can be done every three years depending on the results, but if it is positive, you will be referred for a colonoscopy. And it does have some disadvantages just like any test that is really designed to detect cancer and not specifically for screening. So, if you have a precancerous polyp for example, it can miss it. The specificity and sensitivity goes down for detecting polyps as compared to cancer. It can be as low as 40% so it’s important to understand that when you’re doing this test, that it can miss the tumor in the early, precancerous phase, and that’s why we still recommend colonoscopies.

KIM: You shared all of the tests that are available to diagnose colorectal cancer. Can you share how these tests are recommended?

DR. KAMAL: In deciding as what to test is most appropriate, each patient is different, each clinical case is very different, but for the general population, we still recommend colonoscopy at the age of 45 unless you have risk factors like a family history. If you’re unable to get a colonoscopy for a medical reason or you are not interested in more invasive colonoscopy test, you can consider the other testings. We usually reserve, for example, virtual colonoscopy to patients who are unable to complete a colonoscopy for medical reasons or technically colonoscopy is not feasible, then we consider it as an alternative modality combined with a stool based testing. With regards to Cologuard, it can be considered useful in patients who also can’t get a colonoscopy for medical reasons, or for example have multiple medical issues that it’s too risky to do a colonoscopy for them or they have advanced age that they don’t wanna get an invasive procedure. These tests are used. So, we have to be, just, careful of how we recommend it and to discuss it more in detail so that the patient is well informed.

KIM: Yeah, so it sounds like it’s much more of a conversation with your doctor about what you’re comfortable with and probably what your risk factors are.

DR. KAMAL: Correct. And at some point, like any screening modality is better than nothing, but some of them are better sensitivity and specificity to detect these polyps and tumors.

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ZACH: Genetic testing is completed after cancerous polyps are found during colonoscopy to discover if genetic mutations were a factor in colorectal cancer developing. About 5-10% of colorectal cancers have a genetic cause. There are at least 30 genes that are associated with hereditary colorectal cancer. It can be found during clinical genetic testing. This means that there are thousands of genetic mutations which can increase a person’s risk of developing the condition. One of the most common genetic causes is Lynch syndrome, which is also associated with increased risk of endometrial, ovarian, gastric, urinary tract, brain, and pancreatic cancers. Your doctor may also recommend genetic testing if you have a strong family history of colorectal cancer. Not sure of your family history have colon cancer, or simply curious? Direct-to-consumer genetic testing kits can give insight into your family tree and ancestry. May not be the best bet if your main questions are about genetic health risks. These direct-to-consumer tests only screen for two common genetic variants, and one gene linked to hereditary colon cancer. These tests should not be used to make healthcare decisions. If you’re worried about your risk, talk to your primary care provider.

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KIM: We know that colonoscopy is part of the screening recommendations for those over 45. Can you speak to how they’ve evolved over time? And do you think if this trend of younger and younger diagnosis continue, do you think it would be lowered below -- to 40, or?

DR. KAMAL: So, yeah. We used to do colonoscopies at the recommended age of 50 and after studies came out showing that increase in trend and colorectal cancer for younger patients, that has changed and shifted us to 45. And again, that can continue evolve and change depending on what trends of incidents of colorectal cancer we’re seeing. At the moment from a screening of the general population it makes sense to recommend it at 45, but this can definitely change in the future.

KIM: So, I’ve seen those ads for the at home tests, can you tell me who would benefit from one of those and is it better than doing no screening at all?

DR. KAMAL: Yeah, obviously they’re very convenient because you can do it in the comfort of your own home, you don’t need to do a prep like the colonoscopy, but like I said, they’re designed to help detect cancer and not specifically detect the precancerous phase, which is the polyp phase. So, they are useful and they have their -- definitely their indication and use. But certain patients who are just the general population who wanna have the screening and make sure they don’t have polyps, I still believe colonoscopy is the best method. For patients who have medical issues and they can’t undergo a procedure with sedation, and definitely that’s a good option to do, and it can be repeated every three years. So, it’s much shorter interval compared to the colonoscopy which gets repeated every ten years. So, it definitely has its usage because it’s less invasive and it’s easy to do at home.

KIM: For those of us who might be concerned by the trend and naturally medically anxious, I may fall into this camp, those tests have to be prescribed to you by your physician, right? It’s not something that you can go to a pharmacy and purchase?

DR. KAMAL: Correct. It’s usually ordered routinely by primary care physician or a specialist like a gastroenterologist or a colorectal surgeon. And the reason why is you need to understand, you know, what does it mean to have a positive test or a negative test. They do have some, you know, false positives and false negatives, so it’s important that you have that discussion with your physician. A negative test is great but nevertheless, it can still mean that there might be a polyp there and be missed. So, yes we do recommend that you have that discussion with your doctor.

KIM: There seems to exist a hesitancy among some folks around colonoscopy. Kind of like before people having discomfort with talking about their bowel habits or they just don’t -- simply don’t wanna think about it, and that makes the idea of having a colonoscopy seem daunting. What would you tell a person who would have that kind of anxiety?

DR. KAMAL: Yeah, colonoscopy and the prepping and even the anesthesia we use have evolved and changed. It definitely had a bad rep of being, you know, difficult to finish the prep and, you know, cumbersome, but nowadays it’s a very simple, safe, routine procedure that takes about 20-30 minutes to do and the endoscopy in it, there’s an anesthesiologist available for  sedation to keep the patient comfortable, and it’s a very effective test in a sense that if you find a polyp, you remove it, you directly look at the colon and the rectum and know your for sure your diagnosis. And I try to, kinda, explain to the patients what to expect from the prep as well, which has also improved and it’s not as difficult to complete, and all these instructions are usually explained to the patient ahead of time so there’s no surprises.

KIM: For those who might be averse simply because of the prep, can you talk about how the prep has changed? Is there a way for you to hack your colonoscopy prep?

DR. KAMAL: Unfortunately, there’s no hacking. You still need to prep and clean your colon somehow. Most of their preps are liquid based. We do use a small volume prep nowadays in a split dose format so that means you take -- You’re on a clear liquid that day before and then you take half the prep in the evening and half the prep early in the morning for your colonoscopy, and that’s been shown to give us the best results for the prep. But some patients don’t like the taste of the prep itself, so we do have the option of having capsules or pills, pill format of the prep. And some patients prefer that and which works just fine. So, each patient has a specific request we try to, kinda, prescribe them the right prep. The other thing I also recommend for patients is to try to take the prep and follow it by lots of water ‘cause that makes the prep work better. But the prep itself is, just like I said, about 16 ounces, it’s 6 ounces that you mix with water and 16 ounce, so it’s not too bad and you don’t have to drink it all at once, you can sip it a little bit slowly to have it complete.

KIM: Can you add things to the prep? Like, could you put a little crystal light or electrolyte drink to make it taste better? Or is that recommended? Or is that not --

DR. KAMAL: Yeah, I wouldn’t add that to the prep itself, but you can definitely add some flavored water to the water that follows ‘cause you do have to drink two 16 ounces of water afterwards, so you can definitely do that. But do avoid colored drinks, you know, like the colored Gatorades and things like that which can change the color of your stool, and sometimes the red ones can alarm you that there might be blood there, so I would avoid that. But yeah, definitely you can add some flavor to the water afterwards.

KIM: Could you talk about treatment plans and how they may differ for people diagnosed at 20/30 versus people being diagnosed at older ages?

DR. KAMAL: So, the treatment plan depends on the stage of the cancer and how the patient present it. So, whenever a patient gets diagnosed following a colonoscopy, we usually follow it with what we call a staging CT scan, which is a scan that looks at the entire body to make sure there’s no spread of the cancer. And depending on that will determine your next step of treatment. And some might be a little different for rectal cancer, it requires MRIs and slightly different pathways, but it doesn’t change between being younger or older. The treatment plans and the workup is pretty much the same, and it all -- Again, it depends on how early the cancer was diagnosed and what stage it is when it was found.

KIM: I understand that depending on whether you have colon cancer or rectal cancer, it could be totally different treatment plans for those, and I’m sure that it’s based on a patient's individual situation. But without getting too deep, can you, kind of, talk about generally what treatments could be like?

DR. KAMAL: Yes. So, as you said, treatment can be a bit more complex depending whether you have colon or rectal cancer. But just a general gist of it is that if your cancer is confined to your colon, the main stay of treatment is surgeries to remove the tumor. And we do the surgery now using minimally invasive techniques like robotics, and laparoscopics so patients recover faster and do well. Certain cancers do require chemotherapy after surgery and some, in rectal cancer cases, can require it before surgery in combination with the radiation. So, this why we have a dedicated team here at Methodist. It’s multiple specialists involved in your care with oncology, radiation oncology. Usually a surgeon and a GI physician and the radiologist and that pathologist. So, we as a team, kinda, help guide the patients to find the right treatment and their right path.

KIM: There are lots of stories and personal accounts online of people that are in their 20s and 30s sharing their experiences of being dismissed as being overly concerned about symptoms or being misdiagnosed and -- Or simply told to take a probiotic and then their symptoms of course worsen. And until the correct diagnosis is made or they end up going to an ER. What are some of the potential misdiagnoses for younger people when they’re experiencing colorectal cancer?

DR. KAMAL: Yeah, something that I commonly see in these cases is having rectal bleeding or seeing blood in your stool and having it attributed to benign problems like hemorrhoids or anal problems. Whereas the patient might have an underlying colorectal cancer. These are unfortunate cases, but I always tell the patient you know your body better than anybody. So, if your symptoms are persisting, you’re seeing blood regularly, their bowel habits have changed. Be persistent about it, tell your primary care physician, request the referral to a specialist for a second opinion, or you can even directly request the referral to a specialist. And we always evaluate the patient thoroughly, make sure they don’t have benign anal/rectal problems first and then go into colonoscopies and that if needed. But definitely be aware that these cancers can still happen in younger patients, and these symptoms should not be ignored.

KIM: If someone is being told that they have hemorrhoids and, you know, they’re going through whatever treatment modality to address that concern and they’re just not getting relief, how long should someone wait for their misdiagnosis to clear up.

DR. KAMAL: This is very common, obviously. Majority of rectal bleeding that we see is related to benign problems, especially in the younger population. So, if they go see a primary care and they treat them conservatively for a month for example or few weeks and the symptoms are still persisting and the patient notices something different with them I think it’s very reasonable to bring it back to the attention of the physician to say, “My symptoms are persisting, can we be referred to a specialist for a second opinion or discuss with him the option of proceeding with a colonoscopy?” I think it’s very reasonable, and most physicians feel very comfortable to refer to us for further evaluation.

KIM: The Colorectal Cancer Alliance also ask patients and survivors about their journey to diagnosis. 75% of respondents said that they visited at least two physicians before getting diagnosed, 40% said their providers dismissed their symptoms and concerns and that was even more significant in that 19-39 age range. 20% said it took them more than a year to get their diagnosis. What advice would you give someone to advocate for themselves when they’re experiencing symptoms and feel like they’re not getting taken seriously or they’re being suggested that they should believe it’s something more benign?

DR. KAMAL: Again, as I mentioned, you know your body more than anybody. So if you feel something is just not right, your symptoms have persisted despite trying to manage your problem in a more simple way or conservative treatment and still persists, just come back and request a second opinion and be -- feel, you know, strongly about it that ‘cause it’s okay to get a second and a third opinion sometimes. Things can be missed in medicine but it’s important that we raise awareness between patients, physicians, primary care that colorectal cancer does exist in a younger patient population and we need to be aware of that. Patients who see the blood everyday or every -- For a persistent period of time and they’re having all these other symptoms, it definitely warrants further investigation. And primary care physicians have access to specialists and they can definitely refer you or you can even refer yourself nowadays.

KIM: While it’s really important that we’re having this discussion and raising awareness, I’m sure it can be a scary, uncomfortable topic no matter how old you are. We spoke about risk factors earlier and while there are factors that are out of our control like family history, are there actionable steps people can take to lower their risk of colorectal cancer?

DR. KAMAL: Yes. Definitely these are the lifestyle modifications, and they include being physically active, avoiding the sedentary lifestyle and obesity, eating more healthier, high fiber diet, and avoiding the high fat processed meats, avoiding smoking and heavy alcohol intake. So, these would be the major, kinda, modifiable risk factors we can try to do.

KIM: Can you speak about how fiber in our diets can help with lowering our risk?

DR. KAMAL: So, fiber helps regulate your bowel movements, it draws water to your stool, it keeps your bowel movements on a more regular, soft basis. So you don’t have to strain and have constipation and changes in your bowel habits. That helps in that aspect, but we still don’t understand exactly how diet and what we call it, the gut microbiome or the bacteria contributes exactly to colorectal cancer and this is something still under study.

KIM: This has been a really great conversation. I’d love to end on an encouraging note. So what can people do to help lower their risk of colon and rectal cancer?

DR. KAMAL: Number one is raising awareness between patients and the general public. Be aware of the symptoms, the worrying symptoms we talked about, and seek attention and don’t delay it. The earlier we can detect it, the more successful we are in treating it. Be very comfortable with talking to your physician about your bowel habits and any changes that you notice, and just adopt a more healthier lifestyle. Be active, exercise, eat healthy, try to avoid smoking and heavy alcohol intake, and I think that’s about it.

KIM: Well, thank you so much for being with us Dr. Kamal. This has been very enlightening.

DR. KAMAL: Thank you very much.

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ZACH: So, one of the most concerning things I learned from this conversation was there have been a lot of misdiagnosis in younger people about colorectal cancer, which is just delaying their treatment.

KIM: Yeah, lots of folks are seeing multiple physicians or, you know, waiting as long as a year to get a diagnosis, all the while knowing that there’s something wrong with their body. So, I think it’s really important to -- For people of all ages to be really active with their healthcare because the reason why I wanted to do this episode is it’s important for everyone to know the signs and the symptoms. You know, we’ve, kind of, talked about how there are certain cancers that have a lot of top of mind awareness around them, but if you’re 20, 30, you know, this could still affect you. So, as taboo or, kinda, weird as it may be, you have to be tuned into what your bowel habits are.

ZACH: As you said, we have a digestive problems episode this season and we talk about some of that. In that episode as well, there’s this -- you know, we call it bathroom shame or whatever but it’s, you know, it’s not something that you wanna go broadcast to the world about what’s going on down there. But yeah, I mean, if you are feeling sick and you go to the doctor, what is the first thing the ask? “Well, how have your bowel movements been? What’s the consistency of your stool? And all these questions. And you’re like, ah, this is weird to talk about, but these are all, you know, clues so they can put together the puzzle of what might be wrong with you. So, you have to -- You have to be honest about it and you have to -- I mean, it’s, kinda -- It was, kinda, gross. I’m not gon’ --

KIM: [Laughing]

ZACH: But it’s necessary.

KIM: Yeah. Well -- And I, you know, I don’t think it has to be super regimented like, you’re using a journal or something like that. If people out there are journaling about it, that’s fine. But, you know, I think having general awareness about your body is going to benefit you in the long run and, you know, help you age as healthily as you possibly can.

ZACH: Right. And that is -- I mean, we’re looking for symptoms, you’re wondering, “Oh, do I have this?” Like, well that’s the first place to look. Right? You know, your bathroom habits if you will.

KIM: Yeah.

ZACH: It might not be your favorite thing to do, but a lot of these health things aren’t, right? You just gotta lay -- I’m not looking forward to doing a colonoscopy one day, but I’m gonna have to, right? ‘Cause it’s just, you know, it’s what we gotta do, right?

KIM: Yeah.

ZACH: So, hopefully we raise some awareness about colorectal cancer, one of the lesser discussed cancers in our experience. But that’s gonna do it for this episode of On Health with Houston Methodist. Be sure to share, like, and subscribe wherever you get you podcast. We drop episodes Tuesday mornings, so until then, stay tuned and stay healthy.

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