hi everyone March is coloral cancer awareness month and ever since I lost my husband Jay to the disease in 1998 when he was just 42 years old I have been a staunch advocate for awareness and early detection the number of colon cancer cases among young people under the age of 50 has risen dramatically the disease is now the leading cause of death for men under the age of 50 and the second leading cause of death of women under 5050 so so why is this happening Dr Andrea cersek is the co-director of the Center for Young onset coloral and gastrointestinal cancer at Memorial Sloan ketering Cancer Center in New York City Dr cersek thank you so much for being here March as you know is colorl cancer awareness month and I wanted to talk to you about the really alarming increase of colorl and other digestive cancers among people under the age of 50 can you tell us about what you've been seeing and why you find this so concerning yeah absolutely you're you're absolutely right it is alarming we're seeing more and more young people um and this has been happening really since the mid 1990s there's been this slow and steady rise of a few percent per year um with of coloral cancer and individuals under the age of 50 um and I think what's scariest is that this is not unique to the United States um or to other um developed countries but it's really happening all over the world um you know every country that that has a registry or starting to kind of gather their data are noticing this Rise um and it's predominantly in left side of tumors What's called the descending colon or the rectum so there are these commonalities across the globe um that really we have not been able to explain in addition to the increase in colorectal cancer you're seeing an uptick and other so-called digestive cancers what are those cancers specifically yeah so other cancers that are on the rise include really they're all digestive cancer so the of the esophagus stomach pancreas appendix um you know the entire digestive tract um is rising in young individuals tell us a little bit about the patient population you're seeing at Memorial Sloan ketering we're seeing many many patients under the age of 50 most of our patients I would say are in their early 40s but we've seen as young as teenagers adolescence where we really you know can't explain it the parents get a colonoscopy they they don't even have a single pop and yet here are these teenagers with coloral cancer that's rare but we're seeing it I would say more and more each year which we weren't used to and so um you know many of our patients are as I mentioned in their 30s their 40s they're starting their careers they're thinking about family planning their young parents parents they're taking care of their um aging parents they don't particularly have any of the obvious or the known risk factors that we think about with colorl cancer you know such as smoking obesity alcohol use red meat and some of them are so young that even if they they did smoke for a little bit they simply can't actually have smoked enough let's say to you know say that this might be a risk factor for for their cancer so most of them are are quite fit and active and um really we have not seen any kind of obvious you know explanation this must be so upsetting for you to treat these patients because coloral cancer often presents itself when there are symptoms and that can mean the cancer has advanced you're absolutely right and especially in this patient population where screening uh is not indicated right we know now screening age has been lowered to 45 because of this rise but as I mentioned we're seeing many people in their 30s and their 40s and so they're not getting screened so therefore the tumors are not caught in very early stages and and and they really present when they have symptoms and oftentimes that's because the cancer is quite Advanced and many times actually um has already spread so you know stage four um and so it's it's devastating it's um you know and from just why me why did this happen how did it happen what did I do wrong what didn't I do um to you know how how am I going to deal with this how am I going to support my family um and and and what happens even in survivorship or or if you know if they don't survive it's it's incredibly difficult it's heartbreaking and many of these people do not have a family history of coloral cancer and I think it's worth noting that what 75% of coloral cancer cases have no family history and I always say no family history is no guarantee that you won't be diagnosed with the disease but again many of them don't have a family history many of them don't many of them don't or many of them also don't know about it until they you know until they tell their families about their diagnosis and then it's like oh so and so had it and an aunt had it Etc so it's just not talked about but most of these patients don't have a family history don't have any reason to kind of even think about an early screening or talking to their um you know primary care physicians about early screening um because it's not anywhere on their radar I think the big question is why is this happening why are so many young people under the age of 50 being diagnosed with coloral cancer and in most cases Advanced coloral cancer that is the million dooll question absolutely curious to hear what you believe is the cause you're absolutely right that is the million dollar question I think the short answer is we don't know the longer and I think increasingly more exciting answer is that there is now a lot of work going into this there are many you know research centers focusing on it many collaborations from an epidemiological perspective just kind of smaller basic science research to try to figure this out most likely this is environmental I think we we all agree that there is an environmental factor or factors uh that everyone is exposed to this is the only really explanation that makes sense for why we're seeing this pattern this rise all over the world uh but what those factors are we don't know and so you know the the suspects are anywhere from processed foods microplastics things that are kind of you know that we're exposed to that we ingest without even knowing it or we do know things like antibiotics potentially other medications um you know all this kind of is is is is out there now under investigation well let's go through some of these theories one is as you mention ultr processed foods and the overc consumption of these foods can also lead to obesity which is a known risk factor for choral cancer can you talk about what scientists are trying to learn about the impact of ultr processed foods on our bodies yeah I think what you know the ultr processed foods and and anything that they might the hormones that are that go into them Etc that that's definitely under investigation people are looking at it in terms of exposures risk factor questionnaires what did you eat as a kid what are have you eaten most you know as a young adult uh those types of questions and then on a more um sort of um basic science kind of molecular scale how do those Foods affect our metabolism you know is there sort of more of an inflammatory State because of all these Ultra processed foods that that really everyone is ingesting even you know despite some of our best efforts let's talk about another theory microplastics why do scientists believe they could be the culprit microplastics when digested there are you know lots of data there can lead to estrogens lead to hormone production change and hormones within the body and some of those hormonal changes can lead to inflammation so there has been description of of microplastics actually found in our organs um in the heart in brains literal deposits of microplastics we know that they are everywhere in the environment you know even people who don't re eat red meat they're all over the ocean they're in the fish we eat that's been known for a long time we know that there there are General shifts in the hormones presumably from microplastics there has not been a direct link but that's certainly one of the I would say you know very high up uh on the on the sort of ladder in terms of uh suspects but it's very very difficult to demonstrate a that that that the changes from just ingesting these microplastics a that we're truly ingesting them that they exist and then secondarily that all of these changes lead to cancer and I think an even more important and tougher question is if this is something that we're all exposed to why are these individuals certain individuals uh developing cancer and others are not so there is still very likely some group of individuals that are predisposed and so I think those are the the key things that we need to think about when we do research is what are the what are the culprits potentially that are causing these changes in our bodies and then who's more susceptible to actually developing a cancer from those changes in addition to microplast ICS there are other theories one is pfas or these so-called forever chemicals that are found in a lot of products can you tell us why scientists are looking at those you know it's for the same reasons as with microplastics we know that exposure uh to these substances and these chemicals can lead to changes uh in our our metabolic pathways in our hormones and so the question is what are those changes exactly and how might those changes be leading to specifically digestive Cancers and potentially other cancers as well there's also uh fear about the overprescription of antibiotics I know when my kids were little and even a few years ago for myself if you had an infection you were quick to be prescribed an antibiotic when it wasn't necessar necessarily bacterial but viral and antibiotics wouldn't have a big impact how has the overprescription of antibiotics come into play in terms of the increased risk of colorl and other digestive cancers absolutely that's one of the other really main suspects is is antibiotic use because what antibiotics do is they change What's called the microbiome or the bacterial world that exists within our digestive tract where we need good bacteria and we have potentially some bad bacteria and the concern is that the antibiotic may get rid of some of the good or protective bacteria and allow the the bad bacteria that are pro-inflammatory and that could lead potentially to cancer to overgrow so it's a very delicate balance and and you know why we're investigating antibiotics specifically is because we know that antibiotics can eradicate certain types of bacteria let's talk more about the microbiome because there is I know some thinking that microplastics may be pierced piing the microbiome somehow not only changing your hormonal level but kind of affecting the delicate balance causing inflammation because some of these particles May penetrate sort of the mucus membrane around the microbiome not to be gross and I hope I'm being scientifically semi accurate but you know the microbiome seems to be the real key to understanding this right we think so you we think so because it's a it's a it's really a whole world right the microbiome it's it's it's an in it's not just sort of this these are our bacteria but it's in the interaction between the bacteria how they protect us how they help us um and so that's why this microbiome is under such investigation the issue is is that there are a lot of things that can change our microbiome it's it's Dynamic it's a huge Universe it's very different you know from if you're eating something you're used to a diet on the east coast of the US and you travel let's say to Asia there have been studies that have shown that within a week the microbiome that we can identify changes drastically so it's a very very hard thing to kind of capture saying okay this is definitely the culprit this is what these patients these are the changes these are the bacteria that the patients has but we are starting to see some signs that there might be some bacteria that some of these young patients do have in common um you know that could perhaps have led to this so we're we're kind we're making some progress but it is a really um sort of I would say like as big as the microbiome is it's is it's hard of a question you know to tackle it is such a challenging question at the same time young people are being diagnosed and many are dying of this disease having said that epidemiological studies can be super hard to conduct and proving correlation is one thing proving causation is another so can you talk about the challenges really pinpointing what may be the cause and if in fact you're starting to think it might be multifactorial absolutely I mean I think it's it's exactly as you said it's a it's a huge challenge just in general conducting epidemiologic studies you need large numbers you need multiple different populations thankfully those research projects are Ono there is now worldwide collaboration it can't be done just from a single Center you know this is our small population it really needs to be um thousands hundreds and thousands of patients um you know to find the answer so I think those are those are absolute challenges but but as you said um investigation is underwear there's more and more funding more and more Grant support which is key uh uh to finding the answer can you explain what uh The Birth Cohort effect is yeah so this is very interesting and I think really kind of pins down down the sort of the crck of the problem or or or or where everything began um what we see is that the rise really started with the Birth Cohort of 1950 and later and and if you know I could show you the graph it's sort of a flatline and then all of a sudden after people born in 1950 there's the slow and steady rise and the slope just keeps going up and up and what that really tells us is that it's something environmental that it's something that people born in the 1950s might have been exposed to maybe in the 50s 60s 7s but we are continuously being exposed there have been some other theories and I'm curious what you think of them one I was talking to an expert in the microbiome at MD Anderson and they were wondering if protein not naturally occurring protein but protein powder some of this ultr processed protein you find in in uh nutrition bars may be contributing to it because they're seen many just Elite athletes and marathon runners and people who are in incredible shape being diagnosed with colon cancer I agree I think that we see that over and over just you know fit fit people who are always fit you know no obesity even in childhood and young adulthood um I think it's certainly possible uh the question you know that that I have is it's I don't know enough about protein bars and protein powder to say that that might be used as much here in the US as it is you know in Asia Australia or even in Africa where we're also seeing this rise and so that would be the maybe kind of you know make me question potentially that this is all it is but maybe this is another contributing factor which is what I suspect it is is that it's it's really multifactorial a 2021 study that you l found that the biology of coloral cancer is very similar in younger and older patients what does that mean and how does it impact your research so this was our our first question when we started out was what is the biology of young onset coloral cancer do the tumors under the microscope and when we look at their genes or their mutations look the same in a 30-year-old as they do in an 80-year-old for example which would be the average onset so we compared the two and what we found was that under the microscope and then genomically when we sequence the tumors and looked at the genetic signatures that make up the tumor that presumably cause it to form and to grow look exactly the same so this suggested to us that it's not a new disease it's not a different you know something something changed and now we're seeing kind of this new version of coloral cancer it's the same colorl cancer that's occurring in 80y olds as is occurring in 30 year olds so from that we presume that the pathway meaning where you first you form a polyp and then there's mistakes being made or mutations that kind of accumulate and then ultimately a cancer forms that pathway is the same in an average onset patient in their 60s 70s or 80s as it is in a 30 or 40 year old so that process is the same we believe but we do think that perhaps later on there's more that goes on once those once those uh genes those mutations are translated into what are called proteins and the way that our cells are formed and interact on that level there might be differences but the way that the cancer first starts and grows really looks to be the same so our immune response may be different when we're older and our immune system isn't as strong as it is when we're younger but basically it is the same cancer and it's not some kind of variation talk about the exposome uh which is a complement to the genome and I understand it represents the cumulative impact of our environment on our health um so how is that being utilized in your research that's another um you know area that that um research are investigating and and it effectively is is is a very you know beautiful sort of scientific summary of what we've been discussing is that we have our genetic makeup then we have changes that occur to our genetic makeup because of environmental factors and things that we're exposed to and we know that cancer you know requires multiple sort of changes to happen and this is one of the areas that that are that's being investigated let's talk about early detection and prevention as scientists try to figure out why this is happening there are certain things people can do when it comes to early detection however the screening age is 45 and over and you're seeing patients in their 20s 30s even early 40s my husband Jay was diagnosed at 41 so for them the screening guidelines don't really help so what can people do and as we' mentioned if you're symptomatic it's often too late so how can people get early detection and how can they prevent this disease absolutely it's so important I think for now the best we can do is tell people if you have persistent symptoms if you have a change in bowel habit um you know bleeding unexplained weight loss abdominal pain get medical attention don't just kind of ignore it try to fight it off see your primary care provider and say listen this is what's happening it may be nothing but it's really important to have that conversation and potentially that work up screening techniques will improve that's definitely you know lots of ongoing research um in terms of early detection easier ways other than the colonoscopy for now the colonoscopy is is far far and way the best test because not only does it detect the cancer it can prevent it because we can catch that pollet before it forms but but unfortunately it's just we're not able to ex to lower the screening guideline because the number the number of individuals required to be screened right would be huge so it's just not something that's doable so for now the most important thing is Raising awareness being your own Advocate and then also on behalf of the physicians primary care providers gastroenterologists if there's this complaint it could it could be um coloral cancer so the patient needs a workup uh some of my followers are asking about at home school stool tests for screening um you're right they can't remove pops but how effective are they are they're great they are effective I think they they detect blood I think if if nothing else that absolutely should be done there's many screening programs out there where you can um do the home stool test and then if it's positive you'll be called in for a colonos opy so I highly recommend that if for some people uh it's just very difficult to get the colonoscopy done any test is is really better than no test so absolutely what about diet and exercise I know that that's something that you can do proactively and specifically I'd like to ask you about probiotics naturally occurring probiotics and the role they may play in overall gut health if you will we don't know the answer to that I think I tell many of my patients that that natural occurring probiotics such as eating yogurt um you know are fine to take fermented food like sour kenchi um kombucha uh things like that can be helpful right absolutely they can they can definitely be helpful I don't you know think that they can be harmful sometimes in our own patients it's a challenge because of change in B movements but for the general public they can definitely be helpful a healthy diet that we should all be eating high in fruits and vegetables fish you know chicken low in red meat um is important and can be beneficial exercise is hugely important we know in terms of prevention uh in patients that are chaal cancer survivors there are data that um daily exercise and a healthy diet actually improve outcomes um there are data for for actually cancer fighting just from exercise itself uh and so that's becoming more important um you know in our in our daily lives so those are definitely things that someone can do and know proactively um to to live a healthy your lifestyle to try to prevent this they're also exciting new blood tests but they're on the horizon and they've yet to be perfected that might help people identify circulating microscopic cancer cells which I think might be easier than a colonoscopy but I'm always hesitant to mention those things because I don't want people people to put off getting screen with the techniques we have at our disposal now especially given that only 20% of people 45 to 49 have been screened for coloral cancer yeah absolutely I I agree with you 100% I think the the blood tests are great that they're available I love that the technology technology is in development I think it will continue to get better more sensitive more specific but as you said you know beautifully it's it's it's not enough if uh you know at all possible definitely the colonoscopy is the right test because it can be preventative someone also asked uh about when they should be screened telling us their grandmother passed away from colon cancer before the age of 50 and this is a good time to remind people Andrea that you should be screened actually if your grandmother uh died or was diagnosed depending on when they were diagnosed if she was diagnosed at 48 you need to get your colon cancer screening 10 years prior at 38 so for example my girls will get one has already been screened at 31 the other will be be screened when she's 31 because my husband was diagnosed at 41 so any firstline relative right like mother father sibling Aunt grandmother uh should you go ahead and get screen 10 years were diagnosed yes absolutely 10 years younger and that's an important that's why it's important to know your family history it's important to ask those questions even if you don't have symptoms just you know have that conversation because yes you you may be eligible to get screened 10 years younger and if not then 45 is a screening age um I think there's still a lot of work you know for us to do to really get that word out that the age has now been lowered to 45 because of this rise yes and I don't think a lot of people realize it this is one of the things I wanted to convey during the course of this interview and during coloral Cancer Awareness Month um while scientists continue to to figure out why this is happening how long do you think it will take before we can point to factors that may be contributing to this rise I more and more data are coming out of you know hints and clues that that were hopefully not just associations but that were find find ing you know potential culprits so I I think it's hard for me I wish I I wish I knew when I could tell you the exact time but I think over the next several years we're going to make a lot of progress in the meantime people need to practice Healthy Lifestyles uh talk to their doctors and about probiotics I'm curious that there are other countries that have a lower incident of coloral cancer I remember when I did a lot of work in this area I thought Japan had a lower incidence of coloral cancer and when Japanese people moved to Hawaii or the United States and adapted a more Americanized diet their incidence of colon cancer went up is that true that's true and there were data to to that end exactly because of the western diet and the sort of more common risk factors for actually for right-sided uh coloral cancer this finding in young adults is is pretty Universal there were a few countries um in Europe where there didn't seem to be this rise and the thought initially was like France for example they they regulate uh their food very much GMO Etc uh but they've actually recently found that they also have increase rates of um young onset coloral cancer so it's not um seems to be that no one's really spared many of my followers asked about IBS or Crohn's and Colitis if you have any of those are you at higher risk of coloral cancer and when should you get screened so it's a really important distinction um that needs to be made between IBD what's called inflammatory bowel disease which is Crohn's and ulcerative colitis which do predispose uh people to colon cancer because what those are effectively is your colon is kind of constantly inflamed from the body attacking it and that can lead to changes and it can lead to cancer so that's been well described and known in patients who have that diagnosis is must be screened on a regular basis it's super super important I can't stress that enough IBS is inflammatory Bell syndrome which is kind of a very broad diagnosis that you know young adults often get it can be stress related it can just be a change in GI habits for whatever reason different foods most of the time it's associated with Stress and Anxiety which unfortunately many many young people have and that's on the rise as well um but what happens with IBS is that many many times these changes happen and they're just attributed to IBS because it's this kind of umbrella you know broad diagnosis but the person doesn't necessarily have a workup doesn't have a colonoscopy they might have change in bowel habits pain with bowel movements anything like that you know with that diagnosis really should have a colonoscopy to make sure that it's not anything else that's going on and then of course the IBS can be managed you and Dr leis Diaz at Memorial slone cering did a very exciting clinical trial dealing with rectal cancer and immunotherapy and the patients had an extraordinary response I'm curious if immunotherapy is applicable to coloral cancers in general and if progress is being made because while I want to focus on early detection and prevention I also would love to give some hope to people who are dealing with Advanced col rectal cancer at this point in time absolutely we're making tons of progress with treatment of advanced disease as well as early stage disease our study was for a small population with mismar deficiency which is known to be very sensitive to immunotherapy either in early stage but or also in advanced disease for most patients with choral cancer it's about 95 90 plus per of them have tumors that are not on their own sensitive t immunotherapy because what happens is the cancer actually hides from their own immune system it kind of finds ways to cover itself and so if the immune system doesn't see it as something foreign then it doesn't want to attack it so there's lots of great research going on and lots of progress has actually been made with that patient population where the T the immune system normally doesn't recognize the tumor to try to get it to recognize the tumor and we're starting to see some responses so it is absolutely really exciting people should definitely have hope we are super excited as a research community in advanced disease about 20 or so% of patients are starting to have responses to new drugs there's new combinations ongoing with immunotherapy and the goal is obviously to extend the success that we saw with this mis metrop deficient rectal cancer population to areas outside of the rectum but then also to the tumors that are not mismatch repair deficient to see those same responses with immunotherapy and again we want to remind people that most coloral cancer cases have no family history isn't it 72 or 75% cases just about yes around 70% of of uh all cases and in in young individuals it's close to 60 65% we still have a higher proportion of hereditary cancers in young individuals but this rise that we're seeing is driven by no family history and sporadic tumors or what are called you know random tumors that can just OCC without any predisposition I always say your family history could start with you and that's why everyone needs to get screen these are such important things to know and understand not only during March but all year long and people really need to be screened because it's one of these cancers that can be stopped in its track tracks because as you said the colon is kind of this this uh human casing and if you can get it before it penetrates the colon wall goes into the lymph nodes and becomes sort of um microscopic disease that can metastasize on other organs your chances of being cured are very very high absolutely well Andrea cersek thank you so much I could talk to you about colon cancer all day but you're you're busy saving lives and helping patients so I really appreciate your time thank you so much thank you for having me