Colorectal Cancer Screening in Younger Adults with Dr. Maggie Westfal

Colorectal cancer is one of the deadliest cancers in the world. While older Americans are more likely to be diagnosed with colorectal cancer, it has been on the rise in people under the age of 50 in recent decades. In this episode, Dr. Maggie Westfal discusses details on new screening recommendations and the latest treatments available for colorectal cancer patients. Dr. Westfal is a MUSC Health colon and rectal surgeon.

“If you're having abdominal symptoms or you have a change in bowel habits and you're not sure what to do, definitely talk to your provider. Don't wait six months, don't wait a year for it to get better. The earlier that we can get you to get a colonoscopy — and hopefully find nothing and ease your worry — the better.”
- Maggie Westfal

Maggie Westfal, M.D., MPH

• Colon and rectal surgeon at MUSC Health
• Member of the MUSC Hollings Cancer Center

Show Notes

• Colorectal cancer is the third leading cause of cancer death in the United States. Luckily, it's preventable with a variety of screening tests like colonoscopies, which can identify and remove pre-cancerous polyps.
• Colon and rectal cancer have typically been associated with older adults. However, patients receiving a diagnosis under the age of 50 are increasingly common, although the cause is unknown. Possibilities include a combination of diet, environment, obesity and genetics. This is why in 2021, national guidelines changed to recommend the suggested age to start colon cancer screening start younger, at age 45 instead of age 50.
• Symptoms are often not present in colorectal cancer, but when they are, they include changes in stool and bowel habits, rectal bleeding, new abdominal pain, and bloating.
• Colon cancer starts with a precancerous polyp, which is an overgrowth of the lining of the colon. It takes about eight years for precancerous polyps to develop, but for those predisposed to colon cancer, they can develop more quickly.
• It is advisable to review your family history of colorectal cancer (and related cancers such as endometrial, ovarian and pancreatic cancer) with your doctor to assess your level of risk. Genetic testing is also recommended.
• If someone has a hereditary disposition to colon cancer, typically due to Lynch Syndrome, screening can start as early as 20 years old.
• African Americans are typically diagnosed with colorectal cancer at a higher stage, at a later stage, and often have far worse outcomes overall.
• Generally speaking, the five-year survival rate for colon and rectal cancer patients is 63 percent. At stage one and stage two cancers, the survival rate can be as high as 91%. At stage three, it’s about 70 percent. When the cancer is metastatic, it’s about 13 percent survival rate.
• Because colorectal cancer survival rates are so much higher when the cancer is caught at earlier stages, it is vital to stay on top of regular colonoscopies.

Transcript

[00:00:00] Erin Spain, MS: Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Colorectal cancer is one of the deadliest cancers in the world. And while older Americans are more likely to be diagnosed with this disease, it has been on the rise and people under the age of 50 in recent decades. This trend has led to new screening guidelines to help catch this disease earlier and younger populations and offer access to leading-edge treatments. They can help people live longer lives. Here with details on new screening recommendations. And the latest treatments is Dr. Maggie Westfal and MUSC Health colon and rectal surgeon, and a member of the MUSC Hollings Cancer Center. Welcome to the show, Dr. Westfal.

[00:00:58] Dr. Maggie Westfal: Thank you so much for having me.

[00:00:59] Erin Spain, MS: Tell me about colorectal cancer and why it's a disease that everyone should be aware of.

[00:01:06] Dr. Maggie Westfal: From a general population standpoint, colorectal cancer is still the third leading cause of cancer death in the United States, and it's preventable. It's preventable with screening, and it's preventable with a variety of screening tests. So, from a colorectal cancer surgeon's perspective, we always recommend a colonoscopy. And the reason we say that is because a colonoscopy can be diagnostic, but it can also be therapeutic. And so, if you see precancerous polyps on a colonoscopy, you can remove them before they develop into cancer. And I think many people, in the general population, don't want to get a colonoscopy because they hear the stories from their friends about the prep, but it really is the best way to prevent colon and rectal cancer.

[00:01:58] Erin Spain, MS: And something about colon cancer is that it can develop without any symptoms. Tell me about that.

[00:02:04] Dr. Maggie Westfal: Yeah, and we're seeing more and more patients with what's defined as young-onset colon cancer. So, colon cancer in patients less than 50 years old. Historically, we thought of colon cancer and rectal cancer as older adults, 60s, 70s, 80 years old. However, now we know that it's happening at higher rates, and those rates are increasing in patients less than 50, whereas the rates are actually decreasing in patients older than 50. And I think that some of that comes from the hesitation to previously performed screening tests in the younger population. Like you mentioned, the guidelines have now decreased from 50 years old as the starting of screening to 45 years old. And I think that's because we're seeing this disease in such younger patients. but it's silent for many in that they don't have abdominal pain. They don't have changes in their bowel habits. They don't have cramping. They don't have bleeding until it gets to the point where it's, higher stage disease than we would have want to first initially find it at. You know, what we say to patients is if you find yourself having new onset abdominal pain, bloating, changes in your stool habits, that's something to raise your red flag and be seen by either your primary care doctor or a gastroenterologist or a colorectal surgeon.

[00:03:23] Erin Spain, MS: What do researchers and scientists know about this prevalence of younger people getting colon cancer? Is there a reason why this is happening?

[00:03:31] Dr. Maggie Westfal: I Think it's, it's really multifactorial. We know that the hormonal changes of obesity can increase one's risk for colon cancer. We know that our American diet, which is often high in processed foods and red meats, is pro inflammatory and, can be, conducive to developing polyps and then colon cancer. And then our environment, which is something which is so hard to study, because how do you quantify environment as a thing to then, say, Oh, patients in the United States are at higher risk than patients at a different country when you can't really quantify what that environmental difference is.

Genetics is a small portion of it. It's really only, you know, less than 10 to 15 percent of all patients with early onset colon cancer. I think environment, diet, obesity, and then the other factors we just don't know yet. You know, the gut microbiome is something that's up and coming in research and that looks at the different types of bacteria that live in our colon. They think that having a lower variety of bacteria may have you at increased risk for inflammation and polyp development, and then eventually colon cancer. But it's still very much a work in progress.

[00:04:43] Erin Spain, MS: A piece of good news is that we do have these screening tools that are able to detect early and as you mentioned, the screening age has been lowered to 45 from 50. Do you feel like this is something a lot of folks know that they should be getting their colonoscopies or doing another screening method starting at age 45?

[00:05:01] Dr. Maggie Westfal: I would say, no, I don't think a lot of people know this yet. And I think we can do a better job of educating our patients. When I tell say ten people in clinic that they're due for their colonoscopy at 45, maybe half know that 45 is the new age, but I would say at least half don't.

It will be interesting to see in the next 10 years if that age goes from 45 to 40, as we see these cancers, you know, coming in patients earlier and earlier. If you're unwilling to undergo a colonoscopy, like you mentioned, there are other screening tests. And there are stool tests that you can send in from your home and there are blood tests , and a variety of different things that you can do, but like I said, the best test is a colonoscopy because it can also be diagnostic and therapeutic in treating those polyps and decreasing your risk overall.

[00:05:51] Erin Spain, MS: Talk to me more about that. How does colon cancer start, and what can be done to prevent it from progressing to that cancerous state?

[00:05:58]Dr. Maggie Westfal: Colon cancer starts with a pre-cancerous polyp, which is essentially an overgrowth of the lining of the colon, and they can be a variety of different types, but some will develop into cancer, and others don't, but the reason why we remove them is because just looking at them, we don't know which ones are precancerous and which ones aren't. On average, for patients without a genetic predisposition to colon cancer, it takes about eight years for those precancerous polyps to develop the genetic abnormalities to then develop into cancer and grow.

In a patient with a genetic predisposition to colon cancer, that can speed up to over two to three years and be very quick. And so the screening that we do for those two different patient populations is different. And so the general population will get screened every 10 years if they don't have polyps, depending on how many and what type of polyps, the next screening test might be three years, five years, or seven years. But in a patient that has a genetic predisposition where that precancerous polyp can develop into cancer in maybe two years. We often screen every one to two years in that patient population.

[00:07:08] Erin Spain, MS: Tell me more about what makes someone high risk or how they know that they're genetically dispositioned to have colon cancer.

[00:07:15] Dr. Maggie Westfal: It's really important to try to find out your family history when that's possible. Ask your loved ones, is there a history of cancer in our family? What kind of cancers are in our family? And the important question is, when did our loved ones get diagnosed with cancer? Was it in their 70s, 80s, and 90s? Or were they getting diagnosed with these variety of cancers in their 30s or 40s or 50s.

And so, there's a set of guidelines that we follow, that talks about how many people in your family have colon cancer or an associated cancer like endometrial cancer, ovarian cancer, pancreatic cancer. And when were they diagnosed? Less than 50 or over 50? And then do you have any first degree relatives that also had those cancers? So based on that kind of screening assessment, we can say, it sounds like you and your family are at high risk for colon cancer. We recommend genetic testing.

And that's if someone has colon cancer, but it's not you personally. If you personally come in and have a history of just diagnosed colon cancer, it's now universally accepted that those patients get genetic testing. And really it's for the patient to know treatment options, etc., but it's also for their family to know that they need to be screened earlier most often and more frequently.

[00:08:34] Erin Spain, MS: You mentioned that there is a way to look at genes and your genetics to find out if you are at higher risk. Can you tell me about that?

[00:08:40] Dr. Maggie Westfal: often we screen patients with colon and rectal cancer. They all get genetic testing universally. Here at MUSC, If a patient comes into clinic and doesn't necessarily have a family history of colon cancer or personal history of colon cancer, MUSC is actually enrolling patients in a study called In OUR DNA SC and it's a community health project that was launched by MUSC, which allows for the enrollment of 100, 000 patients to get genetic testing at no cost.

And so, sometimes insurance will not necessarily cover genetic testing if patients don't have a strong family history. A history or a personal history of cancer. So this gives you the opportunity to be screened and entered into a genetic and research database that'll allow us to look at these genes more closely and try to reduce the risk of cancer in our population here in South Carolina.

[00:09:27] Erin Spain, MS: How young are the youngest patients that you're screening who are at high risk?

[00:09:31]  Dr. Maggie Westfal: so if someone has a hereditary disposition to colon cancer, which, typically is referred to Lynch syndrome, they'll get screened starting at 20 unless the younger person was 20 when they were diagnosed with colon cancer. then it typically falls about five years before that. Personally, I've seen patients with colon and rectal cancer as young as 16. so it's really important to know your family history and know when you need to start thinking about getting a colonoscopy.

[00:10:01] Erin Spain, MS: This issue of younger people being diagnosed is something that you're very interested in and that you are actually conducting research about. Can you tell me about that work?

[00:10:10] Dr. Maggie Westfal: I'm really interested in hereditary colon cancer, rectal cancer, and looking at not only the patients that experience that from a patient perspective, but also their family members. So, trying to identify at-risk families and assess how well we're doing with our guideline concordance screening. So, are we getting these patients to the doctors every year to get their screening tests or because they're not the ones that had cancer, are we not doing well? And so I'm trying to assess the families as a whole instead of just the patients to make sure that we're trying to prevent cancer from happening in these family members before it becomes a problem.

[00:10:49] Erin Spain, MS: I understand that certain racial and ethnic communities are also more likely to be affected by this type of cancer. Tell me about some of those disparities that are seen among different groups.

[00:11:00] Dr. Maggie Westfal: From a historic standpoint, African Americans are typically diagnosed at a higher stage, a later stage, and often have worse outcomes overall. I don't know that we know for sure why that is. but I think it's a topic that we have to look into. We have to find a way to get preventative care to every patient across all races and ethnicities. Is it because patients aren't getting screened as often? Is it because the access to care is different? Is it because the perception of colonoscopies is different across different cultures? I don't think we know that for sure, but it's definitely something that would be interesting to look at from a research perspective in order to better the care that we provide to all patients.

[00:11:45] Erin Spain, MS: What are the survival rates for colorectal cancer if it's discovered in an early stage and then if it's discovered at a later stage?

[00:11:53] Dr. Maggie Westfal: Usually, with survival rates we look at, most often, five-year survival. That's what people usually remember when they're diagnosed with colon cancer. You know, what's my risk of dying within five years? And essentially overall, the five-year survival rate is 63 percent. But if you look at stage one and stage two cancers, that survival rate is as high as 91 percent, which is, you know, very good. When you get to stage three disease, it's about 70 percent. And when you get to metastatic disease, it's about 13 to 15%. So overall, when you average those, it comes out to about 60 percent. But like we said, early stage disease, you're getting your colonoscopies. It's discovered early, that's about 90 percent. And then as you get higher, stage three and stage four, it goes down.

[00:12:37] Erin Spain, MS: What's a piece of advice that you would like to offer to our listeners regarding colon cancer awareness and prevention?

[00:12:44] Dr. Maggie Westfal: Getting a colonoscopy can be scary, and it's often the unknown that's most anxiety-provoking, but talk to your providers about it. There's a variety of different prep options now, and I would say patients are tolerating it much, much better than the past when patients used to drink four liters of this salty solution and be miserable and complain about it and come in dehydrated, you know; we don't often use that prep. It's usually a much smaller volume and much more tolerable.

So I would say if you're 45, definitely get to your provider, get a referral for a colonoscopy. But also, if you're worried and you're having abdominal symptoms or you have a change in bowel habits and you're really not sure what to do, definitely talk to your provider. Don't wait six months, don't wait a year for it to get better. The earlier that we can get you to get a colonoscopy and hopefully find nothing and at least ease your worry, The better. If we do find something, then we can follow you closely. And if we don't, then you can, you know, be screened at the appropriate time going forward.

[00:13:43] Erin Spain, MS: The last question is something we ask everyone who comes on this podcast. What do you do to optimize your health and live well?

[00:13:50] Dr. Maggie Westfal: That's a great question. What I will say is I have been more thoughtful about trying to not eat as many processed foods. I have two kids and so we've been trying to limit the amount of processed foods that we can with the understanding that sometimes you're on a road trip and you need some McDonald's. And so I think, moderation is the key in our house. But if I'm being completely honest, what I really should do is start taking fiber and making my gut health even healthier. So, maybe that'll be my New Year's resolution next

[00:14:21] Erin Spain, MS: Thank you so much, Dr. Maggie Westfal for coming on the show. We appreciate your time and expertise today.

[00:14:28] Dr. Maggie Westfal: Thank you so much for having me.

[00:14:29] Erin Spain, MS: For more information on this podcast, check out Advance.MUSCHealth.org.