The Changing Face of Colon Cancer – Webinar

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New York Gastroenterology Associates

April Webinar Transcription.

Dr. Laura Fredo

Thank you for joining tonight. My name is Dr. Laura Fredo. I am a gastroenterologist at New York Gastroenterology Associates and I’m excited to be moderating tonight’s webinar. Thanks for taking the time to log on and join us tonight. We have a great talk lined up for you and some time at the end where we’ll be able to go over some questions and have a nice discussion. Tonight we’re going to be joined by Dr. Steven Naymagon and Suzie Finkel, one of our GI specialized registered dietitians. I’ll give you a little more info about them, but I’ll do some housekeeping first. So for this webinar tonight, we’re going to chat for about 40 minutes or so. And then after we’ll have about time for about 15 minutes, 20 minutes of questions during the webinar, I will be collecting some of the questions as they come in. So feel free to ask some questions in the chat or the Q and A. And I’ll save some good questions for the end of the talk if they’re repeated. And we will be recording this. So if anyone can’t stay on for the whole time or wants to share it with someone else or reference it later, we will be editing it and posting it to our website.

On our website, you can actually see all our other webinars. Since we’ve been doing this at the start of the pandemic, we’ve been trying to get out some information to our patients and community about once a month on our website, Gastroenterologist New If you go under News, you can see all the previously recorded webinars there. So it’s a great reference. So again, very excited tonight to be speaking to you with Dr. Steven Naymagon and Suzie Finkel on the changing face of colorectal cancer, why rates are on the rise in young adults and what we can do about it. So Steven Naymagon is one of our amazing gastroenterologists at New York Gastroenterology Associates. We’ve accumulated a great group of gastroenterologists at our different office sites all over Manhattan and Brooklyn. He mostly is based on the Upper East Side and where he also trained at Mount Sinai Hospital. And he’s going to be talking to us about colorectal cancer, what it means, what it’s about and what’s going on that’s leading to these higher rates. And at the end of the talk, Suzie Finkel will be commenting on a lot of practical stuff, what we can do about it with diet and lifestyle.

Suzie is one of our four GI specialty dietitians that we have at New York Gastroenterology Associates. We’re very, very lucky to have them help and support our patients through their management and diagnosis of their digestive diseases. She has a master’s in science from Columbia and did additional training at the Columbia Celiac Center as well as the Mount Sinai IBD center. So she is a pro when it comes to dealing with all our digestive diseases. And we work very closely with our dietitians to get our patients feeling better. So without further Ado, I am going to turn it over to Dr. Naymagon and looking forward to chatting at the end of the talk.

Dr. Steven Naymagon

All right. Thank you, Dr. Fredo. Thank you for the introduction. Thanks for inviting me to give this talk. Let me see if I can actually share with you. All right. So as Dr. Fredo said, we are going to be talking about colon cancer or colorectal cancer and specifically colorectal cancer in young people. So for this talk, I have no conflicts of interest to disclose. And I’d like to acknowledge Dr. Laura Fredo and Suzie Finkel for help with getting this talk ready and for moderating the talk and for adding to it. So here is our agenda for the day. So we’re going to talk about some backgrounds about colon cancer. Then we’re going to talk about specifically colorectal cancer in young adults. And we’ll close out with some Q and A. All right. Jumping into the background. So we’ll start with a very broad overview of what is cancer. So cancer is an abnormal cell basically occurs when there is abnormal cell division. So normal cells grow and multiply in a highly controlled manner. And when the checkpoints for cell division break down, cells can multiply uncontrollably and form something called a tumor. And cancer is a disease in which some of the body cells grow uncontrolled controllably.

And cancer can originate in any part of the body, any organ of the body, and can spread to other parts of the body. For those of you who like things more pictorially, normal cells grow in a very orderly fashion. Sometimes abnormal cells develop mutations, which can then grow in an abnormal or disorderly manner into a tumor. And that tumor can spread. And cancer is a big deal. In 2020, an estimated 1.8 million new diagnoses of cancer were made in the US, and over 600,000 people died from the disease. Approximately 40% of men and women will be diagnosed with cancer at some point in their lifetime, which is an absolutely staggering statistic, I think. And specifically colorectal cancer or colon cancer, which is what we’re talking about here, which I’ll sometimes abbreviate as CRC, is cancer that originates either in the colon for colon cancer or in the rectal cancer. So this is an anatomical drawing of the GI tract. So the sandwich had for lunch today, traveled through the esophagus, made it into the stomach, then into miles and miles and miles of small intestine. And so finally ending up in the colon, which is this long, windy organ that eventually leads into the rectum, which is the last you can consider the last part of the colon and then into the toilet.

And colorectal cancer is thought to arise in most cases, initially as a colon polyp. And a polyp is a growth inside the colon or rectum, which over time can continue to grow in an uncontrolled manner as cancer tends to do and ultimately become malignant. And the degree of growth or spread of a cancer is referred to the stage. So in this cartoon, you can see that we can consider a polyp that’s pre malignant as stage zero. Stage one cancer is where the cancer is confined to the surface of the colon. Stage two is when it breaks through the first layers of the colon. Stage three is where colon cancer breaks completely through the wall of the colon. And stage four is when it spreads or metastasizes. And colorectal cancer can spread to other organs, including most notably the liver, lymph nodes, lungs, brain, and perineum. So how common is this disease? Well, the sad thing is that it’s actually very, very common. First, turning your attention to this pie chart, colorectal cancer represents approximately 8% of all new cancer cases in the US. And by the numbers, there will be an estimated 150 plus thousand diagnoses of colon cancer in 2022 and over 500 deaths from colon cancer this year, making it the second leading cancer killer in the US, trailing only lung and bronchis cancer.

In the US, the lifetime incidence of colorectal cancer and the average person is approximately 4%. Breaking down the numbers by race and ethnicity, you can see here that men are somewhat higher risk for colorectal cancer. You can also see that certain ethnicities increase the risk of colorectal cancer, including being African American. And certain Indian Alaskan Natives are also at an increased risk in terms of ages. So the median age for diagnosis of cancer is 66. And you can see sort of this curve where the majority of cancers are diagnosed people in their 60s, 70s, and 80s. And in terms of survival, as we mentioned earlier, colon cancer, colorectal cancer can go from stage one all the way to stage four. And this is crucial because localized disease or stage one disease, let’s say, actually has a very good prognosis with an over 90% five year survival. Whereas once the disease metastasizes, the five year survival is quite low, it’s quite poor. So now that I’ve burned you out, how about some good news? So the good news is that colon cancer rates have been declining over the last three decades in the United States, Colorado cancer rates have declined by 1% per year, which is a 35% reduction over the last three decades, which is huge.

And a lot of this is attributed to colorectal cancer screening and better treatments. But if we look at these numbers in a little bit more detail and break it down by age, you can see that in older adults, the rates have been dropping dramatically, which is fantastic. Middle aged adults, it’s also trending down. But if you can see this last line down here, that represents people between the ages of 45 and 54, and this line looks almost flat, but it’s actually rising. So while deaths from colorectal cancer decreased among persons aged 55 to 84 deaths have actually increased among persons aged 45 to 54 during the same time. So this brings us to the crux of the talk, which is colorectal cancer in young adults. So a lot of you probably heard about this when Chadwick Boseman died of colorectal cancer, sadly, at a very young age, and this made it into the popular press and really getting a lot of traction for colon cancer awareness. And it made people say, well, how common is it that the young people would be dying from colorectal cancer? The numbers have really been on a steady increase over the last several decades.

So, for example, in 1992, the incidents was approximately 8.6 cases per 100,000 people, whereas in 2016 it was up to 13.1% per 100,000 people. A significant increase. And currently, early onset colorectal cancer or colorectal cancer in young adults accounts for approximately ten to 12% of all new colorectal cancer diagnoses. And a lot of studies project that this will only increase. So in 2010, colon cancer in young people accounted for about 5% of all cases, whereas in 2030, it’s estimated that it will account for 11% of all colon cancer diagnoses. For rectal cancer, it’s even more significant, 9% of rectal cancers occurred in young people in 2010. And it’s estimated that over 20% will occur in young people in 2030. I’m very excited to share this paper, which was recently published in the Journal of Gastroenterology, one of the most preeminent GI journals, and not only excited to present it because it really presented some very important data, but also because a lot of the authors were some of our colleagues at NYGA and Mount Sinai. So this study analyzed over 3 million colonoscopies. How fun is that to determine the prevalence of and risk factors for colorectal cancer and polyps among patients aged 18 to 49 from the years 2014 to 2021?

In terms of predictors of colon cancer and colon polyps, they found that increasing age is a predictor, male sex is a predictor. Interestingly, they found that white race increased the risk of colorectal cancer and polyps in this age group. Whereas previously I had mentioned that being African American was a higher was a risk factor, family history was a risk factor, and a presentation with rectal bleeding was also respect for cancer. So what if they actually find so this is a picture of representation of their most important findings, and we’ll sort of go through some of their most important findings. So they found that advanced polyps, which are represented in this graph, and advanced polyps are ones that are large or have the highest risk of becoming cancer. Advanced polyps among those ages 45 to 49, almost as high as those in people aged 50 to 54. So you can see these bars are very closely linked. And the rates of colorectal cancer are actually even higher in people aged 45 to 49 represented here, as opposed to those between 50 and 54. Among 40 to 44 year olds, the rates of advanced polyps were almost as high as those aged 45 to 49.

You can see here. And colorectal cancer rates were also comparably high. And Interestingly, even among the youngest people in the cohort, between the ages of 30 and 39, up to 20% already had any polyps on colonoscopy, and two to 4% had advanced polyps. And not an insignificant number also had colorectal cancer. So this data just highlights the fact that colorectal cancer and polyps occur at a significant rate in people who are in their 40s and even in their 30s. So the question is, why is this happening? Well, there could be a number of reasons. These are the classic risk factors and protective factors for colorectal cancer that we know for all ages. So being older increases your risk, certain genetic syndromes increase your risk. Having a family history of colon cancer, being a smoker race, we mentioned African Americans have a higher risk. Obesity and certain chronic conditions increase the risk of colorectal cancer. Protective factors include physical activity, aspirin use, having a healthier diet, and having a colonoscopy and having a polyp removed. There are also some controversial factors that we won’t go into so young people, what could be causing this rise in colorectal cancer?

So one proposed reason was that perhaps colorectal cancer in young people is simply a different disease. Maybe the biology of it is different. And the data that supports this is the fact that the increasing incidence rates of early onset chlorophyl cancer has really been driven by increases in distal cancers. These are cancers that occur in the sigmoid colon, which is the last part of the colon, and in the rectum. Also, tumor analysis have identified differences in mutations and molecular profiles among patients with different ages of colorectal cancer diagnosis. And finally, young onset colorectal tumors are more likely to have poor differentiation and lymphovascular invasion and other features of more aggressive disease. So all of these features kind of make scientists and doctors think that perhaps there’s just something different about the biology of colorectal cancer in young people. So could genetics be the answer? Well, we know that about 25% of individuals with early onset colorectal cancer have a family history of colorectal cancer, but that’s only 25%. There are genetic syndromes that predispose to colorectal cancer, but they only account for a small percentage of early onset colorectal cancers. And multi gene analysis test panels did not identify a dermal mutation in 80% of individuals with early onset chlorophyl cancer.

So if we look at this pie chart, you can see that in people over 50 diagnosed colon cancer, about 10% can be attributed to certain genetic condition syndromes, whereas 90% are called sporadic, whereas in younger people, the piece of the pie that’s attributable to genetic conditions is higher. It’s 20%, but that still leaves 80% that cannot be fully explained by a germline mutation. All right, well, what about our environment. So we do know that there are significant geographic differences in disease prevalence, which suggests that environment plays a role. So this could include things like agricultural runoff and industrial pollution and lifestyle related factors and occupational exposures. And if you look at this map of the United States, which shows the rates of colorectal cancer, you can see that the darker colors represent higher rates. And some of these areas that represent the highest rates are some of the areas that have the highest risk of things like agricultural runoff, especially pollution and certain lifestyle factors in the populations in these areas. Another big one is obesity. So approximately 10% of colorectal cancer in all age groups is attributable to obesity when controlling for all other risk factors.

And we also have found that weight gain during young adulthood is associated with risk of colorectal cancer as well. In addition, obesity during childhood has been shown to be associated with colorectal cancer. And we know that childhood obesity has increased significantly since the early 1960s. So this is data from the CDC showing obesity rates from the 90s to the 2010s. And the numbers have really skyrocketed. So it is possible that increases in childhood obesity and obesity during young adulthood could be an important risk factor for colorectal cancer. And intimately tied to obesity is type two diabetes. We know that the mean age at diabetes diagnosis has decreased from 52 years in the 1980s to 46 in the 2000s. And diabetes leads to chronic inflammation and tissue injury, which could possibly increase the risk of colorectal cancer development. Okay, what about diet? So first of all, more to come from Suzie. But I’ll just mention that back in 2015, Time magazine on their cover had a story called The War on Delicious, which talked about certain common dietary trends and foods that increase the risk of colorectal cancer. And in addition to that, physical activity, which is tied to diet, of course, has been shown to be an important risk factor among all age groups.

Colorectal cancer rates are lower among physically active people. And unfortunately, we have all become more sedentary due to our deskbound jobs. So some other proposed factors, changes in the microbiome tolerance and preservatives in food, extensive use of antibiotics, both in agriculture and in medicine, reduced rates of breastfeeding, cesarean delivery. Basically, all of these things kind of highlight the fact that this is a very complex disease, and there’s an interplay between genetics, environment, and lifestyle that has led to an increase in the incidence of colorectal cancer in young adults. So what can we do about it? Well, the main thing that we can do about it is screen people. Colorectal cancer screening has been responsible for, in large part, for the dropping rates of colorectal cancer in older adults. So it should also help in younger adults. So screening is defined as looking for cancer before a person has any symptoms. To help find cancer at an early stage. And there are multiple tests available for colorectal cancer screening. But colonoscopy is currently considered the gold standard for colorectal cancer screening. As many of you know, colonoscopy involves a patient being lightly sedated so they’re not experiencing any discomfort or pain.

And then a doctor carefully guiding a device called the colonoscope through the rectum and the colon, allowing them to inspect the lining of the rectum in the colon, identify precancerous polyps, and remove them right then and there. And as I mentioned before, the advent of colonoscopy or screening colonoscopy in the 1990s is one of the major reasons for this steep drop in colorectal cancer. And people in their 50s, 60s, 70s and 80s. And because colonoscopy has been so effective and because of the increased rates of colorectal cancer in young adults, the United States Preventative Services Task Force has recently updated their guidelines and are now recommending that all adults aged 45 to 49 be screened for colorectal cancer, just like their 50 to 75 year old Patriots. And so, as all the cool kids are saying, 45 is the new 50 for colorectal cancer screening? Well, the 45 is a new 54 people at average risk. Well, what if you have an increased risk of colorectal cancer, and what does that mean? So individuals at increased risk could be those with a family history of colorectal cancer. As we mentioned, about 25% of individuals with early onset colorectal cancer have a family history.

And how does that impact one’s risk? Well, you can see in this graph that if you have one first degree relative with colorectal cancer, it more than doubles your risk of developing colorectal cancer in your lifetime. If you have a relative who was diagnosed with colon or rectal cancer at a young age, that almost quadruples your risk. And if you have more than one relative with colorectal cancer, more than quadruples your risk of colorectal cancer. Another way that one can have an increased risk of color cancer is if there are hereditary cancer syndromes in one’s family and if you have inflammatory bowel disease, such as Crohn’s disease or all sort of colitis. This graph shows a startlingly high rates of colorectal cancer in people with something called familial adenomatous polyposis or hereditary non polyposis colon cancer. You can see that, for example, in the average 50 year old, the risk of colon cancer is relatively low, whereas the risk in people with these genetic conditions is incredibly high. So if one has a family history of colorectal cancer, then the screening recommendations are a little bit different. It’s recommended that you start screening at age 40 rather than age 45 or ten years before the youngest affected relative is affected by colon cancer.

So, for example, if your mom had colorectal cancer at age 35, then you should get screen at age 25. And it’s recommended that colonoscopy be performed more frequently every five years instead of every ten years. And if there are many family members of colon cancer in the family or other cancers in the family, one should consider genetic testing. So the hereditary colon cancer syndromes are brought a huge topic in itself and beyond the scope of this talk. But the one thing I’ll highlight is that people should know their family history and know whether there are certain cancers, such as colon cancer, endometrial cancer, uterine cancer, bladder cancer, kidney cancer in the family because all of these could impact your risk. And if you have inflammatory bowel disease, you should follow closely with your GI Doc for cancer screening recommendations. So another super important factor is awareness and timely diagnosis. So failure to consider the possibility of colorectal cancer by both patients and doctors contributes to delays and diagnosis in younger adults. People just simply don’t think that a young adult with certain symptoms could potentially have colorectal cancer. In fact, in symptomatic young adults diagnosed with colorectal cancer, the diagnosis is made, on average, six months after the onset of symptoms.

And thus, young adults with colorectal cancer are more likely to be diagnosed with advanced stage disease. So what do you do? We have to be aware of red flag symptoms such as rectal bleeding, iron deficiency anemia, changes in your bowel habits, or abdominal pain. That’s unexplained. And you should see a doctor about those things. So we’re talking all about colonoscopy and we’re talking about screening. So are all these colonoscopies actually going to make a dent in colorectal cancer rates? So this is data from the USPSTF United States Preventive Services Task Force, and it’s a busy slide with lots of numbers and graphs. But let me just sort of break it down for you. So this is trying to summarize the net gains of starting colorectal cancer screening at age 45 instead of 50. So per 1000 person screens, it will lead to about 22 to 27 additional life years gained, two to three additional cases of colorectal cancer averted and one additional colorectal cancer and death. Now, if you’re not impressed by that, if you do a quick backup envelope calculation for the 20,000,045 to 49 year olds, give or take in this country, that’s an additional 440,000 to 540,000 additional life years gains, 40 to 60,000 additional case of colorectal cancer averted and 20,000 additional colorectal cancer deaths.

Huge numbers. So to summarize, what can you do to decrease the risk of colorectal cancer? No adults. So get screened, know your family history, do not ignore symptoms, quit smoking, maintain a healthy weight, eat a healthy diet. And since I said eat a healthy diet without further Ado, I will send it over to Suzie to talk about dietary things that we can do to decrease colorectal cancer risk.

Suzie Finkel, Dietitian

Perfect segway, I’m going to share here. All right. So let me just back up. There we go. I want to talk about the role that nutrition can play here. And while environmental and genetic factors play a major role in the pathogenesis of colon cancer. There’s extensive research suggesting that nutrition can play both a causal role and a protective role in colon cancer development. There have been now close to four decades of a ton of research on dietary and lifestyle factors associated with disease risk. It’s kind of ever evolving with lots of gaps, but definitely some things we can say are pretty strong associations. You might have seen headlines that are sort of popping up all the time and I want to try to synthesize the latest research we have so we can consider some specific actions to take for prevention. This research is really exciting because it tells us that there are very likely modifiable factors to help better position us for a lower risk. So what exactly have researchers found to date? This looks like a lot here, because it is in fact a lot. Dietary links are based on reviews of findings from hundreds and hundreds of studies which together have included probably well over a million research subjects to assess what happens with their colon cancer risk over time.

And also if a person has colon cancer, what did their diet look like beforehand? So I’ll focus on some factors here that have the most convincing evidence, according to recent research analysis, on the association between diet and risk. So meat perhaps the most famous diet component linked to colon cancer risk. It’s been well established that regular intake of red meat, meaning proteins like beef, pork and lamb, and processed meat as well meaning deli meats, Salami, luncheon meats, packaged sausages increase colon cancer risk. Why? Because red meat and processed meats can generate carcinogens, including what we call nitrosa compounds, as well as heme, iron, sulfur containing amino acids and some contain saturated fat. So across studies, our latest figure is that there’s a 20% increased risk of colon cancer per three and a half ounces of red meat consumed per day and close to 2oz of processed meat per day. So for red meat, that’s about a deck of cards serving, and for processed meat that could be two to three deli slices per day. Other research has found a 13% increase risk amongst higher intakes of meat, which was about 1.7oz or more daily. That’s like one hot dog.

And Interestingly remote rather than recent intake of red meat was significantly associated with colorectal cancer in some studies, which suggests that there could be that initiating role in colorectal cancer promotion many years earlier. So dairy another nutrient here with high grade, convincing level evidence. And in connection to dairy, there’s a growing amount of research on dietary calcium intake as well. So dairy products may inhibit colorectal cancer development due to a few theorized mechanisms which include fatty acids like linoleic acid, as well as the production of a short chain fatty acid called butyrate with anti inflammatory benefits in the colon and potentially even lactic acid bacteria and fermented milk products. Also, dairy contains a high amount of calcium and vitamin D in the fortified dairy products, which may be a potential mechanism as well. So across studies, there’s a fair amount of research on total dairy consumed. But the most convincing evidence recently is that high intake of yogurt 8oz per day reduces risk of colon cancer by 16% compared to non yogurt eaters. And there’s an extra protective benefit that was found when this was consumed 16 to 20 years prior to a study date.

So more compelling research has also shown that men who ate two eight ounce servings of yogurt per week had a 19% reduced risk of colon cancer compared to non yogurt eaters. So part of this may be due to the dietary calcium, because calcium has also been shown to reduce colon cancer risk by around 23% when consumed in larger amounts, meaning then more than 700 milligrams, which is about two and a half glasses of Milk’s worth. On the causal side we see an increased colon cancer risk is associated with dietary calcium intake of less than 700 to 1000 milligrams per day. There’s limited findings for calcium supplementation. Research really points to calcium from food sources and the dairy products in particular. So fiber if you’re a patient of mine, you’ve definitely heard me talk about fiber before. But here we’re looking at the evidence that’s linked high fiber intake to lower risk of colon cancer. Fiber has potential anticancer mechanisms by way of binding bile acids, increasing stool weight, decreasing colonic transit time, and importantly, bacterial fermentation that affects PH and the production of short chain fatty acids. High intake of fiber has most recently been shown to lower colorectal cancer risk by 16% compared to low fiber intake, and specifically with a 10% lower risk associated with each additional 10 grams per day.

And there’s extra buzz now on the research showing that three servings of whole grains in particular are linked to a 17% decreased risk in colon cancer. So a nice plug for that high fiber carb source. Fruits and vegetables on their own contain phytonutrients and antioxidants and vitamins and minerals, and have been linked to reduce cancer risk. But the most emergent recent evidence is focused on how fiber helps to feed the gut microbiome, particularly the growth of butyrate producing bacteria over other bacteria because of the anti inflammatory facts of the short chain fatty acid. On the flip side of this, there’s a bacteria that have been associated with colorectal cancer development and have been repeatedly found in colons of populations that consume low fiber diets. So vitamin D is also a factor here with suggestive evidence for the reduced risk of colon cancer development. A vitamin D intake of greater than 450 International units per day or more was recently linked to a 50% reduced risk of early onset colorectal cancer in women, and this link was strongest for dietary versus supplemental vitamin D. Other studies have also found reputed associations between vitamin D deficiencies and greater risks of colon cancer.

The evidence for vitamin D supplementation, though, is shaky. But we can get vitamin D from fatty fish, a bit from egg yolks and mushrooms, and as I mentioned, fortified dairy. We can also get from the sun, but we want to get a good report from the dermatologist. So just being careful there. So I want to pause just on the dietary pattern piece here, which is really probably the most important kind of concept to consider, is that nutrients and foods tend to interact, and we know from science that an overall dietary pattern plays a really important role. I’m talking about these individual factors. These are things that we know to have association, but a lot of these factors in conjunction with one another and habitually versus occasionally including these things in your diet or not can be most important. So specifically here, there’s a significant association of higher cancer risk with adherence to a Western diet, which includes high consumption of processed and red meats, refined grains, soda and sweets, versus the prudent diet pattern, which includes high intake of fruits and veggies, fish, poultry, whole grains, and legumes. So important to note here that higher cancer risk has also been repeatedly associated with childhood adherence to a Western diet.

A variety of diets seem to oppose the Western diet pattern, though, and these include a Mediterranean diet, semi vegetarian diet, other generally high fiber diets, which are repeatedly linked to lower colorectal cancer risk. Recent research on what’s called the dietary inflammatory index of food, which is the propensity for a food to have a pro inflammatory effect or an anti inflammatory effect in the body, has shown an increased risk of colon cancer for proinflammatory foods as well. So alcohol also has convincing evidence here. The incidence of colorectal cancer, strongly associated with consumption of four or more drinks per day compared to zero or occasional drinks, and heavy drinking has been shown to increase risk by 58%, which is huge compared to low or no consumption. Association between alcohol drinking of more than one drink per day also elevates colon cancer risk. Physical activity, as Dr. Naymagon mentioned, is an important link here as well. Several mechanisms have been proposed for this, including reduced insulin resistance, anti inflammatory action, direct immune action, and decreased, I’m sorry, generation of higher vitamin D levels. Physical activity of five to 6 hours per week of moderate to vigorous intensity has been shown to reduce colon cancer risk by 20% to 25%, compared to a lower level, which is about a half an hour per week or less.

And what’s interesting is that a significant protective effect has consistently been found across subjects of varying body sizes with different types of physical activity, which suggests that it’s really the habit of the regular exercise that may provide the important benefit there. Smoking also a factor that is not really known to provide any benefits and can be cancer promoting, but specifically for colon cancer risk, we know that there’s a sort of dose response relationship here with intensity and duration. Current smoking is associated with a 59% increase. Again, huge number there compared to non smokers, former smoking is associated with a 19% increased risk and quitting immediately starts reducing your colon cancer risk. So there’s a lot of nutritional questions that are still underway. And so I just kind of want to touch on some things that we don’t quite have good evidence for or no evidence for. Again, it’s important to consider that nutrients and foods tend to interact and dietary pattern is really what’s emergent here. And so I can tell you, as the research stands now, we don’t have any evidence that there’s a supplement regimen that you can take to lower your colorectal cancer risk.

So with fiber products, for example, fiber supplements that can help to manage GI symptoms but have not been shown to feed the gut microbiome the same way that fiber from food does and produces the anti inflammatory effect in the gut. This is also true with antioxidant supplements, which there’s a lot of buzz around taking vitamin C and vitamin E, A and selenium. But isolated from food, they have not been proven to effect on cancer risk. This would also be true for probiotics probiotic supplements. No evidence of probiotic supplements offer benefit in humans for cancer prevention. Microbial composition may play a role in colon cancer risk, but it’s not substantially altered by bacteria pills. And then there’s still more research to do around fat content in our diet. Neither total fat nor specific types of fat are well established with colon cancer risk. In particular, though, there’s some evidence around saturated fat being a risk factor or high intake of saturated fat. High saturated fat diets have been shown to be pro inflammatory and increased intestinal production of cancer promoting agents. But we do need more research for the colon cancer risk specifically. So what can you do?

Moving forward from the research here, we can put together some sort of tangible things definitely eating plant foods we know to be beneficial. Fruits, vegetables, nuts and seeds, whole grains, all the fiber that you can tolerate depending on your TI condition is going to be excellent. Moderating intake of red meat and processed meats, right. Splitting the plate so that you have some plant foods to have less of a meat component if you are consuming meat, but really trying to minimize the frequency, choosing other lean proteins instead, minimizing moderating alcohol, that’s also going to be an important factor. It’s recommended that you have less than two drinks per day, two for men, one for women on average. Consuming calcium rich foods may also be important here with the research on dairy, the plug for yogurt in particular, we don’t fully know, but there’s really good evidence so far. So some low fat dairy leafy Greens are also sources of calcium on its own. Fortified foods and choosing whole foods, because we know that a lot of these nutrients in tandem may work best together. The research is really on the full diet pattern here, things coming from whole foods most compelling for the food piece, not so much the supplements, regular physical activity.

Find a form that feels fun, engaging for you and not punishing all the time, but hopefully some movement that you can do depending on your ability and really avoiding low fiber diets. Right. Trendy diet, fad diets. You probably know a few that I’m referring to. Keto diet, perhaps other forms of low carb diets that are cutting out whole grains and beans and fruits and things that have the fiber, the substrates for our beneficial bacteria that may play a really protective role here. And also just think overall about your dietary pattern and habits generally, not to really stress over individual meal choices, every little food that you eat in a day, but really what your diet pattern and lifestyle is looking like overall, because those cumulative effects may be really important. And, of course, you’ll meet with a dietitian for some personalized guidelines to review your diet, talk about ways that you can optimize your intake and ask questions, and come up with a customized plan, if that’s of interest to you. So thanks, everyone, for attending, and we’ll open it up for any questions.

Dr. Laura Fredo

Thank you, Suzie.

That was great.

And thank you, Steven Naymagon I hope our participants got something out of that.

I’m sure they did.

Because there’s a lot of information. We got some great questions coming in.

And I tried to answer some of them.

But some of them I want to share with you guys so everybody can partake in those answers. One thing that I don’t think we really touched on that I just wanted to bring up was what are the actual symptoms of colon cancer? We’re talking about what colon cancer is and what it does. But what should people be looking out? I don’t want them to go home and be scared that they have colon cancer. But what are the red flag things that you really want to bring to attention of your doctor?

Dr. Steven Naymagon

Oh, yes, Laura, that’s a great point. So one of the important messages, I guess, is that in many cases, colon cancer can be as no symptoms at all, which is why we sort of are standing up and hollering on our soapbox about screening young asymptomatic people. The trouble is that once colorectal cancer causes symptoms, it tends to be at a more advanced stage. So those precancerous polyps and those stage one cancers typically won’t cause any symptoms. But once it becomes more advanced, it can cause things like I mentioned, like rectal bleeding, changes in your bowels, whether it be more difficult to go the bathroom or the characteristic changes. It can cause abdominal pain, it can cause weight loss. That’s unexplained. So those would be the things to look out for.

Dr. Laura Fredo


Thank you. We had some questions just about polyps in general, but specifically what causes polyps, which we kind of talked about that’s the whole pathogenesis of and all these risk factors that lead to colon cancer. But kind of talking just briefly, we don’t have to get too detailed about what causes the Poly up and what changes the Poly up into cancer and what’s that timeline look like. And how does it change when we look for cancer and that sort of thing?

Dr. Steven Naymagon

Yeah. So I completely agree with you, Laura, that the pathogens polyps and cancer is sort of one and the same. So there may be a mutation in one individual cancer cell that then propagates. And over time, that collection of mutations leads to the uncontrolled growth of cells, which is what defines cancer carcinogenesis. And that process takes in most cases years to decades. So with the exception of certain high risk syndromes, most polyps will take a very long time to turn from a precancerous or benign polyp into a cancer. And that really works in our favor because it allows us to find those polyps and remove them before they can cause a problem.

Dr. Laura Fredo

And on that same guideline, that’s why when we remove the polyps, if you’re someone who makes polyps, we don’t want to wait necessarily a full ten years for a repeat colonoscopy. We’re more in like the five to seven year range because we want to catch them before a new Polyp develops and it changes over that time. But in the same line, we don’t need to do them yearly, luckily, because it does take a while for the normal tissue to turn into a Polyp to turn into a cancer. So I think we’ve kind of found that sweet spot where if we can check the asymptomatic, people find them before they become an issue. And on average, if you’re low risk and haven’t had policies, taking a look every ten years or so is usually the guidelines at this stage. We had some other great questions about for Susie specifically, everyone always wants to know about processed meat. And is deli meat really that bad? What about if it says nitrate free or things like that?

Suzie Finkel, Dietitian

Yeah. So interesting question about nitrates. Nitrates. So it’s really hard to avoid even if it says it’s nitrate on the package, it’s hard to avoid some of the potentially harmful effects of these processes. So even the organic deli Turkey, whatever, you might know, some brands, they’re still part of this research. So it’s not the added preservative. There’s naturally occurring forms of it as well. And so if you’re having these things occasionally, like I wouldn’t be super concerned, but if it’s your lunch every day, I would switch it up. Really try having something else as your staple and reserve it for occasional eating.

Dr. Laura Fredo

Very useful and helpful tips. Thank you. What about the antiinflammatory diet? Can you give us a little more information on what sorts of foods fall into that category? I mean, obviously alcohol and the red meat we talked about. But anything else that would be interesting to know about?

Suzie Finkel, Dietitian

Yeah, there’s actually a lot it can get very specific. And I kind of like to say that what we refer to as the Mediterranean diet, which doesn’t have to really be Mediterranean in the way Italian and Spanish, although that’s what we think of when we think Mediterranean, but can’t look like really any kind of global cuisine. But that can be the principles of a Mediterranean style diet. That’s what we refer to a lot. It’s sort of the gateway to an anti inflammatory diet, but an anti inflammatory diet gets a lot more specific. And actually, tomorrow, Duker Freuman our other dietitian here, did an excellent, really in depth webinar on all the different foods and how they’ve been classified based on this kind of inflammatory propensity spectrum. And she goes through, like from very specific spices and whole foods. So that’s a great place to learn about it as well.

Dr. Laura Fredo

Yeah, that’s on our website as well, under one of the prior webinars. It’s a super resource. Okay, switching gears again, colonoscopy, of course, is our gold standard for screening for colon cancer. But Dr. Naymagon, can you tell us a little bit about the other options to check for colon cancer and how effective those are? More or less, sure.

Dr. Steven Naymagon

So the alternative to colonoscopy that’s really made a big dent, I think, in the last several years is Cologuard, which is the stool based colon cancer screening test. Cologuard is a test that tests for a number of factors, including blood in the stool or heme in the stool, as well as certain genetic markers that cancer cells and polyps shed. So basically, by testing a stool sample, they’re able to identify patients who are carrying cancer or polyps in their colon. And the sensitivity of this test, basically, which means how good is it at finding those people with cancer? And polyps is pretty darn good. For colon cancer, it’s over 90% sensitive. For colon polyps that are on the larger side, it’s over 70%. And for smaller polyps, it’s probably about 50%. And all of these are numbers that are compared to colonoscopy. So if we consider colonoscopy to gold standard, it’s going to find 100% of cancers. Cold will find 90%. So I think and the way that I counsel my patients, Laura, I’d love to hear how you approach it is I tell my patients that if you come in and tell me, Doc, there is no way on this planet that I’m ever getting a colonoscopy, I tell you, at least get a Cologuard, because that’ll help you risk stratify yourself.

And if it’s negative, by all means, I’m going to leave you alone. And if it’s positive, then we have a different conversation. But for the average young person who is at average risk for colon cancer and who doesn’t have any contraindications to colonoscopy, I usually tell them get the best test possible, because I don’t know if a 50% sensitivity for finding small polyps or even a 70% sensitivity for finding large polyps is good enough if we’re trying to prevent a possibly life threatening disease. In addition to Cologuard, there’s also been called a virtual colonoscopy, which is basically a fancy Cat scan that uses special sequences that looks specifically at the colon. I think the performance characteristics of that are comparable to Cologuard. And then there’s also something called a capsule colonoscopy, which is sort of still in its infancy and not widely available.

Dr. Laura Fredo

Yeah, I agree with pretty much everything you said. For me, it’s one of those things. Why wouldn’t you have the best test possible to prevent and find the thing that we’re actually looking for? I often have this discussion with my patients who are interested in the cooler garden. Again, a screening test, whichever way it’s done versus no test, is the best test. So I agree with that. If you’re absolutely not going to get a colonoscopy Cologuard, great option. Sometimes we’ll use it for someone who maybe they don’t have a good access to getting in for a colonoscopy or something, and it would take a lot of coordination. You have to bring a family member in from out of town. So if we have the whole of guard, that’s normal, we feel a little better. But if it’s positive, then you have a real good reason to get your aunt to come in from out of town and help you out getting home from your colonoscopy, for example. Another practical thing I talk about is sometimes when you do a Cologuard, that ends up being what your insurance counts as your screening test, and then if it’s positive, you still need a colonoscopy, we need to figure out why it’s positive.

So then your colonoscopy ends up being a diagnostic test because we’re trying to figure out what was wrong on your screening test. And sometimes that can change your insurance coverage. Usually it’s still covered, but it gets a little nuanced when it comes to that. So that’s something just real life practically I bring up that may be an issue. And then on similar wavelength, like the CT colonoscopy, we rarely will get that covered by insurance unless you have a reason to get that test. Like you’ve had a difficult colonoscopy in the past and we were unable to get to the end. And then there was one other thing I was going to say about the cologard. Oh, if you have any active symptoms, the Cologuard is not the test for you, because again, it’s a screen. So if you have blood in your stool or something like that, the Cologuard would be positive. So there’s no point in doing the Cologuard. We need to go right to a diagnostic colonoscopy. And if you have any high risk features, it’s really only intended for people between 45 and 75 years old. So sometimes we still screen people later in life if they’re going to live to a healthy 100 years old and it’s not actually indicated for people over 75 or if you’ve had a history of polyps in the past and we don’t want to put you through the Cologuard test again.

So it’s a little nuanced, but again, the colonoscopy, if you’re healthy enough to go through with it, it’s just the best tough to find and prevent the colon cancer. An interesting question I’ve had. It’s kind of basic, but how do you talk to your family about their history? And what specifically should we be asking them to know if we’re at higher risk for colon cancer?

Dr. Steven Naymagon

Yeah, I can see how this could be a difficult thing to bring up with people, but family members at the dinner table. But I think it’s just so important. One of the graphics that I showed was this sort of stepwise increase in risk of colon cancer in people with the family history. So I think people just need to kind of get over that really tough hurdle and say.

Dr. Laura Fredo

Hey, mom, do you have any polyps on your colonoscopy? Were they worried about them?

Dr. Steven Naymagon

Yeah. And did Grandma have any medical problems? Are there any cancers that she had? And it’s not just colorectal cancer, as we alluded to other cancers, such as GYN cancers, genital urinary cancers are also important because they can be a part of a syndrome of cancers that can increase one’s risk of multiple different malignancies.

Dr. Laura Fredo

Yeah, that’s perfect. Just ask the hard questions. A lot of people know someone in my family had cancer, but they don’t know what type of cancer. So arming yourself with that information will only set you up for the right plan that you need. Suzie, anything else you’re thinking of that you want to bring up before we close this out?

Suzie Finkel, Dietitian

I was just going to mention the colon prep quickly, which, you know, there’s so many different approaches depending on who your doctor is. But we definitely have ways to make it more palatable, play with temperatures and flavors. And if that’s ever a barrier for anyone, talk to us, send us a message. The RDS do, but even the doctor will as well, if you’re like. That’s just the taste of it. It’s nauseating. It makes me sick. Whatever it is, it’s one night of your whole life. It’s not the worst.

Dr. Laura Fredo

I always say it’s a very inconvenient day for a lot of reassurance.

Suzie Finkel, Dietitian


Dr. Laura Fredo


Suzie Finkel, Dietitian

If you’re a parent, you might get some really good sleep. Who knows? Some relief, hopefully. Great.

Dr. Laura Fredo

Dr. Naymagon, anything else you want to add before we close out for the night?

Dr. Steven Naymagon

No, I just want to thank everyone for joining us. And as gastroenterologists. I think colon cancer prevention is one of the most important things we do. So just raising awareness, I think is super important. And I really appreciate everyone for listening and Laura thank you for moderating and Suzie thank you for teaching us out with the dietary aspects of it.

Suzie Finkel, Dietitian

Likewise. Thanks everyone.

Dr. Laura Fredo

Thanks, guys. Thanks everyone for joining in. Have a good night.

Dr. Steven Naymagon

Night, everybody. Bye.

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