Colorectal cancer rates are rising among young adults. We are Dr. Chang and Dr. Morris, colorectal cancer physicians at The University of Texas MD Anderson Cancer Center, and Abigail Pardo, a 26-year-old colorectal cancer survivor. Ask us anything...

Is there any research indicating potential reasons for these increases? Further, it seems blood in stool is an easily recognizable symptom - which non-blood related symptom would you say is the largest red flag?

Another red flag would be unexplained changes in bowel habits, such as changes in stool caliber. But sometimes there may be few symptoms, which is why it is important to pay attention to our bodies and seek medical attention should such symptoms develop. - Dr. Chang
I think that the symptoms that people may experience when they present with colorectal cancer are often very similar to other, more benign medical conditions that do not have anything to do with cancer and may sometimes delay the diagnosis of colorectal cancer. Given this troubling trend of rising cases of patients with early-onset colorectal cancer, I think that people having knowledge and awareness of symptoms associated with colorectal cancer - like worsening fatigue, unexplained anemia (low red blood cell counts), bloating in the abdomen, change in bowel habits, for example, especially if they do not go away, should prompt people (regardless of age) to seek further assessment with their medical provider. - Dr. Morris

Abigail -- How were you diagnosed? How did you find out that you had colorectal cancer?

I was diagnosed at the age of 19 (fresh out of high school!). I noticed my stool had blood in it at one point and, like what most young people do, I googled it. When I saw the frequent answer of colon cancer, I was in denial since it was so common to see colon cancer in older folks. I just believed that I probably ate something bad. I continued to put it off and as more time went by, I noticed how easily I would get tired and would get constant headaches/nausea. After four months, I finally convinced myself to go get checked and sure enough, I had a tumor the size of a golf ball in my colon. After that, it was just a snowball effect of one thing after another to get my health back on track. - Abigail

Are we close to implementing less invasive screening tools than the colonoscopy?

There are many advances taking place to make colorectal cancer screening less invasive. Currently, there are tests to identify even small amounts of blood or presence of altered DNA associated with colorectal cancer in the stool. The newest tests are highly sensitive for identifying cancers but are not as good for detecting polyps that have not yet turned into cancer. It is important to identify polyps before they turn into cancer so that they can be removed.
Currently colonoscopy is the best way to identify pre-cancerous polyps and remove them before they can develop into cancer. In another answer, Dr. Morris has also described emerging technologies in blood-based tests using circulating tumor DNA. Although a colonoscopy will still be required after a positive non-invasive stool or blood based test, in order to confirm the diagnosis and to find the cancer within the colon, ongoing advances in non-invasive testing will mean that in the future, more people can be screened for colorectal cancer without the need for colonoscopy. - Dr. Chang

One of the newer technologies that I have been excited about most recently is circulating tumor DNA. This is a highly sensitive, highly specific blood-based test that can be used to identify microscopic levels of cancer cells that may be present but perhaps is too small to be identified by more traditional tests like CT colonography or colonoscopy. Currently, we know that we can use these tests to identify patients with colon cancer (or other types of cancer) who are at higher risk for the cancer coming back. I am very optimistic that future efforts will seek to incorporate this “ctDNA” technology into screening measures for colon cancer and other cancer types. Ongoing trials have started to look at use of ctDNA as a screening method. - Dr. Morris

You say that rates are rising in younger people, but also that very few people have it, percentage wise. On the hypochondriac scale of worry, should I be accutely worried about these things, or just mildly aware? Answer with as much candor as disclaimers allow.

I have always felt like media has portrayed cancer as something everyone gets, but it also feels like that might be an exaggeration, and I just only have so much worry to dole out in my life.

Is cancer a cost basis risk assessment that most people will win against, but that when you lose it's the worst?

Colorectal cancer is still more common among older adults. Today, about 1 in 10 patients with colorectal cancer are under 50 years old. However this is changing: the rates are rising much more dramatically in younger adults (while decreasing in older adults, thanks to screening). In addition, colorectal cancer in younger adults is more likely to occur on the left side of the colon and in the rectum. If the current trend continues, up to 1 in 4 patients with rectal cancer may be diagnosed at <50 years of age. - Dr. Chang

How can one better assess their symptoms at home when they already take a medication (metformin) that regularly gives them diarrhea/soft stools (some with blood/some without), tiredness, reduced appetite, stomach cramps etc already commonly associated with colorectal cancer? My aunt just went thru 3 years of treatment for it - and it was hell on her (she is not blood related).

We are sorry to hear about your aunt. This is a very good question and one that we get asked A LOT. Certainly many of the symptoms associated with colorectal cancer can be similar to other medical conditions, or, as you mention, side effects of certain medications. I think this is one of the reasons it is important to have perhaps a heightened concern when someone notices that, while on a certain medication (citing your example), symptoms start to change while on the same dose.
So, if you been on the same dose of metformin for a while now, and you notice that your appetite is getting even worse or your bowel patterns seem different and don’t seem “normal” for you, then it is important to mention this to your provider in order to make sure there are not other conditions/processes going on in your body, beyond other conditions you may be getting treated for. - Dr. Morris

What do we know so far about why rates of colorectal cancer are on the rise in younger people?

In addition to the earlier comment, other lifestyle factors that are important for people of any age to keep in mind for cancer prevention include regular exercise, maintaining a healthy weight and healthy diet. - Dr. Chang

Any ideas why?

We don’t fully know, but it may be associated with a number of environmental and lifestyle factors. Recently, we are learning more about the role of the gut microbiome as well. - Dr. Chang

Will having colonoscopies every 5 years always catch polyps before they become cancerous, or do some grow very quickly?

Although some polyps can become cancerous more quickly than others, in general, it takes a long time for polyps to become cancers, often several years. Having colonoscopies at regular intervals is the most effective way to catch polyps before they become cancerous. After a normal screening colonoscopy, it’s currently recommended to repeat the test in 5-10 year, as long as you don’t develop symptoms in the interim. - Dr. Chang

How big of a factor is a healthy diet in preventing colon cancer? I always hear “eat a healthy diet”, but how much power does that actually have to reduce your risk of cancer?

We recognize that diet is very likely related to development of colorectal cancers. For example, low-fiber diets and diets that are high in red meat consumption may be associated with a higher likelihood for getting colorectal cancer. These (Western) diets may be contributing to the rise in early-onset/young adult colorectal cancers. At MD Anderson, we also are strong believers that diet is very important for patients who have been treated for colorectal cancer and/or are currently being treated for colorectal cancer. For this reason, we work closely with dieticians who have experience specifically in helping patients with GI cancers, in order to provide a comprehensive approach to their care. - Dr. Morris

First, how would you summarize the most important signs/symptoms of colon cancer? Second, what actions can the average person take to attenuate the risks of developing colon cancer? Finally, what medical screening/exams/tests can one seek to evaluate colon health?

These are great questions. In general, I would respond that “knowing your body” and recognizing anything that doesn’t feel normal for you (especially if it does not go away) merits discussion with your medical provider. For the more common “warning signs” associated with colorectal cancers, I would say that blood in your stool (sometimes bright red or sometimes black, tar-like stools), abdominal bloating, unexplained fatigue (with or without unexplained anemia), persistent abdominal pain, and/or changes in bowel patterns are often symptoms patients tell us they experienced when they were first diagnosed.

For a patient with “average risk” for developing colorectal cancer, it is very important to make sure that you are getting appropriate screening for your age. Tests like colonoscopies can detect precancerous adenomas, which may develop after several years and can be removed before they turn into actual cancer. For the past year, since the COVID-19 pandemic started, we, as providers, have been concerned that patients may be reluctant to seek out preventative cancer screenings like colonoscopies (or mammography, Pap tests, etc.) while the pandemic is ongoing. There is a risk (and some early data to suggest) that delaying screening may result in delays in diagnosis of otherwise potentially curable cancers such that, if diagnosed, this occurs at a more advanced stage. We encourage people to seek the appropriate cancer screenings for their age and gender. More information is available here: https://www.mdanderson.org/prevention-screening/get-screened/colorectal-cancer-screening.html. - Dr. Morris

What is your favorite word in the english language?

“Yes” - so much so that I commissioned a neon sign that says “yes” to hang on the wall in my house :) - Dr. Morris

“Yet.” There’s so much power in the word “yet”. :) - Abigail

After Dr. Morris’ answer, “Yes” is my new favorite word! - Dr. Chang

Fellow Houstonian here! Thanks for all your help over the years. MD Anderson has always been a huge part of Houston and brings me so much pride knowing you’re a part of us!

Any advice on healthy eating habits or your favorite superfoods? Also for busy people on the go what’s your go to healthy meal that can be quick and easy?

Great to have you join us and thank you for the kind words. We are also proud to be a part of and serve the Houston community. As for healthy eating habits, you can never go wrong by incorporating more fresh fruits and vegetables into your diet. An easy and frequent addition to our meals is a fresh salad (romaine, tomatoes, cucumbers, and red onion slices are easily put together!), and fish is a quickly prepared protein (as a main or even on the salad). - Dr. Chang

I’m an elementary 4th grade math teacher, so you can imagine that I’m always on the go during the day. My favorite healthy choice is a pre-chopped salad kit mixed with a tuna packet. As for a snack, I like to pack fruits and nuts to eat! - Abigail

Abigail how does it feel to be a young cancer survivor? Does it change the way you see life?

Thinking back on my experience with cancer today, it almost feels surreal. I’m 100% healthy now and it feels as if it were a bad dream. I can definitely say that I take pride when I say ‘I survived cancer’ at such a young age. My experience with cancer has made me more grateful for the health I have today. It’s also taught me that I need to listen to my body when something is wrong. I live each day to the fullest now! - Abigail

I’m in my late 30s with GI issues for years. Doctor chalked it up to IBS and doesn’t seemed concerned. (Waking up with diarrhea in the middle of the night often..stomach pain often..Having to RUN to the bathroom at times, many times a day..then having days where I cannot go for many days, but the pain is there)

My grandfather died of colon cancer in his late 60s, my father has intestinal cancer in his 60s, and my doctor says they don’t screen for it until 10 years before your family member was diagnosed.

And because I’m young(ish) my insurance won’t cover a colonoscopy and my dr doesn’t seem concerned at all. Just keeps saying I don’t need it until I’m in my 40s

What can I do to screen for colon cancer or other intestinal cancers in the mean time?

Should I demand a colonoscopy? Am I doomed knowing many family members who have been diagnosed so young?

Is there another way to look for cancers besides the colonoscopy?

We often hear, particularly from our younger patients, that they had worsening symptoms for a long time before they finally got a work up. Current recommendations for colorectal cancer SCREENING are to start at age 45 OR at an age 10 years younger than when your first family member was diagnosed. However there is no minimum age when it comes to the DIAGNOSTIC evaluation of patients with symptoms that may be associated with colorectal cancer. If your symptoms are persistent, it’s worth discussing further with your doctor and insurance provider. One other alternative is to look into obtaining an at-home colorectal cancer screening test. - Dr. Chang

Reading your question, I can definitely relate to the frustration you’re probably feeling! Before I was diagnosed, I went to the hospital twice and they wrote it off as something else. Unfortunately, my colon cancer was discovered when I was at the brink of a coma from the lack of blood that was in my body. I believe you should advocate for your own health and ask for that colonoscopy from your doctor! Your health is so important and you only get one body. I’m sure if I would have known that colon cancer could affect me at such a young age, I would have requested one as well and perhaps it could have been caught earlier on! - Abigail

Serious question that I’ve never gotten and answer to - sometimes I can only move my bowels between about 10am and 3-4pmish.. no matter how badly I have to go.

Seriously, 9pm at night, not happening! Even if I’m bent over in pain needing to go..

I’ve brought it up to people and they treat it like a joke, but mostly I’m too embarrassed to say..

Is there some kind of internal body clock with my colon/intestines that happens? Or could that be a sign of some kind of issue?

I’m sorry that that has been your experience. I will say, first of all, as a provider, I never want you to feel that you are embarrassed about ANY symptom you may have. Symptoms that you have --however big or small that they might be perceived -- are real and merit serious evaluation and consideration by your provider. So I would just say that to hopefully empower you and encourage you to speak about anything that you feel you need to when meeting with your medical provider! For the second part of your question, I think that there are many factors which can affect how our bowels function: diet/certain foods, water intake, fiber intake or exercise, for example. Other non-cancerous medical conditions (for example, irritable bowel syndrome, which may affect as many as 25% of Americans) can also affect bowel habits. A gastroenterologist would certainly be a good specialist to speak with who might be able to help you. - Dr. Morris

For the Docs - should I go to my primary care to get checked out? Or should I head directly to someone like a gastroenterologist?

I’m 30 y/o and had a colonoscopy about 5 years ago as I was having regular stomach aches and irregular bowel movements, including thin stool, straining to evacuate, feeling of fullness/heaviness. That gastro didn’t find anything on the scope and said it was just IBS.

Now a few years later it seems I’m feeling those symptoms again. Passing gas always takes an extra push and bowel movements require extra straining. Stool is always solid. Pardon if this is crass, but it just feels like my rectum is very tight? Haven’t noticed any blood and I feel generally well, but my behind just seems very tense at all times making using the restroom difficult.

Any thoughts?

You should never be embarrassed to discuss your bowel concerns with your doctor! If it has been 5 years since your last exam, and if those symptoms improved and you are now newly experiencing symptoms, it is definitely worth mentioning them to your doctor again, either your primary care doctor or your gastroenterologist. The most important thing is to get checked out. - Dr. Chang

Do you have any advice about talking to family members about colorectal cancer risk? I think it still feels like entering into taboo subject matter sometimes

It’s never taboo to talk about your health! I’ll be honest and say that I was definitely embarrassed at first with having that conversation about my colon. With everything that I went through though, it has made me realize that we shouldn’t be embarrassed to talk about, well, our poop. We must be able to take care of ourselves (since there’s only one of us in this lifetime) and never feel afraid to talk to your loved ones about colorectal cancer. It’s so preventable! - Abigail

This is a very valid concern that we frequently hear from patients. Sometimes people mention that they feel the same taboo that you mention in talking about the risk of colorectal cancer, and sometimes our patients feel some stigma once they have the diagnosis of colorectal cancer. We have collaborated with various patient advocacy groups which can connect patients with other patients who have worked through the same concerns with their own families, and who serve as excellent support systems for patients with colorectal cancer. We have social workers at MD Anderson as well who meet with our patients regularly and can work with them to help with any psychological or social concerns which may arise in making sure that people have the support that they need and deserve. - Dr. Morris

My wife is a colorectal cancer suvivor, going on 19 years now. One of the lasting side effects of her cancer is almost yearly bowel obstructions that require an NG tube to alleviate. We know that the obstructions are due to the resection surgery where a part of her colon and, of course, the cancer were removed. The surgery left scars which are the reasons for the ongoing obstructions. I have 2 questions: 1) Can anything be done to prevent these obstructions? Have been told my multiple doctors that diet has no effect and it “just happens” and 2) has surgical techniques improved to reduce or even eliminate this scarring?

You are not alone in this question. One of the greatest risk factors for developing bowel obstruction is prior abdominal surgery. Fortunately, bowel obstructions can often be managed without surgery, but sometimes surgery is required if the obstruction does not resolve. At MD Anderson, many patients are now treated with newer minimally invasive (such as robotic or laparoscopic) surgical techniques that help patients to recover more quickly, decrease the risk for intra-abdominal scar formation and can in turn decrease the risk for developing bowel obstructions in the future. - Dr. Chang

Does a barium CT scan rule out colon cancer if completely normal?

Double-contrast barium enema tests and air-contrast enhanced CT colonography tests are other ways of screening for colorectal cancer. At present, they both require a bowel prep, and if an abnormality is identified, will need to be further evaluated with colonoscopy. The barium enema test has advantages, such as no need for sedation and less cost, but is less accurate than colonoscopy. CT colonoscopy can be a sensitive test, but is dependent upon the experience of the radiology department, as well as the radiologist. A standard CT scan with barium oral contrast is generally unable to detect early lesions within the colon. - Dr. Chang

What are the preferred treatment options for mCRC pts with isolated lymph node mets? I have seen studies of LN resection from France and Korea, but not from the US--is there a reason for that?

We consider treatment of isolated lymph node metastases on a case-by-case basis here at MD Anderson. In select cases, we will consider a locoregional therapy, like surgery or radiation. Factors that may influence our decision to recommend treatments like this sometimes include how many lymph nodes there are, how many parts of the body have lymph node involvement by tumor, how long it took for the cancer to come back to those lymph nodes following any prior treatments, and if the lymph nodes are responsive to chemotherapy. In general, there is growing interest in better understanding how we best treat what we call oligometastatic (few sites of metastatic) colon cancer. Recent research has shown that many patients treated with these locoregional therapies will experience a cancer recurrence despite getting these treatments. At MD Anderson, Dr. Emma Holliday and Dr. Chad Tang are looking at the role of radiation in treatment of limited-site metastatic colorectal cancer, lymph nodes included. Here is one such clinical trial: https://www.mdanderson.org/patients-family/diagnosis-treatment/clinical-trials/clinical-trials-index/clinical-trials-detail.ID2018-0349.html. - Dr. Morris

My 33 year old husband was diagnosed with colon cancer last month, we are still waiting on the stage. He had a 10cm tumor removed last week.

My question is how long would it take for a tumor that size to develop? I read about colon cancer latency and it made it seem like this tumor could have been developing since he was in his 20s. Do younger people with colon cancer seem to have faster growing tumors?

My mother passed away from colon cancer in 2010, so I’ve joked this month that I’m way too f-ing aware of colon cancer! I am ready to spread that awareness to others and helped them to get screened.

Thank you so much for all of your work and best wishes to you Abigail!

Hi there! And thank you for the wishes! I wanted to chime in with my own experience. I do recall my own tumor being the size of a golf ball and I remember thinking ‘good gravy, how long has that been in there?’ When I posed the question about how long it could have been in my colon, there was an uncertainty or no real count to how long it could have been in there. Hearing that response was a real eye opener to the idea that cancer can just really strike at any given moment and sometimes it can’t be measurable. I’m so happy to hear you’re spreading awareness! - Abigail

We don’t know if colon cancers grow more quickly in younger people. However younger people are more likely to have a more advanced stage at diagnosis. Often the reasons for this are that younger patients take longer to seek medical care after they have developed symptoms or that it takes longer for their doctors to make the diagnosis. This is why we are highlighting the issue of young-onset colorectal cancer in this AMA! Our message to young people everywhere is to pay attention to their bodies and to seek medical care and get a work up if they are experiencing new, unresolving symptoms associated with colorectal cancer (blood in stools, change in bowel habits, unexplained abdominal pain). - Dr. Chang

I was diagnosed with sigmoid colon cancer on October/2020. I had surgery to remove it 15 days later. My gastroenterologist said that he is seeing a lot more colon cancers in younger people. Why is this?? Our diet?? Environmental issues??

We are seeing more and more patients who are presenting with colorectal cancer before the age of 50. Certainly diet and environmental factors may be some of the reasons contributing to this trend, but we don’t know for sure at this point. There is also ongoing research to understand if the biological drivers of colorectal cancer in patients under the age of 50 may differ from those who are diagnosed at older ages as well. At MD Anderson, we have a multidisciplinary team of doctors, genetic counselors, dieticians and social workers who collaborate to care for patients with early-onset colorectal cancer and to try to understand better why this is happening, with the goal of tailoring treatments accordingly in the future. - Dr. Morris

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We don’t think there is an association between HPV and the development of colorectal cancer. However, prior infection with HPV is strongly associated with the development of anal cancer, which is a different disease biology and treatment strategy compared to (adjacent) colorectal cancers. In general, the HPV types (HPV-6, HPV-11) that cause genital warts tend not to be the same HPV types (HPV-16 and HPV-18 being the most common) that cause cancers of the cervix or anus. If you are feeling a bump like you mention, I would recommend having your provider evaluate it further. - Dr. Morris

Has genetic testing for DPD Deficiency prior to chemotherapy become commonplace? I lost my wife to 5-FU (Flourouracil) poisoning in 2008. DPD Deficiency was like a black hole back then, any pretesting for risk was never mentioned and in her case, it only took one treatment. Wishing you all the best in research and raising awareness.

I am very sorry to hear of the passing of your wife. I would say that testing for deficiencies in DPD or UGT1A1 (which can, as you mention, increase susceptibility to toxicity of drugs like 5FU or irinotecan, respectively) is not something that we do routinely for every patient. With that said, it is imperative that providers recognize these deficiencies when caring for patients with GI cancers. There are some new medications that can reverse/mitigate the symptoms for severe 5FU toxicity. In our GI clinics at MD Anderson, we work hand-in-hand with a dedicated pharmacist assigned to each individual medical oncologist so that we can treat patients safely when administering chemotherapy, with the goal of minimizing chemotherapy-related symptoms and trying to foster the best possible well-being for every patient. - Dr. Morris