 Today we're going to be talking about colon cancer, so we're going to do a, we'll talk about a number of things. We'll talk about the demographics. These are things that I find that I get asked about all the time in the office. So it's demographics, the causes of colon cancer, risk factors, the treatment, screening, and prevention. So those are all of the big topics. So we'll just get right into the epidemiology. Everyone born in the United States, most Western nations have a lifetime risk of developing colon cancer of 4.6% now. And that's actually very good because when I started doing colon and rectal surgery back in the 90s, your lifetime risk was 6.2%. So that risk has gone down considerably. So that's great. So we find about 135,000 new cases present per year and about 57,000 people die in the United States from colon and rectal cancer. It's the second most common cancer killer. And it affects men and women about equally. So in New Jersey, in the United States and New Jersey, so if you look at all cancers, about 600,000 cancer deaths from all cancers in the United States. If you look at New Jersey, that breaks down to about 15,000 deaths from cancer. And if you break it down into the kind of the big four, breast cancers about 1200 deaths in New Jersey are colorectals 1360, lung 2930 and prostate 700. Since this is a women's wellness, we need to look at how that affects women, okay, because colorectal cancer, like I said, affects men and women about equally. So if you break this down, so you say 1400. So that means about 700 women are dying from colorectal cancer. And roughly the same thing for lung cancer. Lung cancer is a slightly higher predilection in men. But if you just figure, you know, half of this, so say 3000 1500, it's still lung cancer is still the most common cancer cause of death in women. But then breast cancer would be the second highest over colorectal. Because again, you got to cut this in half. So and of course, women don't get prostate cancer. So if you this, this screen just kind of gives us a distribution of the cancers nationwide by state. And New Jersey is a little higher on this. So that's kind of 575 deaths per 100,000. So we're on the higher end of the spectrum. So it's that means more cancers in New Jersey than other states as opposed to the dividing line is down here. So if you're below this line, then your state has fewer cancer deaths. So what causes colorectal cancer. So, you know, it really is a genetic mutation. And most of the mutations that we see lead to loss of control over DNA repair or growth, or what we call differentiation, which is how the cells decide, you know, which direction they're going to go in. So all of these different types of genetic functions can be affected through environmental changes. Most of the colorectal cancer that we see and what we call acquired. Okay. So it's not, you know, while the mutations are genetic, you're not born with that. Okay. So things change from a variety of different reasons. These are the way we eat. If we smoke, all of those things could predispose us to the mutations that lead to colorectal cancer. So 95, probably more like 96, 97% of all of the colorectal cancers are what we call acquired. Only a small percentage are actually genetically, genetically programmed. So there are certain people who have the genetic makeup that predisposes them to colorectal cancer from birth. Those patients have FAP, that's familial adenomatous polyposis. That's a genetic mutation. Only 1% of the only 1% of those patients who present with colorectal cancer have that. And then HNPCC, which is hereditary non-polyposis colorectal cancer. And that's another 2% or 3%. So that only gives you 4% of all of the colorectal cancers that are genetically programmed for colorectal cancer from birth. So what are we talking about? And this is not going to be a whole genetics talk. This is just going over because people ask this all the time. So you have normal, what we call mucosa, which is the skin inside the colon. And that goes to a small polyp and from there it continues on to a large polyp with cancer and then a colon cancer. And these are all of the genes that could be affected along the way or really have to be affected along the way in order to develop the colorectal cancer. So what are what are our risk factors? So I like to break down the risk factors in terms of intrinsic risk factors, things that we can't really control versus extrinsic risk factors, which are things that we can control. So the intrinsic risk factors include age. So the peak age for colorectal cancer is about age 70. We can't control that. When we get to 70, we're at risk. Obviously we're at risk earlier, but the peak age is 70. Only about 5% of colorectal cancers present below age 40. And that's changing a little bit and we're going to discuss that in some detail. The other intrinsic risk factors, your personal history. So if you have a personal history of colon cancer, then you're at higher risk to have a recurrence. If you have a personal history of polyps, so if you had your colonoscopy and they removed a bunch of polyps that are the pre-cancerous type, then that could increase your risk. If you have inflammatory bowel disease, which is Crohn's disease or ulcerative colitis, you're at increased risk for developing colorectal cancer because that is, by very nature, inflammatory. And we'll try to talk about that a little bit later. The inflammation is what predisposes you to the cancer. And if you have a significant family history of colorectal cancer, that is also another intrinsic factor. We'll talk about that in some detail as well. Some of the extrinsic factors, these are things that we do to ourselves that we could actually prevent our obesity diet. So we generally have a diet that is high in fat and low in fiber. We really want the opposite physical activity or lack thereof. Excessive smoking, alcohol, and some medications that we take, such as aspirin, hormone replacement, and folate, that actually decreases our risk factor. I'll talk about that a little bit. So diet specifically, we want a diet or we really need a diet that's high in fiber and low in fat. So that means fresh fruits, fresh vegetables, whole grain, cereals, and breads. Those are all the things that we should be eating a lot of. And you also want to drink plenty of water. So unfortunately, we don't do that. We have a diet that's high fat, low fiber, and the bulk of us don't eat a lot of fresh fruits and fresh vegetables or whole grains. So I think I usually tell people that the average daily fiber intake should be about 25 to 35 grams of fiber a day. And I would say that most people get maybe about nine or 10 grams of fiber a day if they're trying. In terms of family history, so like I said in the beginning, everybody borns, your general risk is 4.6%. So you're born in the United States, you have a 4.6% chance of acquiring colorectal cancer in your lifetime. Now, if you have a first degree relative, mother, father, sister, brother, who acquires colorectal cancer, that increases your risk by two times. If you have two or more first degree relatives, that increases your risk by four times. And probably the most important one is if you have a cancer in a primary relative that presents early. So generally under the age of 45. So even if they're 50, if they have a significant cancer with metastatic disease and all that, they probably acquired that at a much younger age. So 46, 47. But it does take time to grow. That is pretty much what we call a red flag. I mean, that increases your risk by over five times. So if you have a primary relative who is under the age of 50 or 45, you're at high risk for developing colorectal cancer. And then, like I said, if you have a personal history of familial adenomenous polyposis or FAP, you have a 100% chance of getting colorectal cancer. So that has to be addressed. Fortunately, like I said, that's few and far between at the FAP. Your risk is high. What are the other risk factors? So if you have inflammatory bowel disease, so again, called Crohn's disease or ulcerative colitis, particularly ulcerative colitis greater than 10 years, your risk increased by 1.5 times. Obesity, if your BMI is greater than 30, data shows us that those people also have an increased relative risk of developing colorectal cancer by 1.5 times. Diabetes, red meat, tobacco use, as well as alcohol use, more than three drinks a day, all increase your relative risk by roughly 1.5 times. So all of these things increase and they're all additive. So if you have two or three of these things, you're increasing your risk of colorectal cancer significantly. Some of the things that can decrease your risk. So these are things that we can do to minimize our chance of getting colorectal cancer. We exercise 150 minutes a week. That'll decrease our risk by about 0.7 times. Again, the high fiber diet 25 to 35 grams a day, which is a lot. You can decrease your risk by 0.7 times. Dairy and milk consumption, there's ongoing data that suggests that that helps us decrease our risk, usually because we're increasing our calcium intake. Some of the other things that decrease or potentially decrease our risk factors are the use of aspirin, folate, again, calcium and hormone replacement therapy. Now, generally speaking, we don't recommend for people to take aspirin to reduce your risk. But we do notice that people who take aspirin therapy for other reasons, maybe for their arthritis or what have you, have a lower risk of developing colorectal cancer. Same thing with folate and calcium and hormone replacement therapy. Obviously, we don't recommend hormone replacement surgery, hormone replacement treatment as a means of decreasing your risk. But if you are undergoing a hormone replacement therapy, then you get the side benefit of potentially reducing your risk. What are the signs and symptoms? This is another popular question. Typically, you could have blood in the stool. You could have bleeding. That's why you have recta-bleeding go to the bathroom. You actually see blood dripping into the bowl. You could have changing your bowel habits. It could be that you're regular all the time you go to the bathroom. You could almost set your watch by it. Suddenly, that's changing. You're more constipated or you're noticing smaller caliber stools. Those change in bowel habits could be a sign of developing colorectal cancer. When you get to the point of having abdominal pain and weight loss, those are pretty far gone signs and symptoms. If you, in fact, have colorectal cancer, those are late symptoms. The most common sign and or symptom is none. Most people feel absolutely fine. They don't have any bleeding. Their bowel movements are fine. They say, Doc, I have no problems. Why do I need, say, a colonoscopy? Well, because we want to find that cancer early. To bring home the point, I've had patients who, the only reason why they came in for a colonoscopy, let's say, is because their neighbor was recently diagnosed with colorectal cancer. They said, you know what? I've been putting it off for so long. I figure I should just have a colonoscopy. They come in and they, in fact, have colon cancer. You can feel fine. Everything can be normal and you can be diagnosed with colon cancer. You want to meet that diagnosis early if it's going to happen because then you have the best chance for cure and colorectal cancer is totally curable. The treatment or the cure is surgery. So the surgery, surgical resection of the tumor remains the only curative treatment. So you have to have surgery to be cured from your cancer. And it doesn't matter how you have the surgery. You could have a standard open resection. You could have laparoscopic surgery, robotic surgery here at Old Bridge and as well as Bayshore. We do all of these. And then what about chemotherapy? Chemotherapy, whether you get chemotherapy for colon and rectal cancer depends on the stage of the disease. And we don't know what the stage of the disease is before the surgery. Typically, we find, you know, once we remove it and send it to the pathologist, they examine it under a microscope. And there are two things that are most important, the depth of penetration of the tumor and whether or not lymph nodes are positive. So we don't see, you know, we don't really see the lymph nodes necessarily on, say, a CAT scan or any of those things. So they may or may not be positive. And the depth of penetration is also not something that we could really ascertain prior to surgery. Notice I didn't say the size of the tumor. The size of the tumor doesn't matter. You could have a very large tumor and the lymph nodes could be negative and it could actually not penetrate the bowel wall very much. And you may not need chemotherapy. And you could also have a very small tumor that goes straight through the bowel wall and have positive lymph nodes. So the size of the tumor actually doesn't matter. It's the depth of penetration and whether or not the lymph nodes are positive or not. So as I said, we'd rather prevent the cancer. So early detection is the key for both prevention as well as cure. So for that, we do screening. So there are only a few things we do screening for. You know, obviously, as a women's group, so everybody knows about mammography. Hopefully everybody's getting their mammograms. So that's a screening test for breast cancer. For colon cancer, we do screening. We do stool tests and we do colonoscopy. So for we do screening for common cancers that are lethal. Okay, they have to have a long preclinical phase. So that means that you can't just pop up and then the cancer goes very fast. So it's got to be something that grows relatively slowly. Colon cancer grows relatively slowly. It has a preclinical phase of five to 10 years. And then the screening has to be safe and accurate. Some of the issues in screening are compliance and costs and whether or not the screening tools we use are very sensitive and people have to have access to them. So sometimes things like colonoscopy, people may not have access to that. For colorectal cancer, we used to say everybody over the age of 50 needs it. We've moved that to age of 45. That's very important. So hopefully anybody who remembers 50 now remember 45. You should get your first colonoscopy at age 45. African Americans still get their first colonoscopy at 45 or slightly higher risk. If you have a significant family history, and particularly if you have a, like I said, if you have a family member who acquired their colorectal cancer under age 50, you should get your colonoscopy 10 years before the age of that person. So for instance, if your father had colorectal cancer at age 38, then you need to start your colonoscopy at age 28. That's very, very important. Again, the goal is to identify it as soon as possible. Another indication for screening, inflammatory bowel disease. Like I said, those patients are at increased risk. Again, bringing this home for the women's group, if you have a history of ovarian endometrial or breast cancer, you should also have a colonoscopy. So if you, and not necessarily wait until 45, because if you're diagnosed, say with breast cancer, you have a slightly higher risk of colorectal cancer. So even if you're 35, you should probably go ahead and get your colonoscopy. Some of these tools that we use, the fit test, fecal immunoassay test, we stool DNA test, and then a fit DNA. I think many people are probably familiar with this because they advertise it on TV, which is the colicard test. The fit test and the stool DNA, you get once a year, and the colicard, they recommend every three years if you're going to go that route. The old test was the fecal of cold blood test, which we is no longer recommended. And then any of these that are positive. So if you get a fit test or stool DNA or colicard, if those are positive, they require a colonoscopy. So a fit test, fit and colicard are very similar. Basically, you get a package, you get a sample of the stool, you follow the directions, and you mail it in. Same thing with the colicard study. If you get a stool sample, you take a specimen and you mail it back, and you'll get the results in the mail. I'm going to skip that. So those are your noninvasive tests. And then the more advanced test, pretty much the standard test is colonoscopy. Everybody should get a colonoscopy every 10 years, again, starting at age 45. For those people who can't get a colonoscopy for whatever reason, there's virtual colonoscopy, which is kind of a reconstruction of a CAT scan, and that's done every five years. Sigmoidoscopy and double contrast barium enema are really not really recommended all that much. So virtual CT, again, like I said, it's an X-ray. So you go, you get a CT scan, the abdomen and pelvis is noninvasive. It still requires a prep, so you still have to drink a lot of stuff, clean out the colon prior to doing the study. The benefit is you don't require any sedation. So this would be getting your CAT scan, and then you'll get some pictures that look like this. They get regular CAT scan images, and then they do a 3D reconstruction, and they might see something like that. Again, if they do see something that they're concerned might be a polyp, then you have to get a colonoscopy. Just to understand what we're looking at here, so this is the colon, and this is the small bowel. So we're talking about, so this is typically also called intestine. So the small bowel is the intestine. This is the colon here, and then the rectum comes down here. So normal healthy colon, kind of, you know, little polyps or a cancer. And then again, on the on the 3D reconstruction of the CAT scan, you might see something like this or something like that, which would lead to a colonoscopy. Who gets a virtual colonoscopy? There are a number of reasons, you know, most, I would say probably most commonly people would fail their incomplete colonoscopy for whatever reason you can't get through the high risk for colonoscopy. Maybe they have significant cardiac disease and can't undergo this sedation. The colonoscopy is still the gold standard because when we do see those polyps, we can remove it. So when we remove a, you know, even a small polyp, we are potentially preventing a colon cancer. Hopefully in the future, we'll have something that's a capsule colonoscopy. You swallow a pill, it takes a bunch of pictures, and then it will give you a similar type of picture that the CAT scan gave you. But that's not here yet. So, but that's something they'll look forward to. So overall, there's good news and there is some bad news. The good news is that the incidence and prevalence and death rates of colorectal cancer have significantly declined over the past 10 or 20 years. It's, you know, pretty remarkable. So if you look at these graphs, this goes from 1990 to 2014, and they continue to go down. But this is the incidence in men and women. I mean, that's a fairly significant drop as well as the death rate. Very significant drop in both incidence and death rates over the last 20 years or so. And if you break it down into, you know, risk groups, here's where we see a problem. So if you look at age 50 to 60, you see a, you know, a reasonable drop. You look at age 65 and over, you see a fairly significant drop. Unfortunately, if you look at age 20 to 49, so everybody below age 50, you see that the slow rise in prevalence, which means a number of new cancer diagnoses and death rate. And if you break that out, you know, a little bit more specifically, this is what it looks like. So this, you know, under age 50, colorectal cancer is on the rise. Above age 50, it's on the decline. And obviously, above age 50 is when we were starting screening. So I think our screening colonoscopy, removing polyps, you know, early on has made a dramatic impact in the incidence and death from colorectal cancer. And now we're starting to see this. And we don't quite understand why it's increasing in that young patient population. But it is a definite factor. What is going on with these younger patients? Again, I said we don't really know. So there are a number of theories. So the prevailing theory now is this lack of biodiversity. Obviously, the easy thing to do is say, which we did, it's the diet and kids are eating too much fast food and McDonald's and et cetera and so forth. So that was kind of an easy thing to tag. And that probably is not it. Obviously, it's going to be something multifactorial. It's not going to be one thing. In any event, I was saying that if you take this mouse model and high fiber, low fiber, you feed them both and then you introduce bacteria that causes inflammation. And you look at inflammation specifically in the gut. The mice that have the high fiber diet do very well. And the mice that do not, they pretty much they have a significant toxicity to the bacteria. So that's what we call that's the basis of the biodiversity or the microbiome. So the take home message is, in terms of the younger patients, we're not entirely sure what's going on. We have said that the microbiome or the health of the colon plays a significant role. One of the functions of the colon is to make, the colon makes the layer of mucus. So this would be the layer of mucus in the colon. So these would be the colon cells. This would be the layer of mucus that keeps all of the bacteria and other toxins away from the actual cells. When we don't have a diet rich in fiber, then you can have this situation where the toxins can actually attack the cells. So that's where the current thinking is in terms of seeing more of the young patients. And I again, I don't think it's going to be one issue. I think it's going to be multifactorial. But for now, we don't have a single reason, but this is one of the ongoing theories. Of course, that promotes inflammation. So the next question, obviously, you would ask is what about the role of probiotics in cancer prevention? And probiotics are absolutely fine. Because you can hear it says the development of colic cancer is unclear, but the gut microbiome contributes to colon cancer through initiation of inflammation. So you can do probiotics, which will populate your colon with the healthy bacteria. You still got to do the fresh fruits, fresh vegetables, whole grain cereals and breads and all that to to make sure you have a healthy colon. Let's skip this. We kind of lost a little time there. A couple of things to remember. Colorectal cancer is the second leading cause of cancer death among men and women. And maybe the third leading among just women. There are places you can go. You can go online to find a colorectal cancer risk profiler. And most of those will look at your age, gender, height, weight, ethnicity, whether you smoke, whether you exercise, all of the things that we talked about in the beginning of the talk, will go into these profilers and it'll help you determine your risk of developing colorectal cancer. So for those people who are younger or moms and dad who are concerned about their children developing colorectal cancer, there's a website called Never Too Young for colorectal cancer. Particularly if you are, if you have a loved one who's a younger individual who has already been diagnosed, then you may want to go there. It has a lot of resources. All right. Thank you.