Kanthi Yalamanchili, MD, a Board Certified Gastroenterologist at Baylor Medical Center of Grapevine, for Texas Digestive Disease Consultants, talks about colon and rectal cancers rates rising in patients at a younger age.
Interview conducted by Ivanhoe Broadcast News June 2017.
So you do a lot of what colonoscopies? Then follow-up if there are complications?
Dr. Yalamanchili: Correct, I see patients mainly in the hospital. If there is a patient from my practice that gets admitted to the hospital, I see them here for all their GI (gastrointestinal) concerns, which can be a gamut of concerns, including; abdominal pain, nausea, vomiting, diarrhea, change of bowel habits or GI bleeding. We also see inpatients who may not have a gastroenterologist but need GI care.
Jennifer was taking blood pressure medicine, and she was getting constipated, so they thought that was a reaction to the medicine so they changed it, but she kept feeling that there was something wrong down there? And eventually she came and consulted with you, is that right?
Dr. Yalamanchili: Correct, she is young. She is only 44 years old, so you would not think of rectal cancer or colon cancer as your first diagnosis when she starts having constipation because you do not expect colon or rectal cancer in young patients. It is certainly reasonable to think that it is a medication side effect and change her medication like her primary doctor did. However, I know she had begun having more issues with the constipation, started feeling faint and light headed. That is how she ended up in the hospital. We saw her in consultation and at that point, reviewing her symptoms and knowing that she did have the change in bowel habits, the thirty pound weight loss, and rectal bleeding off and on, we decided it is appropriate to proceed with the colonoscopy. I met her at that point.
So she came into the emergency room, and she said she had a CAT scan. Was that done right then or was that something that you ordered after that she came up from the ER?
Dr. Yalamanchili: She had the CT in the ER before I examined her.
Okay, but that was not the colonoscopy that ended up with your diagnosis?
Dr. Yalamanchili: Correct, we were able to review the CAT scan results, review her history, and then bowel prep her for the colonoscopy. The colonoscopy is a separate procedure in the GI lab at the hospital.
Did she go home first, or did she stay in the hospital?
Dr. Yalamanchili: She stayed in the hospital.
Was there something in that initial CAT scan, that made you have concern?
Dr. Yalamanchili: The CAT scan did show thickening in her rectum suspicious for a rectal mass, so we did have a clue.
So did you start doing with suspicions, but you were doing a typical colonoscopy?
Dr. Yalamanchili: Correct, we prep the patient with the bowel prep and once they have a clear bowel movements, they are considered ready. We bring them down to the GI lab procedure room where they receive anesthesia for sedation. Once they are ready, the first thing I do is a digital rectal exam with my finger. In Jennifer, I was able to feel the rectal mass right away; it was absolutely heart breaking knowing that she is 44, she is the mother of two, but you have to keep going. At that point after I finished the rectal exam, we insert a long black tube, about a dime size in diameter with a light at the end of it. This tube is inserted into her rectum. We saw the mass right away but I had to finish my colonoscopy. I took several pictures of the mass and I completed the colonoscopy. You essentially start in the rectum and advance the colonoscope to the cecum, which is the first part of the colon. At the cecum you can identify the appendix orifice. Then you start the withdrawal. You look carefully in a circumferential manner for any other polyps all the way back to the rectum. When I reached back to the mass, I took a bunch of biopsies of the mass. We took a lot of good pictures that I could show Jennifer afterwards and then we finished the colonoscopy.
And you did not see anything else that polyps or anything in the colon itself?
Dr. Yalamanchili: No, it was all concentrated on the rectal mass. At times the masses can be obstructive. Those patients tend to have a little bit more acute indication to have surgery right away. Luckily in Jennifer’s case, it was not a complete obstruction. I was able to get my colonoscope through the mass through to the beginning of the colon.
She said that you also found some spots on her liver? Was that subsequent?
Dr. Yalamanchili: Correct. We had some spots in the liver on the CT. One of the first sites of spread that the rectal cancer goes to is the liver. So we did have a high suspicion that these liver spots are likely metastatic disease.
What was her diagnosis, was it a certain stage of cancer?
Dr. Yalamanchili: Because she has distant liver metastases, she is a stage 4 colorectal cancer.
Does not sound too good?
Dr. Yalamanchili: It does not, but there have been a lot of advances in colorectal cancer management so at this point I usually send them to an oncologist who is more specialized in treating colorectal cancers.
And so now she is getting chemo?
Dr. Yalamanchili: Correct.
What would be the normal procedural sequence of events for somebody like her?
Dr. Yalamanchili: With Jennifer, once we diagnosed the cancer, we have to determine if the cancer is isolated to the rectum only. Rectal cancer is treated a little bit differently. Normally, in colon cancer, surgery is the first treatment, so if her colon cancer was above the rectum, she would usually get surgery first. She would have the colon cancer removed with the lymph nodes around it removed and that would really be the ultimate staging for her. In Jennifer’s case, with rectal cancer we usually do neoadjuvant therapy, which is chemotherapy & radiation first to try to shrink the rectal cancer because of the location. This is a tough location to operate as the goal is to preserve anal function. Once we shrink the cancer, then at that point we would determine if she is a surgical candidate later. But once again, all that treatment is usually handled by the oncologist.
So now her chemotherapy, she is on the seventh or eighth week of like a 12 week cycle?
Dr. Yalamanchili: Correct.
Then after that would they consider radiation or something else?
Dr. Yalamanchili: They might, and once again this would be a question for the oncologist.
What are the possibilities?
Dr. Yalamanchili: There is a possibility that they will probably image her again to determine how much all the tumors have shrank. They will reimage her liver and certainly the rectal area, most of the time it tends to be a PET (Positron Emission Tomography) scan. Usually the staging is determined with a PET scan, and the PET scan will tell oncologist tumor up take in multiple areas. So if there is minimal uptake in the rectum and minimal uptake in the liver that is great news. That means that she obviously is close to remission and at that point her oncologist will call her colorectal surgeon and it will be a multi-disciplinary decision about the timing of surgery.
So she could be a candidate for surgery?
Dr. Yalamanchili: Yes.
What do you hope for somebody like Jennifer?
Dr. Yalamanchili: Well, you hope certainly for remission with the chemo and possible radiation that her oncologist has planned. Hopefully, surgery is next. After surgery, Jennifer will be on an aggressive surveillance to look for any reoccurrence of cancer. You always worry is it going to come back again? But all you can do is hope for the best and certainly we do have miracles in medicine. With all the advances we have nowadays, I do hope that Jennifer is able to achieve remission with chemo and radiation, get the surgery, and then stay in remission thereafter.
These new studies that are showing that the colorectal cancer is showing up in younger and younger people, what do you know about that and what are you seeing in your practice?
Dr. Yalamanchili: In my practice we are starting to stress doing colonoscopies on people younger than 50. Traditionally, all the guidelines of our GI society have recommended anybody with average risk for colon cancer should start screening at age 50. However, recently there was an article in the Journal of National Cancer Institute. It was an epidemiological study; which focused on a database looking at the younger population and the incidence of colon cancer. There are several possible life style factors that are contributing to the rise in colon cancer. One is certainly obesity. As we all know the entirety of America is seeing an increase in this by the year. Obesity is a big risk factor. Poor diet choices such as a diet high in fat, low fiber, processed foods is the next risk factor. Tobacco use, alcohol use are three and four, and then lack of exercise is number five. Those are the big factors we are seeing that are contributing to the rise of colorectal cancer in young patients or young people. The other factor is we are also noticing a trend in some races, so African American men and women seem to be at higher risk for colorectal colon cancer. Our society the American College of Gastroenterology came out with the census statement and revised their screening guidelines stating that African American men and women need to start screening at age 45.
If you can dig a little bit deeper into that, you might be able to show that the particular diet of the African American family might focus a little bit more on those foods that you talked about?
Dr. Yalamanchili: Exactly. Unfortunately, a lot of young people tend to ignore their symptoms. They say it’s okay, it’s no big deal. I am not 50 yet. I do not need a colonoscopy. But warning signs including an unintentional weight loss like Jennifer’s. Any persistent change in bowel habits, and what I mean by that is, you had diarrhea when you’ve never had it before or constipation you’ve never had before, and the condition persists. Or change in stool caliber. If you always had formed stools and your stools become pencil thin caliber stools, this is another warning sign. Certainly a family history of colon cancer is huge, especially any first degree relative such as a sibling, a child, or a parent.
She did not have any of that?
Dr. Yalamanchili: She did not. Jennifer’s mother had pancreatic cancer at the age of 76.
How does that pancreatic cancer connect with colorectal cancer?
Dr. Yalamanchili: It does not. You can have certain genetic syndromes that run together. I think hers was honestly sporadic and what is interesting is that studies have also shown that not all colorectal cancer in young people have a genetic predisposition. Only three to ten percent of young patients who are diagnosed with colon cancer have a first degree relative. The majority of the colon cancer in young people is still sporadic.
That is why without real hard proof; the overall research community is looking at all of these dietary factors, right?
Dr. Yalamanchili: Correct dietary and multiple others, certainly tobacco and alcohol play a role, lack of exercise. What you put into our system.
There really is not that much of a mystery about that anymore; we are what we eat, we have been saying that for years?
Dr. Yalamanchili: That is absolutely true. I think we are seeing that effect in all aspects of life. We are seeing a lot of data on gluten free and low sugar diets, and low carb diets that are healthier options. I think our generation as a whole is not really cooking normal food at home. We are eating out a lot more, a lot more processed stuff, a lot of reach for the freezer and in the oven. Yes, it comes down to what we are putting into our system, absolutely.
When you look at this study, if you look at the data that is associated with the study what they are really looking at, is it startling? To what degree is it alarming that the age is coming down to younger and younger people?
Dr. Yalamanchili: To me the most alarming factor is young people are being diagnosed with more aggressive cancers. I do not know how to figure that out. I have seen 60 year olds and 70 year olds get diagnosed with stage 1 colon cancer, isolated to the colon itself and then the go to surgery and remove it. There is barely any lymph nodes involvement since they are stage 1 and they are cured verses these young people who are diagnosed younger with a lot more aggressive cancer which has spread. And it is interesting among the colon cancers, rectal cancers is the one that is rising in young adults.
And it is also the most difficult one to treat?
Dr. Yalamanchili: Correct.
And again that is because?
Dr. Yalamanchili: We are not exactly sure.
The big problem with surgery in the rectum is if you have to take out too much of it then you lose the function of the rectum, right?
Dr. Yalamanchili: Correct you lose the function of it. You develop fecal incontinence, and the anastomosis may not hold, so you possibly get a leak, or an abscess. If ultimately the area cannot be fixed you will end up a permanent colostomy bag which no one wants.
If all the various academies come out with new recommendations, and then you have to work on insurance companies to approve this, the typical screenings will be recommended at younger ages, right?
Dr. Yalamanchili: If a young patient has alarm symptoms, it would not be a screening to begin with. If you do have alarming symptoms, such as the abdominal pain, the weight loss, the change in bowel habits, or the GI bleeding you would have a diagnostic colonoscopy. If anyone is having an alarm symptom we will recommend a diagnostic colonoscopy. It really would not be in the screening category, but it would be the diagnostic based on symptoms and our clinical suspicion to make sure nothing is wrong. Sometimes, we do have to write the insurance companies to get approval for people younger than 50.
If we continue with this trend in America, with obesity and with all the risk factors increasing rather than decreasing because we are not changing our habits, do you expect it in the future that they would have to lower the age for screening purposes?
Dr. Yalamanchili: They might. There is a lot of data. They are looking into how tobacco, alcohol, and other factors are affecting it. So certainly I do believe that society has their eye on all these factors and they may end up modifying the guidelines as we move into the future. You know it takes a while. This is the first time the ACG revised their guidelines in a while. The initial guidelines for age 50 was created in 2000; so you are 17 years into it and finally for African Americans it has gone down by five years, so we do have a long way to go. But our GI society is clearly looking into this, because this is a huge risk for generation X and the millennials right now. I would say anybody who is age 20 to 40 right now, are the ones who are certainly at risk; they certainly do practice the lifestyle factors that I mentioned. All of us as a whole are eating more processed foods, and a diet that is higher in fat and low fiber. Certainly tobacco use is a big factor and alcohol is also a big factor. A lot of our young generation X and millennials closely follow social media and this is a good way to get the message across. I think we need to pipe into other areas that they pay attention to, getting the point across: Yes, colon cancer is on the rise in young patients.
This sounds like it is potentially extremely serious, getting younger and younger?
Dr. Yalamanchili: It is serious. I think it has to be individual control on the individual person and the individual household. So certainly it is good to be aware of what is coming. I am not saying that every person in generation X or millennial is going to get colon cancer. We certainly hope not. But if they know the warning signs and pay attention to the risk factors, we can get them in for an early diagnosis and treatment. This is what I hope to achieve.
With Jennifer, would you say hers was an early diagnosis or not?
Dr. Yalamanchili: Jennifer’s was not an early diagnosis.
So this is a problem that she had been developing for a long time?
Dr. Yalamanchili: When you look back and talk to Jennifer, she claimed she had symptoms starting back in about October. We diagnosed her in January when she was about three months into her symptoms. She was also quite surprised at how quickly the rectal cancer had spread. One of the other complicating factors with Jennifer was that none of her labs gave us a clue. Normally, a colon cancer, rectal cancer patient develops anemia over a period of time because you are losing blood through your GI tract. But with Jennifer all her labs were fine. Her liver test was normal, not indicating of anything wrong with her liver and she was never anemic. Even at the time she came to the hospital with her symptoms and I met her, her hemoglobin was completely normal which did not give us any clue. So Jennifer’s case was interesting in the sense of it really was a big surprise to all of us.
You mentioned that she dropped about 30 pounds, why was that?
Dr. Yalamanchili: It was unintentionally for her, I believe it started around October/November time frame, she had a low appetite and just found herself really not eating and kept losing this weight. But she did not pay that much attention to it, as she already felt that she would love to lose weight,. She did not think that it was going to be a cancer that was causing the weight loss; it was not the first thing she thought of.
It would not be the first thing anyone would of?
Dr. Yalamanchili: Correct, correct, but certainly I would say if it is more than a 10 pound unintentionally weight loss you need to pay close attention because 30 pounds is very atypical.
What are some other warning signs? She said she felt like she was sitting on a rock?
Dr. Yalamanchili: From a GI standpoint, the warning signs would include abdominal pain, any vague abdominal pain that is persisting, that is not going away, any change in bowel habits. What I mean is your one-bowel-movement-a-day person and suddenly you notice that you are going more or you are going a lot less. That would be a warning sign. Straining to go can be a sign. You go and want to have a bowel movement but you are just having a hard time having it coming out. A change in caliber of stool is a warning sign. Your bowel movements change from a formed bowel movement to pencil thin. Last of all, if you see red or black, any rectal bleeding rectum, any dark black sticky stool, black and tarry is a concern, that is certainly GI bleeding. This is also a warning sign.
So if you see black in the stool that is like dry blood or something?
Dr. Yalamanchili: Yes it is usually dry blood or it is blood from the upper GI tract. Most of the time colon cancer, because it is in the distal colon or it is in the bottom half of the GI tract, it tends to be more bright red. So in colon cancer, rectal cancer, you will see more bright red and dark red. The typical black tarry tends to be a stomach ulcer from above. It is scary, absolutely, and it is hard breaking to tell patients like Jennifer that they have colorectal cancer, especially at that young of an age.
Tell us a little bit more about this group that you are with?
Dr. Yalamanchili: I work for Texas Digestive Disease Consultants we are a 120 GI physicians group in the state of Texas and we are the largest in GI group in the country.
END OF INTERVIEW
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