Disability and Progress-April 18,2024- Dr. Emil Lou on Colorectal Cancer

[00:00:00] Speaker A: KPI.org. Your tune to KFAI 90.3 FM, Minneapolis and kfai.org. This is disability and progress, where we bring you insights into ideas about and discussions on disability topics. My name is Sam. I'm the host of this show. Thanks so much for tuning in to this April 18, 2024 episode. Charlene Dahl is my pr and research woman. Hello, Charlene. Hello. Good evening, everyone. And Miguel Vargas is my engineer today. Thank you, Miguel. Erin is my podcaster. Thank you, Erin. This week our topic is colorectal cancer, and we are speaking with Doctor Emil Liu. And Doctor Liu is an associate professor at the University of Minnesota Medical School and Masonic Cancer center. Hello, Doctor Liu. [00:01:56] Speaker B: Hello. Hello. Great to be here. Thank you for having me. [00:01:59] Speaker A: Thank you so much for giving us your time. Colorectal cancer. And there's been some changes and stuff, and I want to at least kind of go through and get basics first. But before we do that, can you give me a little bit of background on you and how long you've been in the field and how long have you always been at the u? [00:02:19] Speaker B: Absolutely. Yes. It's a great opportunity to work with you and to chat with you and to your wider audience and to provide education. That's part of my role as a physician. [00:02:32] Speaker A: Ours too. [00:02:33] Speaker B: Yeah, absolutely. So that's where we have many things in common. And so one of many things, and to today's topic, colorectal cancer is very important. So in terms of my background, I kind of use my job description as physician, scientist, but I'm also an educator in many ways for patients and for up and coming doctors and training and others. My background is I am a physician. I treat patients here at the Masonic Cancer center at the University of Minnesota. And I've been here about twelve and a half years. And I principally help patients who have diagnosis of colorectal and also other types of gastrointestinal cancers that can include pancreatic or stomach cancer and even some rare types of cancers called neuroendocrine tumors and appendix cancers and other rare ones. And at the same time, the scientist aspect of my job description. So what I do in my day to day work is I have a research lab and I do what we call translational research projects, trying to discover things in the lab that can make a difference in human lives by translating some of those ideas and findings into practice in clinical trials and discovery to try and find the next great medications that can help patients. And the ultimate overarching goal is cure. So that's what I and oncologists throughout the world try and strive for. And there have been a lot of great advances in colorectal cancer, very specifically. So much we'll talk about during this time. [00:03:56] Speaker A: Yes. Can you tell us a little bit about what are the most common signs and symptoms of colorectal cancer that a person might be, might find themselves feeling? [00:04:11] Speaker B: Sure. Some of them are very nonspecific, as we say in medicine, nonspecific. And so there's a lot of overlap with other things that have nothing to do with cancer. So sometimes it's hard to tease out, and others are more likely to be associated with a colorectal cancer. But general symptoms, starting with general would be abdominal pain of an unclear cause is the way I describe it. So if you get a stomach flu or a stomach bug, as someone might say, then it's something that might be fleeting. You get maybe food poisoning or a virus, and that something that might last 24 hours or pass after a few days, and that might cause abdominal pain, too, or might cause diarrhea or something else we call gastrointestinal distress. But that's something that's expected to come and then go. But abdominal pain or any of those type of symptoms or others that are not going to go away, whether it's in a few days or a few weeks or especially if they worsen over weeks or months, are something that we might see that eventually, when someone's diagnosed with a colorectal cancer, you might say, oh, that was directly caused by the cancer. Another thing that might be something towards something that would indicate colorectal cancer would be bleeding in your stool. And I know I just acknowledge up front in this discussion, these are when you talk about guts and stool, and these kinds of things are not something that people want to talk about in their average daily conversation with friends and family. But of course, I have a lot of experience doing that because that's a lot of what we have to ask. But just acknowledging it's not the most comfortable thing to talk about, but it's important to recognize, at least be aware so, of if somebody looks on in the twilight and sees in their stool that there's blood, whether it's bright red stuff or something that's dark and tarry, for example, so that's not normal. And people can have things that have nothing to do with cancer, like hemorrhoids, that might cause it. But I think the amount and the persistence, if it's something that's something that's there, definitely bears checking out and discussion with your healthcare providers, whether it's starting with a primary care doctor or some people see physician assistants or nurses in their clinics that they go to. Just reporting it to somebody and having that evaluated is really important as a first step. [00:06:17] Speaker A: What are some maybe risk factors for developing colorectal cancer? And are there lifestyle changes that can help or alter, reduce that? [00:06:28] Speaker B: Yeah. And kind of taking your last question first, I think definitely across the board for so many cancers, and colorectal cancer is a prime example of it, that being active and exercising rather than being sedentary is a huge. It's been identified and studied very extensively as something that can decrease the risk factor. Maybe none of these things can bring it to zero, but it's taking control of our own bodies and doing the best that we can for things that are under our control. So an example of that is, I have had patients who do marathons that do extraordinary things that even I don't do. Just an example is walking 30 to 45 minutes rather briskly, or even just a nice leisurely pace. But that's something, that's a great activity that's proven to be a very robust activity for reducing the risk of colorectal and other potentially other cancers. Doing that, for example, four or five times per week, can be very valuable. And the flip side of it is living a purely or very much sedentary lifestyle. And that's not something that most people might say, well, I'm not sedentary, but we think of even myself. I'm at both of this. We have desk jobs. We're at desks most of the day, and we get absorbed in computer screens, and then we don't move for hours. And that can be described as sedentary in its own way. And trying to keep active is one important thing. Diet is a very important question. And so, just broadly, if our diet is full of fatty foods or fried and fatty foods and fat, fast foods, and not balanced out, you know, in proportion, I think all things in moderation, I'll be the last person to say that you can absolutely eliminate that stuff from your life. But. But really minimizing it and really focusing on foods, fruits and vegetables, four or five servings per day, or things that we consider for the FDA pyramid to be good, healthy, nutritional foods, really focusing on that are also things we can control. A common question we get in our clinic, and I address it proactively as someone doesn't have the question for me when we first meet or subsequently, is, is it hereditary? People will commonly ask, well, you know, did I inherit this from someone in my family. And so I start by answering that question with other questions and saying, do you know of anybody in your family who had colorectal cancer? And if someone had what we call first degree relative, like a parent or sibling, that had colorectal cancer, then that might increase the risk that someone else in the family genetically, who's genetically a biological relative, would have a risk. But a lot of times we have people who come in who don't have colorectal cancer in their family, and they might have colorectal cancer. And that could be people in their twenties, thirties, forties, as well as people older than 50. [00:09:08] Speaker A: And so staying on that topic of genetics and in the family, what's, if you have it in your family, what's the likelihood? Like, how much more does it raise your chance of getting it? [00:09:25] Speaker B: Yeah, I think it's substantially more, but it's not a foregone conclusion. I want to at least say that part to reassure your listeners that if someone in their family, for example, a parent or a sibling, has a proven diagnosis of colorectal cancer, and long time guidelines have said that any given individual who has that relative should get colorectal cancer screening probably sooner, on average, than the average person who doesn't have a family member or have symptoms. So, for example, the traditional rule was, let's say you have a parent who was 53 when they had a diagnosis of colorectal cancer. So what the recommendation is when the person has children who grow up, that person's children should grow up in their early forties to get colorectal cancer screening and not wait until later years. So it's ten years earlier than the time of diagnosis of their close relatives who had colorectal cancer. If the parent had it at 40, then the child growing up should look at 30 as an age to start colorectal cancer screening. There are some family syndromes that have increased risk and maybe even higher risk. My answer, I guess, would be, it depends. [00:10:38] Speaker A: And you're thinking that even ten years before, they could find something. That's why you're doing the ten year mark, right? [00:10:48] Speaker B: If somebody has a close family member that has had a diagnosis, and what. [00:10:54] Speaker A: Would you consider a close family member? Is it uncles, even, or parents? [00:10:59] Speaker B: Well, for sure. Parents, siblings. So those are what we call first degree relatives that are kind of the closest. When you draw out a family tree, often people will tell me about their grandparents. And so we'll kind of even draw a family tree in clinic and say, is it from the maternal side, your mother's side? Paternal side is from your father's side, and maybe it'll be uncles. And sometimes it becomes clear in hindsight that there's a family history of cancer, not only of colorectal cancer, but there are some known family syndromes that also include other types of cancer. For example, breast cancer, which is most prevalent in women, certainly, or uterine cancer in women, and cancer, the endometrium, the uterus. And there are sometimes family histories of cancer as well, aligned with known genetic syndromes, and some that we don't yet know, and several of which involve colorectal cancer risk. [00:11:49] Speaker A: Can you talk a little bit about the importance of early detection? Some cancers are really slow growing, and if you find them five years later, it may not be as big of a deal. Talk a little bit about how important it is for early detection for this colorectal cancer. [00:12:07] Speaker B: Sure, sure. Just to round out the part about family risk since that came up, the risk of it being hereditary is under 10%. So the flip side, in transitioning, it's about 90% to 95%. Things that are not considered or known to be hereditary, that could be the risk factors that we just discussed. And so early detection and screening, this is it. Colorectal cancer is one of the few cancers that we have screening tests that have been validated and evaluated and around and readily available. We can't say that for all the other cancers that certainly that I treat patients with pancreas cancer, we don't have screening tests or many other cancers. We don't have screening tests. Breast cancer, mammograms, colorectal cancer, various kinds, including colonoscopy, but not limited to that. So early screening, the purpose of early screening is intended to find something earlier than it otherwise would be, with the idea that if you catch it earlier, then you can treat it with an intent to cure. When cancers are found at more advanced stages, then sometimes they are not curable just because they're too widespread and not something that surgery can be performed because it's only one place. When it's no longer only one place, it becomes a lot harder and not necessarily safe or feasible to do surgery. The idea of curing someone. So in more advanced cases, if the cancer is spread, colorectal cancer can go different parts of the body. Then a treatment like chemotherapy or such therapies are given with palliative intent, meaning they don't have the ability or capability of eliminating or inducing a cure or a long term cure, but they can manage the cancer and try to help someone live longer. But if you can cure cancer by finding it earlier. That's where the success of screening for colorectal cancer lies. [00:13:55] Speaker A: I wonder if you could give some information about what screening methods are available, because there are some different screening methods that I have learned that, you know, that are available. [00:14:09] Speaker B: Right, right. So kind of going back to the varying levels of comfort that people have talk about guts and poop and stool, these kind of things. The most common one that people think of is colonoscopy. So there's a lot of great technology, and it includes colleague experts of mine who are doctors called gastroenterologists, and a lot of them do colonoscopies. And so these are long devices, like snake like devices that have cameras at the end that they can actually visualize and capture photos of things that might be tumors or might be suspicious. Some things are called polyps, which are little nubs that stick out of the wall of your intestine. And then a lot of them can be benign. Benign meaning not cancerous. And then some might be a little bit more advanced, but not cancerous, but they might call it precancerous. And so a biopsy that's taken of those by the expert gastroenterologist who visualizes it could take it out, and a pathologist who people rarely get to meet, but they look under the microscope and help give us feedback and saying, yeah, this was benign. And then the gastroenterologist might say, hey, you don't need another colonoscopy for three or five years. And if colonoscopy is done and it's, quote, clean, nothing is seen, then the recommendation might be as much as ten years later to get the next colonoscopy. If something is suspicious, it might be a whole lot sooner. [00:15:27] Speaker A: So what's the accuracy of a colonoscopy? [00:15:31] Speaker B: It is the most accurate test because I would say there's nothing better than visualizing something. And so it's paired, not just visualizing it, but the ability of an expert trained in that procedure to, they call snare, to take out the polyp and give it to a pathologist to look under the microscope. And that's the most accurate form of testing. Some of the other tests that are done and sometimes can be done before colonoscopy and are also considered colorectal cancer screening are tests where they call it fecal immunochemical testing or some things where basically a card is given. You go to your primary care provider, they provide you a card to go home with, and you, you take a poop, and you take a stick, and you smear a little bit of on there, and then it be given back to the lab when they do tests to determine whether or not there's blood in it or fecal occult blood testing. FOBT is a fancy word for saying trying to find blood. That may not be obvious, but if it's in the. It's in the stool, can be detected in the lab on a test might indicate, hey, you might need to get a colonoscopy. [00:16:30] Speaker A: And how accurate is that? [00:16:32] Speaker B: Yeah, I mean, it is a high level of accuracy, but it's far from perfect. And so it's one of those that when we talk about, we use words, spend sensitivity and specificity, that if the blood is not there, it doesn't 100% assure you that there's absolutely no colorectal cancer to be found. But it provides more reassurance than not doing the test at all. [00:16:53] Speaker A: So presumably you would say, if you have a history, you probably shouldn't do that test, and if you don't, it might be okay to do it. [00:17:02] Speaker B: Yeah. So, I mean, some of these tests are more for the average person who does not have a family history of colorectal cancer. For example, a parent, siblings, or anyone else close, and they themselves don't have a history of colorectal cancer in their past. And some of these might be helpful to start with. And it's kind of, I always call it negotiation and mutual discussion and 50 50 partnership with your primary care provider, whether it's a nurse or a physician assistant or doctor, to say, okay, I'm at this age where I need colorectal screening, and likewise from the clinic, they should say, hey, you're due. Here are the risks versus benefits. Do you have symptoms? Do you have family history? And understanding that history for any given person helps to formulate what test to go forward with. But I think any of it is better than not proceeding with any form of screening whatsoever. So we don't want to miss opportunity to find them as early as possible. [00:17:56] Speaker A: I'm wondering if you could talk a little bit about some misconceptions that people have about this type of cancer that you could dispel. [00:18:06] Speaker B: Oh, sure, sure. Beyond kind of just talking about guts, that people don't really want to talk about colon and rectum, and sometimes there is a barrier to getting tested for it. For that reason, I think there's maybe some misconceptions about what the ability of early screening can do. Someone will say, well, if I don't have symptoms, then there's no need for me to get the screening. And so therefore, I will go. And so when someone comes with a diagnosed with colorectal cancer, it's diagnosed by a colonoscopy. By the time they come meet with me as an oncology and cancer specialist clinic team member, I often say ask or find out, was it their first colonoscopy? And there is a significant number of people who are diagnosed with colorectal cancer, but at the age of 60 or even in their seventies, it was their first colonoscopy ever. I kind of asked, did you get one elsewhere, or did you ever have one? And a common answer might be to answer directly your question on misconceptions. People will say, usually, like, I didn't have symptoms, I didn't think I needed it, or I didn't think it made a difference. So that tells me, as a medical community, we have to do a better job through forums like this one to get the wider audience to become knowledgeable. And so we can convey, here are the benefits, and here's how we can decrease risk here, how we might be able to detect cancer earlier, and here's how it benefit someone who can have that found earlier. [00:19:33] Speaker A: Yeah. And I think sometimes I'll hear people say, well, I feel like, you know, it's supposed to make clean you out, to use a description when you're taking the medication and you're going to go through the colonoscopy. And some people will say, I feel like it will wipe all my good bacteria out, and I'm worried about replenishing that or getting something that will harm me from that. So what do you tell them when they say that? [00:20:01] Speaker B: That's a very interesting perspective. And having gone through the colonoscopy, I can vouch that the clean out things you drink are not, they don't taste like flavored Gatorade, that's for sure. It's not always pleasant. So it is a reality that in order for a gastroenterologist, we talk about current technology that we have access to. For someone to add colonoscopy, to put it on a colonoscope, from a gastroenterology standpoint, to visualize it, has to be the colon has to be clear up stool. And so the reason we take the preparation is to clean out. It is an interesting perspective that you bring up, because bacteria, the gut and our colon is rife with a lot of bacteria, a lot of which is good bacteria. And so usually in someone who's healthy will be dominated by the good bacteria. Part of that role of bacteria is to digest our foods normally. So bacteria have a great ability to replenish themselves. And so an example of something that sometimes might alter what we call gut microbiome, or in other words, the bacteria that live in our gut. Normally, if you take antibiotics, like for a lung infection, if you take it long term or for a prolonged period of time, then it might alter the ratio or proportion of some of the good, the bad bacteria, which is interesting, because then it can lead to other infections. But in general, to do a preparation for drinking the things, and then you get a colonoscopy, the bacteria in the gut have a remarkable ability to replenish themselves. And so I would not expect or know that any data for the idea that in the long term it would be harmful in that respect. [00:21:39] Speaker A: Are there things that people can help, that can do to help replenish them if they're concerned? [00:21:46] Speaker B: I know a lot of probiotics are available over the counter, so that's not an uncommon question. Whether patients with cancer is diagnosed and they're undergoing chemotherapy, or people just in their normal daily life. I think all things in moderation, a lot of things that are supplements that are available over the counter without need for prescription, are necessarily FDA approved. I think reading the label and just being informed, I think understanding a lot of those supplements don't yet have, don't necessarily have data to prove or have had trials to say, if you do this intervention, this is what's going to happen, and it's beneficial compared to not doing it. So it's up to the individual to do the best they can to inform themselves. It's something under active investigation in colorectal cancer about whether or not some chemotherapies may work better or not work as effectively based on the bacteria in the gut. And it's an exciting area of research. It's really risen the last five years here at the university. I have colleagues working on it, and groups around the world are uncovering a lot of things specific about colorectal cancer. And along those lines of questioning, I. [00:22:51] Speaker A: Want to jump in a little bit. Is there any way that they could make the prep for the colonoscope could be a little easier. [00:23:02] Speaker B: If I invent that, then I think I'll get very rich, very rich at some point soon. I wish that I'll tell you if by easier, if you mean better flavor, that could be tolerable. I'm with you there, and I wish, like someone will come up with that soon. Certainly by the time I get my next colonoscopy, it's. It's a lot because it is definitely not foolproof. Sometimes people can do the best they can, and of course, it gives you the runs because it's intended to clean out your colon system. And then on occasion, people will go through their scheduled appointment, and then the gastroenterologist might say, you know, it's not clean enough for me to see accurately. Gosh, we may have to do this again. And that's a really tough, tough phyllo swallow, so to speak. And so I hope people will come up. I would say start with good flavors, because it just doesn't taste good. And it's a lot. Right. It's not something you may have experienced this yourself. Like, it's not just, you drink one, like, one gatorade bottle size worth. It's like a jug. [00:24:03] Speaker A: It's like several days. [00:24:04] Speaker B: Yeah, yeah, exactly. And then you can't sit there and have a steak dinner, for example. I'm talking about an extreme, but you gotta restrict what you eat, clean you out, and you get tired, and it's quite a process. So maybe I'll, maybe, Charlene, I'll answer your question by saying there are things that are. That do exist. There are scans that one example is a CT colonography. It doesn't yet reach what we call the sensitivity and specificity, in other words, the accuracy of actual colonoscopy camera. But it's an outside, it's a CT scan that's intended to look inside the colon. And so sometimes it has a role for patients that the colonoscopy cannot be performed for whatever, multiple reasons, including if it's just not possible to pass the colonoscopy through. People have a narrow colon, for example. It just doesn't have as high of an accuracy enough to make it something that's fully primetime to replace a colonoscopy. Wide scale nationwide for every situation. But it does exist. [00:25:07] Speaker A: Mine's coming up here in a few months, so I'm really excited to do it. [00:25:13] Speaker B: Well, I'll start saying congratulations, and good for you for doing it. It's important, and I hope your listeners will take inspiration from you, that you're going forward with it. [00:25:24] Speaker A: Yep. I would like to talk about polyps because, I mean, that's what you're looking for, basically, right? If you see a polyp, can you tell if it's cancerous or not? And if you cannot, do you remove all polyps in there, or. And do you. And how are they removed? [00:25:50] Speaker B: So they. The, I mean, the colonoscopy gadget is really amazing. If there are any comic book fans out there, among your audience, I think, of Spider Man's villain, Doctor Octopus. He had these long tentacles and he had snares at the end. And the colonoscopy, actually, they have, the people who operate the machinery have great dexterity, so they're operating the camera with the long snake like device and then they have another button they push to put out a snare. So it comes out. It's almost like the arcade game thing too, to get the prizes that you never get to win. But they come out in the snare and they grab the polyp. And so part of the answer to your question, I think, is a gastroenterologist, when they gain experience, they can see something that might look suspicious, or if they see something, they always try to take it out. And so the snare grabs it and cuts it just enough and then it comes in through the long, snake like colonoscope device. And then they put it in a dish to give the pathology team in the lab to look under the microscope. It's only when they slice it and look under the microscope and do certain tests that they can say, this polyp was benign, this polyp was precancerous, or, gosh, this polyp actually is cancerous and then need to proceed. Decisions need to be made about what to do next. They'll do that. They will take out as many polyps as they can and then based on that, if it looks like they're benign and not cancerous, the gastroenterology team will come back with a recommendation to somebody after reviewing the results and say, we think because of the polyps or the nature, we suggest you come back at one year. For colonoscopy. We suggest you come back at three years. The answer for when to do it next depends on what's found. [00:27:26] Speaker A: And presumably polyps grow back. [00:27:29] Speaker B: They could, or they might crop. If someone has polyps in a certain area of the colon, the colon is many yards long, then the other areas may be susceptible. So it's possible it can grow up in the same area or it might be different areas just because all of its might be susceptible. [00:27:48] Speaker A: And so people, I don't think. Think about how long is the colon? [00:27:53] Speaker B: Oh, man. I know I looked this up at one point. I mean, I would say yards, meaning as what's yards or three, 3ft. I mean, I would say, uh, dozens of feet long. [00:28:05] Speaker A: You don't think of something that long being inside your. [00:28:08] Speaker B: Oh, yeah, yeah. It's, it's, it's very much, you know, it's a long and winding road to go. Through, um. I mean, if you think of small intestine. So the way I describe our digestive system to folks is you eat food and goes to your esophagus. It's your. Your pipe that leads into your stomach, and then from there, you get small intestines that are different parts of it, or segments, and then your large intestine. Well, when we say larger test and the same thing as meaning colon, it goes along and goes up and across your body and down and kind of intertwining with other organs, and then it leads to your rectum, and then that's when stool comes out from your anus at the end. So it's a lot of square footage, and all of it's intended to grab water and nutrients from the food we digest and the water we drink, and really just to help nourish us. And so it's a very efficient organization, but it's really big. [00:29:00] Speaker A: What advice would you have for somebody who has recently been diagnosed with colorectal cancer? [00:29:08] Speaker B: Yeah, so I think if someone hears the diagnosis, you have cancer of any kind, it's something that's likely to be anywhere from discouraging, to say the least, extremely devastating and anywhere in between. I think really, with so many resources available, I think, really. And everyone's different. Some people like to do online researching. Some people like to hear. Some people like to read information. But understanding what goals are and how to best gather information, it can be different for every individual, surrounding themselves with the people that care about them and to help them have eyes and ears that hear beyond. There are studies in medicine that say that because of all the emotion, they get swept up and hearing about cancer and everything that goes with it, someone might only retain 10% of a visit with me. We do our best that we can from our standpoint, but having people who care about us, with us in those visits and other things are really important and helpful, because they'll take notes, they'll be there for the conversation. They can help prompt questions for the time that we have together. And advocacy, it's huge. Speaking of advocacy, I want to give a shout out and credit to a lot of wonderful advocacy organizations that they're at the national level, regional level, at the local level, very much, including a number ones that are here, Minneapolis St. Paul based Colon Cancer Coalition, the Minnesota Colorectal Cancer Research Fund. Just a lot of great, great organizations that are here in our own backyard and front yard, as well as at the national level. And they have. They are there people who have gone through it, colorectal cancer diagnosis, hearing those words, you have colorectal cancer going through treatment and come out the other end. And a lot of them are so willing to meet with people who have new diagnosis and to explain and review their journey with them and say, there's hope. We just have to go through the journey together. And so when someone is diagnosed, you know, really, you know, feeling empowered to ask questions, don't be afraid to ask questions of the doctor telling you you have cancer and say, can you explain this to me, please? Until the person understands, and then asking for a referral. And if somebody sees an oncologist or a gastroenterologist and says, I request a second opinion from my side, I always want to honor that. And I think it's worth its weight in gold for reassurance at least, and then at least an opportunity to gather more information, and then someone can decide on who they want to be part of their care team and help them through the journey. From an oncology standpoint, a lot of times it may be appropriate to meet with a surgeon who has expertise and dealing with a colon rectal in that part of the body. For cases of rectal cancer, radiation may be an appropriate part of the treatment plan. So meeting with a radiation doctor, building a team, and just making sure that the team works together to try and come up with the best possible plan for, for any given individual. [00:32:10] Speaker A: I really like the idea that you suggest a second opinion, because I do think that's really important. Even if you like the doctor that you first meet with, like, you don't know if another doctor is going to bring anything else up that was forgotten or just didn't get brought up. But I do realize there's a substantial amount of people who come in by themselves, excuse me. And they may not have good family support, and I don't, it feels like the idea of recommending, you know, somebody who can offer some support, you know, like somebody who can take notes, as you said, doesn't always get brought up. Can you speak to that? [00:32:56] Speaker B: Yeah. I always love it when people come with others. And so when I introduce myself and I have the patient usually starts by introducing themselves. I say, please tell me who's with you. Introduce your colleagues or the people who are with you. And so sometimes, a lot of times it's family members, sometimes it's friends from the neighborhood. Sometimes it's people from someone's faith, community or others. And what it shows is that they're loved and somebody cares about them enough to come to these appointments. And even if it's just one time, you know, that they're in the background and reassuring to where I think for us as caregivers from the clinical side, to say, oh, these people have people to turn to that way in the case of an emergency, or just from day to day just needing help, that these people have support and that's really great. [00:33:44] Speaker A: But you can suggest an advocate if you need to. [00:33:48] Speaker B: Well, there are a lot of these patient advocacy organizations. I named just a few of them in colon Cancer Coalition and others, that they are great resources, they have hotlines, and sometimes they can connect. Sometimes if we have people, sometimes we've had people who've gone through the treatment journey, diagnosis of treatment journey, who offer saying, feel free to call upon me on a time, connect me. If somebody needs an advocate or just someone to talk to, here's my phone number. Please feel free to connect me with them. And that's been really nice. There's a support group that's through the University Cancer clinic, the masonic cancer clinic that meets monthly. And I think a lot of patients and family members and caregivers take us up on that to be part of that support group. And that's another helpful advocacy route. [00:34:32] Speaker A: I'm wondering what are some of the common challenges that patients do face during a colorectal cancer treatments? [00:34:46] Speaker B: Certainly I think the hope for research in this field and for other cancers is the ultimate goal, which we don't know will ever be attainable, is 100% chance to cure and 0% side effects. But I'm far from being in that position as of yet. So the always think of the symptoms that come from the cancer itself. We've talked about some of those already. And then when you're trying to neutralize the threat of a cancer with chemotherapy is often the staple. And there's some role for targeted therapy based on patients individual tumors that are tested. But in general, chemotherapy can have some significant risks and side effects. In general, people that are otherwise healthy and don't have major medical issues besides the colorectal cancer, may end up tolerating the chemotherapy better than people who have other significant medical conditions that also require significant medical attention. But at the end of the day, none of it is without side effects. Some of the common side effects that occur by chemotherapies that we use to treat patients with colorectal cancer, the most common one across all chemos, is fatigue. It can make someone more tired than would be otherwise. And a lot of people work. You need to make a living. And so I've had patients who work part time, full time, and for some people, full time might mean 70 hours a week. Some of it's maybe physical labor, and some of it might be more desk job, but all of it can be compromised, and it's tough. When getting chemotherapy, usually the rhythm of that, or frequency, for example, is every two weeks. So a lot of it's a cumulative side effect. So the more times people get it, some people go from saying it affected me for the first few hours after I got it, or the first 24 hours, and then months later, they'll progress to saying, you know, it affected me a lot. For three, four, or five days, I get it. And then they get maybe a week to feel that, like they're recovering until it starts all over again. And then we call a cycle, and cycle continues. And so, um, one of the most common chemotherapy drugs used internationally for many years is one that's based on the metal platinum, using jewelry and other things. And it, it's a cumulative side effect, but it's very notorious for neuropathy, numbness or tingling. I rub my fingers as I speak all the time because it, it's most prominent in the hands and feet. And as we live in Minnesota, it actually makes a big difference because this symptom is stimulated by the cold. So as you round the corner into fall and winter in Minnesota, and I'm giving this drug, I especially want to make sure to remind patients, and it's very common for them to say, wow, it was an especially cold day. I had to put on double gloves because the cold bothered it and triggered that symptom even more. It's not that that can't occur to patients in Florida or in Arizona or summer Minnesota, but it's definitely more pronounced as just one example, in mid Minnesota, winter. [00:37:35] Speaker A: Well, and your toes, like you walk your toes go first. So you may. I mean, terrain changes could mess with it and things like that. So you talked about chemotherapy. I think you said, touch that radiation is sometimes used. I think people get concerned about surgery, like having to have any removal of any part of the colon and get worried that, oh my gosh, I'm going to be attached to a bag the rest of my life. How often does that happen? And if it does happen, are there anything that can reverse that? [00:38:15] Speaker B: Yeah. So I think back to a question you asked earlier about stigma or misunderstandings. I think that is, in many cases, an assumption that a lot of people come with, that. Sometimes it is necessity and sometimes it's not required. It really depends. What it depends on is the location of the tumor. In the colon or rectum and how much it might be taking up space, we call that obstructing. So if it's sometimes someone who does a colonoscopy, gastroenterologist will report near complete obstruction or obstruction or pending obstruction, as opposed to 50% of the room taken up. And so that might make a difference. And the surgeon might need to do an ostomy. An ostomy is basically kind of fusing a part of the colon to the outside skin and creating a bag for the stool to come out of instead of going through the usual system of plumbing. And so, again, it depends on the location and where the tumor was and how it was big and other factors, but in some cases, that can be reversed. So maybe after someone undergoes surgery and then chemotherapy, that maybe later on, if there's no evidence of cancer, that can be revisited and an expert surgeon who put it in, can reverse it and seal it up and restore their kind of their normal digestive system with whatever remains of the colon, excluding the part that's been taken out. And then in other patients, it is something that would not be advised or could not be done again because of the amount of colon that needed to be taken out safely to treat the cancer or the location. But it's not 100% of the time. I think a lot of people do come in making an assumption. We do have at least one staunch patient advocate who had metastatic or stage four rectal cancer over a dozen years ago and had it cured. And he lives very avidly and actively, and he's a massive fundraiser for colorectal cancer research here at the university through cruise for cause, the Mezzan Coates Colorectal Cancer Research fund. And he gives talks around the country, talking about ostomy and the products and saying, you can live an active life. He golfs, he sails, he does many things. And so there's no one better that I know of in this area who first hand has gone through it and acknowledges the stigma and says, here are ways you can live up. It's not perhaps as bad as people think, but it's not for me to say as a doctor, but no one better than someone who's gone through it, who has that perspective. And he meets with patients a lot to. To say, here's what you can expect. Here's what the truth about it is. Here's his personal experience, and here's what you might expect. [00:40:58] Speaker A: Are there any complementary or alternative therapies that you find some people use that might be beneficial in conjunction with traditional. [00:41:08] Speaker B: Treatments yeah, I mean, I would say sometimes I'll package that with food people. A common question will also be, well, what foods can I eat? I want to say, honestly, the best food is exercise and keeping hydrated. They're kind of going back to the Internet as a resource. Internet can be a powerful resource. There are great advocacy organizations, or cancer.net is a wonderful online resource with information in lay language from our professional organizations. But there might be an equal or even higher amount of things that may not be as accurate on the Internet. Yes. Yeah. With these supplements, alternatives, it's very, again, a very common question. There are very nice websites through the National Cancer Institute, Morrison Kettering Cancer center called about herbs, and they have apps, and they're very good. But I think if you go through and pick any given app, sorry, any given supplement, if you look at the level of data, often it's from cells in a petri dish, but not in human beings, in a trial, in human beings, half of whom get a supplement, half of them don't. Otherwise, everything else is equal. To answer the question with certainty, I think there's a lot of claims made, claims made in Internet or otherwise, by people who may be looking to make profit off of that. So I think it's something where I don't tell patients yes or no, take it or do not take it. What I offer is just consideration a few ways that these supplements often or almost exclusively are not approved by the FDA. So you don't necessarily know that what's been the label is actually in the product that you'll be buying. So I use that as a caution. And also, I think another unknown is we don't know how any given supplement, again, kind of extract or all these kind of things, or alternative medication approaches might interact with chemotherapy and maybe make. Maybe make it not work as effectively as it otherwise might. So what I tell people is, if you go that route, and if at some point we get a scan that shows growth in which I will not be able to accurately interpret whether or not it was the chemotherapy itself that no longer worked or did not work at all, or is it something that was interfering with its ability to work? And I tell patients, if you project yourself hearing that information and feel that you would regret taking the alternative for herbal supplement, then you would have your own answer. If someone says, well, I want to do that, understanding the potential risk, then I support either way, I just want people to feel that they understand that here are things that we know and here are things we don't know. [00:43:43] Speaker A: Yeah. I especially think that is important. You can find anything on the Internet that will tell you what you want to hear. And so I think finding legitimate places that will give you accurate medical information is really important. What do you do for families that are affected by people who are going through colorectal treatment or cancer? What are some advice that you might have for the families? [00:44:20] Speaker B: Definitely for family members of people diagnosed with colorectal cancer is for them themselves. Inform their primary care doctors, primary care physician assistants, or whomever team members an updated of their own medical history and saying, I have a parent, I have a sibling, I have someone in my family who's diagnosed with a colorectal cancer at this age, you know, primary care person, I want you to know about this update in my family history of cancer and how that might affect me and my timing for a colorectal cancer screening. And then from the other standpoint, you know, our oncology team extends far beyond just the doctor oncologist like me, beyond our nurses and other team members. We have here at the University of Minnesota an excellent team called cancer risk management, cancer genetic counselors. And these are people highly experienced in that ability to counsel people with cancer and their families about. Here's a potential risk that this cancer may have been hereditary in nature, and here are tests that exist that we can do with x amount of accuracy to help inform you if you want to know that information or if your family would want to know that information. Not all people want to know that information. So that's why the counseling is done first. But if someone hears the counseling and says, yes, I want to proceed with testing, then testing may be performed and including the ones for colorectal cancer. And if the gene is identified and the people who are the relatives learn about this, and it might spur them to have a more in depth conversation with their doctors, or maybe for themselves. To cancer genetics specialists is to determine how frequently they should have colorectal cancer screening to try and find it early, if they're at higher risk than the. [00:45:58] Speaker A: Average person, are there disparities? So, like, does this particular cancer partial to males or females or any ethnicities? [00:46:09] Speaker B: Yeah. No. That's an excellent question. It's very timely because in the last five to ten years, the medical field has recognized the wide gaps in what we call healthcare disparities and the, frankly, injustices in terms of having equity as well as equality and access to care. Starting in colorectal cancer with screening, if we don't find it early, but we have to be able to offer colorectal cancer screening appropriately to anyone, everyone who needs it, regardless of race or ethnicity or background of any kind. And there remain healthcare disparities just in offering colorectal cancer screening, colonoscopy, and even just the basic tests. And then in terms of populations that get colorectal cancer, I mean, it's high and it's rising across the board, but it's especially in young adults, to find people lower than the age of 50 or 55. And that rate is double what it was ten to 20 years ago, really? And that's something of. [00:47:08] Speaker A: Do you think that that's because the tests are better, or is there something environmentally or something that's making it rise? [00:47:17] Speaker B: We're. We're working so hard to try and figure out answers to all those questions. It might be some combination of better testing, but it's not. It's far from exclusively being answered in that way. I've had patients in their teens, twenties, thirties, and I feel like the. Honestly, if I look at my clinic panel, I would say the majority of my patients now with colorectal cancer under age of 55, now defined as early onset or young adult colorectal cancer, for a cancer that traditionally, the average age had been in the early sixties, like late fifties, early sixties. And that's why traditionally, until 2018, the colorectal cancer screening age was recommended at age 50, if you didn't have a family history and then didn't have symptoms, and that's been lowered as of five, six years ago by many societies, to 45, and five years from now or earlier, it might be 40, we don't know. But there is a disparity in terms of age and in terms of ethnicity. You know, african american, native american populations in some pockets and regions of the country may have higher incidents and diagnosis of colorectal cancer. And we're trying to tease out, is it because we didn't offer widespread, equitable access to colorectal cancer screening, that population? Or is there something inherently biological in the genome, or is it the microbiome, the bacteria that differs? We know that bacteria can be affected by diet, and so, but also in the white population, there is still an unacceptably high rate as well. And there's so many great researchers working in the healthcare disparities fields. I will also mention an important, acknowledged field. The last decade has been financial toxicity. How expensive it is to have to go through cancer care. It's like I tell many patients, it's like, wow. To go through what they go through. It's almost like another part time or full time job, just to show up for all the appointments that we have to offer as part of the care come from a scan, get these blood tests, see patients, and then when they get sick as a result of chemotherapy or the cancer, more tests, more hospital visits, more clinic visits. It is tough. And then I have a great colleague, Doctor Arjun Gupta, a fellow gastrointestinal oncologist here who works and is a national leader on this idea of time toxicity. The amount of time people spend when diagnosed with cancer, they spend just taking care of the cancer rather than being able to live the lives that they want to live. Time toxicity, financial toxicity, the disparities, these are important topics that are being recognized more and more in recent years that will only become more important for researchers to investigate and to try and solve the problems of in the years to come for colorectal and other cancers. [00:49:55] Speaker A: Doctor Liu, I'm wondering what you see for the future of colorectal cancer. Like, are there treatments that you feel were on the edge of coming out in the next, like, ten years? What are you seeing? [00:50:08] Speaker B: Yeah, a lot of exciting things that I hope if we have an opportunity and I have the privilege to meet with you again a year from now, three years from now, five years from now, I hope to come armed with great excitement. Even more so, I think things that have happened in the last five to ten years are exciting, are our ability to test any given individual patient's tumor for what I call the genomic fingerprint. It's not just knowing the genes that happen in colorectal cancer in general. What's happening in this individual's patient that I, as an oncologist or fellow oncologist, can use to make a treatment decision that would benefit the patient. There's so many exciting things. It's really the tip of the iceberg at this time. I'm very proactive. And for every single patient, it is international standard of care to test for patients with stage four or metastatic forms of colorectal cancer. Hundreds of genes get tested. It's not necessarily true yet that the tests make a difference because we don't yet have drugs to fit the targets, so to speak. But people are working so hard in clinical trials to prove that certain drugs that are coming to market, and I could say now 2024 compared to 2020 compared to 2015, there are so many more options than there were a decade ago, and there are more on the way for specifically treating patients with colorectal cancer, for specifically treating each individual patient. Immunotherapy is a topic I just want to make sure to mention because it's on everyone's lips and minds, and it's something that has. I mean, it's. I'm not prone to overstatement, but for melanoma, skin cancers that are stage four or lots of types of lung cancer, immunotherapy has really revolutionized the way that we've been able to offer treatments that work better and have more profound effects, have people live longer with greater quality of life. And we're trying to replicate that in colorectal cancer. We have exciting clinical trials here at the university and around the world. There are exciting clinical trials trying to make immunotherapy work better for patients with colorectal cancer. Right now, there are certain markers that we can test for that may predict success of immunotherapy. But that marker is only seen in five to 10%, maximum 15% of all patients with colorectal cancer. So that means 85% to 95% of patients don't yet have markers that we've identified that immunotherapy will make any difference. But we're working so hard to find different combinations with chemotherapy or immunotherapy by itself. We've run a clinical trial since May 2020 here to look at cell therapy, taking someone's own cells from a tumor and genetically engineering in the lab to become a cancer fighter and cancer assassins and put them back in against the cancer. And that's showing, I think, I would say, at the cutting edge of what our ability to do. And it's not science fiction. Just in February, the FDA approved the first ever solid tuber cell therapy of t cells from someone's tumor, from melanoma, because of great response. And so that's something. It's not a new concept. It's been around since early eighties, at least. So if you want to venture to, say, 40 years in the making, melanoma, it may just be the first of many and many other trials, ours and others around the country, for colorectal and other cancers to look at. Can that be the next frontier, a success for patients? When you try chemotherapy, it no longer works. Can that work better than anything else that we have? And I think some exciting developments are underway that I hope a year from now and years to come, we could say will become mainstream and widely available. [00:53:34] Speaker A: What do you see if any AI playing in a role in this? [00:53:41] Speaker B: You read my mind. I think maybe with AI, because that's another. Yet another hot topic, and I'm initiating collaborators with. With global leaders in this field, other institutions, because AI is not just the future, but it's the now. And if we don't catch up in many aspects. So some of the things we have here, working on a project here, multiple institutions, with University of Minnesota as a lead site, is using artificial intelligence to read scans from patients, with CT scans that pick out features that may help us predict whether or not chemotherapy is destined to not work as well in some patients, individual patients, than others. And that's really exciting. And some of the preliminary information on that has been published in colorectal and other types of cancers. And we see that on a large scale, taking something that's not at all used in daily clinical practice and making that mainstream is a big goal. It will take a lot of work, but I think it's. The work in AI is accelerating. Looking at the slides can give us information from someone's biopsy, the two dimensional representations of a three dimensional entity called the tumor, but there's so much more that can be read out of it. And I think AI will be able to us with greater efficiency to pick out things that we, with the human eye cannot see or uncover or identify, but make associations with. How well chemo may work, how well immunotherapy may work, and try to uncover new biomarkers or targets that we say, if we test this and find this in any given patients, then we should be using this drug. And AI helped us to make that connection. I think AI is the here and now. It will only explode exponentially in the years to come. [00:55:18] Speaker A: Yes. Now if we can only get insurance on board. [00:55:22] Speaker B: Exactly. That is a whole other hour I think we'll need to spend together that is always coming back to that financial toxicity. It's such a challenge. But we need to have affordable care for people who need it, no matter what their background, where they live, suburban, urban, regional, but no matter where they are in the country. But whoever needs it needs to get the best care possible. [00:55:44] Speaker A: And I'm guessing your advice to our listeners would be get your colonoscopy and be aware of your choices of life. [00:55:55] Speaker B: Absolutely. I don't think I could have said it better than you just said it. [00:56:00] Speaker A: Is there anything else you'd like to leave us with? [00:56:03] Speaker B: I think maybe the overarching message of hope. There are so many great advances. Even if someone hears that, the dreaded words, you have colorectal cancer. There are many great treatments these days. If you don't have symptoms, whether or not you have someone in your family, get colorectal cancer screening. It's one of the few cancers we have. Screening tests. Let's find it early. Let's work together and really partner with your care team, your medical team. I think partnership is essential and there's a lot of great advancements coming along the way. [00:56:36] Speaker A: And where's the best place that you think people can go to learn about colorectal cancer online? [00:56:42] Speaker B: Yeah, a lot of great resources. Cancer.net is an excellent resource. It's from our national organization, American Society of Clinical Oncology. Patient advocates have written an in language in partnership with clinical organizations and leaders to ensure that people have widespread access. They have an iPhone app you can download locally. Colon Cancer Coalition, it's just a fantastic, fantastic advocacy organization. And they have a great website and they have a great resource and they put on events that people could come to for education. Minnesota Colorectal Cancer Research Fund and many others are here to help. They're raising money for research. They're here to help people at all stages of learning about diagnosis and going through the cancer treatment journey. [00:57:21] Speaker A: Doctor Liu Saint, thank you so much for your time. I feel like I've been educated, so hopefully somebody else out there will too. Charlene, do you have any more departing words? Thank you very much, doctor. I learned a lot. [00:57:37] Speaker B: I'm glad. Thank you so much. I really appreciate the forum. You guys are doing great, great work. Keep it up in all facets and count me as a fan. Thank you. [00:57:45] Speaker A: Thank you. This has been disability and progress. The views expressed on the show are not necessarily those of KFAI or its board of directors. KPI dot.org dot.