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National Cancer Prevention Month: Rising Trends and How to Combat Them With Samuel Kareff, Matthew Hadfield, Waqas Haque, and Joseph Kalis

In honor of National Cancer Prevention Month 2024, members of the Oncology Data Advisor Editorial Board and Fellows Forum sat down for a panel discussion about the rising incidence of cancer diagnoses, factors contributing to them, and how to counsel patients in light of these emerging trends.  

Samuel Kareff, MD, MPH: Good afternoon, everyone. Welcome to the Oncology Data Advisor Fellows Forum. We have a very special edition this week for National Cancer Prevention Month. Ironically, we're filming this on Mardi Gras, a day on which some folks may or may not participate in activities that are conducive to cancer development. At any rate, we're going to go ahead and launch right into the special edition today.

On a more serious note, what we want to start off discussing here are some of the worrisome findings we've noted in US-based epidemiologic studies related to cancer burden within the US, specifically the rising incidence and prevalence of metastatic colorectal cancer in patients under age 50. We've recently seen some headlines talking about how colorectal cancer is now the leading cause of cancer death in men under 50 and the second-leading cause of cancer death in women under age 50, even though these numbers have actually been declining in adults age 65 and older. Now, we do know from risk-based studies that some of the sort of Western lifestyle attributes are contributing to this, such as increased red meat consumption, decreased fiber consumption, sedentary lifestyles, and others.

What I'm really hoping we can focus on today as this episode kicks off is, what are some of the trends that we're seeing here in the clinic, and how are we counseling our patients to prevent the worrisome rise in colorectal cancer?

Matthew Hadfield, DO: It's a remarkably concerning problem that I think everyone's starting to pay more and more attention to over these last four or five years. Personally, one of my colleagues recently saw a patient on consults in the hospital who was 41 years old and had metastatic de novo colorectal cancer. It's one of those things that you're seeing in the news and the media at large is talking about this issue, but you're also seeing it in clinic.

I think the big thing that all of us are wondering is, what is the underlying etiology for what's driving this trend in colorectal cancer? I did want to bring up a really interesting article that I just recently read. It looks as though this rise in colorectal cancer could be a birth effect. It's a birth cohort of patients that are coming of age right now, and it makes you wonder if there's some type of exposure during pregnancy when this cohort of patients was conceived that could be leading this.

There was also a very interesting article recently about microplastics, essentially how we're starting to use more and more plastics and are seeing increased plastic consumption. Microplastic breakdown in the environment ends up in our food and can cause gut inflammation. It's concerning, and no one's really teased this out yet. Hopefully, we can get a little bit more of a grasp on what's driving this.

Joseph Kalis, PharmD, BCOP: Sam brought up some great points in the evidence. You see red meat, processed foods, and other things, and I think it could be multifactorial, like you said, with the generational effect. What were these patients or even their parents exposed to, and how does that carry forward genetically? I think you hit on a great point, Matt, about inflammation in the gut. As a patient myself, I had recently had some gastrointestinal (GI) workups and they were a lot more open to doing the colonoscopy earlier. It seems like some of this awareness is getting into fellows and other clinicians like us.

With the patients I'm seeing, I've also gotten a lot of those questions like, "Hey, I'm 50, and I've got metastatic colorectal cancer. What does screening look like for my children or for my siblings?" Even for parents, because as you said, these cancers are happening much younger than that 60-to-70–year-old age bracket where we anticipate cancers happening.

Waqas Haque, MD, MPH: Thanks for sharing that point, Joe, about screening. I'm currently finishing my Internal Medicine Residency, and I'm actually taking care of a patient now in his mid-thirties, inpatient, who had Lynch syndrome but never really got follow-up. Even for those patients with increased genetic risk, I think there's a lot of potential to really increase the role of screening.

One thing I find interesting is that there may be some warning signs of younger-onset colorectal cancer that present differently than patients who are diagnosed above the age of 50. There was a study published last year that looked at a lot of different insurance claims and looked at a study of over 27,000 patients—5,000 with early-onset colorectal cancer and 22,000 without cancer—and matched them by age and sex. What they found was that there were four types of warning signs that were more common in patients who were diagnosed with early-onset colorectal cancer below the age of 50. These were abdominal pain, rectal bleeding, diarrhea, and iron deficiency.

Obviously, these four things can be due to a lot of other things as well, but one interesting thing is that rectal bleeding and abdominal pain were more common among early-onset colorectal cancer patients than among people diagnosed above the age of 50. There may be some patterns that we'll be able to tease out as we get more data on this on this alarming trend.

Dr. Kareff: All excellent points, gents. I think that in terms of the secondary prophylaxis of colorectal cancer, we've historically heard lots of things. We've heard about vitamin D intake, aspirin consumption, lots of fiber, that sort of thing. Maybe the pendulum is swinging against some of these things, aspirin in particular, but they're still things that we have to keep in mind in the clinic when we're counseling our patients on how to prevent second primaries and that sort of thing.

I love how two of you brought up the emphasis and importance of primary prevention of colorectal cancer. We talked about a few lifestyle things, but Dr. Kalis, maybe you could kind of kick us off a little bit on talking about the primary preventions for disease in general, maybe using colorectal cancer as a case example, for instance.

Dr. Kalis: Sure, there's an emphasis on primary prevention in many cancers. A lot of the focus I've been reviewing with patients recently is on diet, exercise, maintaining good physical activity, and healthy diets with fiber and vegetables, like we've said before, to help clean through anything carcinogenic that might be in the gut.

I think even beyond that, regarding some of the primary prevention and screening that happens, a lot of the discussions I'll have with patients center around, what do we test for? Why are we testing for it? Often, I'm fortunate enough to have the ability to go into detail with them on the pros and cons of screening. I think there are some perceptions out there where it's as simple as running a blood test, and it can tell whether a patient has cancer or not. For us as clinicians, we're looking for markers of something that might indicate cancer but might also mean something else.

I had a patient recently ask me, "Well, why aren't we tracking my carcinoembryonic antigen (CEA) level?" It turns out he was a smoker, so we could track it, but it's going to be artificially elevated because of lifestyle choices. Another topic I've seen come up in conversations with patients is the idea of what we call sensitivity or specificity around tests. How accurate is that test in identifying a positive result or a negative result? I think a part of screening and testing that often goes unnoticed is what the patients can go through whether they get a positive test or a negative test. What does that mean? I think in my own institution, recent changes have led to the results of scans or imaging or other lab tests reaching the patients often at the same time it reaches us.

On one side of the coin, that's a good thing. On another side, it can cause some concern if a patient's not quite sure. "Well, doc, what does the report mean? When I read it, it said the number is larger." Well, that could be inflammation from immunotherapy. It could be a number of things. It's created quite a variety of conversations that I think really need more time to be discussed and to focus on some of the nuances around testing and around screening.

Dr. Hadfield: You raise such a good point about the day and age that we live in where patients are getting access to results, in some situations ,before we do, and then are trying to take those results and interpret them on their own. I mean, we could probably have an entire conversation about that alone, but patients can really have anxiety over some of the indices even on a complete blood count (CBC). They call me saying, "Oh, my mean corpuscular hemoglobin concentration (MCHC) was 0.1 higher and there's a red exclamation point next to it. What does this mean?"

It causes a lot of anxiety, and it is something be very cognizant of. I've tried to start explaining to patients, especially with computed tomography (CT) scans as we're starting to restage, that we really just want to wait until we can talk together about the results. But it's challenging. It's a great point you bring up.

Dr. Kalis: Much like you said, the anxiety over the red color on lab work has been another recent trend I've been seeing. I spent some time last week with a patient where we went through every category on their lab result. I think even sometimes when there are reference ranges, there's still a bit of that disconnect regarding what it means and whether it's relevant to their case.

Dr. Haque: Definitely, and to pick up on that, I think one challenging thing with screening is always the risk of false positives or the risk of indeterminate findings that require more workup. We have actually been seeing more studies that are looking at blood-based methods to detect cancer. Even in one study that was published last year of the PATHFINDER study, what they found was that in patients who needed confirmatory testing when they had positive circulating tumor DNA (ctDNA), it took about 74 days for diagnostic resolution to confirm that there was or was not a cancer. Joe, to take your patient who is concerned about his CEA levels, he's going to be just as anxious about waiting 10 weeks to see if that blood test doesn't mean anything or if there's something scarier behind it.

Dr. Kareff: Dr. Haque, I've got to really emphasize this point because we're hearing and talking about these in clinic so often, right? There are these not-yet-approved assays that are looking for early cancers. Of course, we're so excited to discuss these things and eventually embrace them into clinical practice, but they're just not ready for prime time yet. A lot of folks will end up going for these sorts of pan–magnetic resonance imaging (MRI) scans of the body looking for things. We really should be talking, in addition to sensitivity and specificity, about things such as positive predictive values and negative predictive values and translating those into lay language, and it's really tough. Obviously, we have a lot on the clinician end to do in terms of discussing preventative techniques, but also talking about tests that look to avoid things before they become problems. A whole lot of work needs to be done here, that's for sure.

Dr. Kalis: Just today, I came into today's discussion from seeing a patient with newly diagnosed prostate cancer. In discussing it with the patient, it brought to mind a past patient from several years ago. I worked with a coworker who had come to me and said, "Oh my gosh, my father's prostate-specific antigen (PSA) is elevated." I said, "Okay, well how elevated? What are we talking about?" She goes, "Oh, his PSA is at 7.0 and he's freaking out. I'm freaking out. Could this be prostate cancer?" So, we got to discussing some of the factors that could have artificially elevated the PSA. I asked, "Was he taking finasteride or saw palmetto? Had he been sexually active the evening before the PSA was drawn?" She kind of looked at me jokingly like, "You really want me to go and ask my father all these questions?" I was like, "If we're trying to get to an answer, these are some important details."

Some of those things did turn out to be true in his case, and fortunately, it wasn't prostate cancer. But the impression I've gotten both from being in practice and then from the patient side is there is still a lot of perception that it's just a simple blood test, when in reality, there's a lot more nuance to what we're looking for and then the results we get.

Dr. Hadfield: I think that's such a good point, and there are a lot of conflicting messages that get conveyed to patients. To play off all of your points, I just met a patient yesterday in clinic who has metastatic pancreatic cancer. They're going to be enrolling in an early-phase trial and were really passionate about getting circulating tumor DNA to track whether or not the therapy is working. We had a very long conversation about how we are going to do restaging scans to assess disease, since that's the way the protocol works. It raises the important point that these companies are really marketing to patients to come into their office and ask about circulating tumor DNA. To piggyback off Dr. Kalis's point, we're not ready for prime time with that. We're still doing validation studies.

We're trying to figure out which patient populations a lot of these tests and screening methods are appropriate for, when we should use them, if we should use them, and which assays we use. In this simultaneous way, having these things marketed to patients who are very anxious about their disease and want more information really creates a complex problem, especially when we start talking about potentially screening patients with these platforms in the future and how that could really change things. It's something I think we're going to have to discuss with patients a lot more in the future.

Dr. Haque: I definitely agree with that. I think there are examples like Joe said, with the patient you were talking about where, we have United States Preventive Services Task Force (USPSTF) guidelines to recommend for screening for prostate cancer, but unfortunately, over 70% of cancer deaths in this country are actually outside of the purview of USPSTF guidelines. That's where the blood-based screening could be exciting and maybe tilt the balance in the future.

Dr. Kareff: Somewhat related to that point, what I think has been very exciting, at least for the duration of my fellowship and a few years before, is actually seeing the embrace of chemotherapy prevention for a lot of common cancers. I think of breast and prostate that come to mind quickly, where we've actually adopted these strategies in an earlier setting. I look forward to seeing that in other disease settings, and of course, there's lots of data being developed at this time.

All right, we covered a lot in this session. We went through the realm of primary prevention of any malignancy and then talked about some select areas where secondary prevention could be applied. Any last words for our episode today, folks?

Dr. Hadfield: I would just reiterate one more time that, especially as it pertains to colorectal cancer screening, I think it's really, really important—and Dr. Haque made this point earlier—that a lot of people who are younger might have warning signs and think to themselves, "I'm too young to have cancer. I'm too young to have colon cancer." So, if anyone hears this podcast, if you're having any of these symptoms and you are young, you should really speak to your physician about this because it can be something concerning regardless of your age now, unfortunately.

Dr. Kareff: Absolutely. I'll kind of leave us all with a quote that came, I think, from the 18th century or so—remember, an ounce of prevention is worth a pound of cure. Take care, everyone. Have a good week.

About the Panelists

Samuel Kareff, MD, MPH, is a Medical Oncologist and a Hematology-Oncology Fellow at the University of Miami's Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital in Florida. He has special research interests in health advocacy, public policy, and the development of cancer therapies.

Matthew Hadfield, DO, is a Hematology/Oncology Fellow at Brown University/Legoretta Cancer Center in Providence, Rhode Island. His research focuses on melanoma and early-phase clinical trials, including development, novel immunotherapeutic combinations to overcome therapeutic resistance, and predictive biomarkers for immunotherapy toxicities.

Waqas Haque, MD, MPH, is a third-year Internal Medicine Resident at NYU in a Clinical Investigator Track. He is an incoming Oncology Fellow at the University of Chicago. Dr. Haque's research interests include innovative clinical trial design, value-based care delivery to cancer patients, and becoming an early-stage clinical investigator.

Joseph Kalis, PharmD, BCOP, is an Ambulatory Oncology Clinical Pharmacy Specialist at the University of Colorado Health. In this position, he educates patients about their chemotherapy and immunotherapy treatments, reviews treatment plans and dose adjustments, and assists with supportive care for patients with multiple myeloma and other hematologic malignancies.

For More Information

American Association for Cancer Research (2024). February is National Cancer Prevention Month. Available at: https://www.aacr.org/patients-caregivers/awareness-months/national-cancer-prevention-month/

Reed T (2024). New cancer diagnoses expected to hit record high this year. Available at: https://www.axios.com/2024/01/17/new-cancer-diagnoses-record-high

Murphy CC & Zaki TA (2024). Changing epidemiology of colorectal cancer—birth cohort effects and emerging risk factors. Nat Rev Gastroenterol Hepatol, 21(1):25-34. DOI:10.1038/s41575-023-00841-9

Li S, Keenan JI, Shaw IC & Frizelle FA (2023). Could microplastics be a driver for early onset colorectal cancer? Cancers (Basel), 15(13):3323. DOI:10.3390/cancers.15133323

Tait C, Patel AH, Chen A, Li Y, et al (2023). Early-onset colorectal cancer: prevalence, risk factors, and clinical features among commercially insured adults in the United States. Cureus, 15(11):e49432. DOI:10.7759/cureus.49432

Transcript edited for clarity. Any views expressed above are the speakers' own and do not necessarily reflect those of Oncology Data Advisor. 


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