August 7, 2019

Colorectal cancer patients warn against dismissing early symptoms

Younger patients say colorectal cancer is a disease that doesn’t follow age guidelines, so pay attention to early symptoms.

Melissa Waddey told her doctors something was wrong when she noticed blood in her stool, but because she was barely 40, they attributed the bleeding to internal hemorrhoids.

Melissa Waddey

Jessica Cash, who noticed similar bleeding at age 31, was told the same thing by a gastroenterologist. A year after doctors made those assumptions, both women were diagnosed with stage IV colorectal cancer.

Waddey and Cash want people, especially clinicians, to recognize colorectal cancer as a disease that doesn’t follow age guidelines. While most cases do occur in people over age 50, recent studies show rising rates of colorectal cancer among younger patients.

An analysis of the National Cancer Data Base published July 22 in Cancer revealed that from 2004 to 2015 the proportion of cases diagnosed before age 50 increased from 10% to 12.2%. Younger patients had more advanced stages of the disease upon diagnosis than those over 50. In Canada, the incidence of colorectal cancer increased at the rate of 3.47% among men and 4.45% among women from 2006 to 2015, according to another study published July 31 in JAMA Network Open.

“A lot of these young patients present with stage IV disease because no one believes their symptoms are cancer,” said Cathy Eng, MD, an internationally recognized leader in colorectal cancer recently recruited to Vanderbilt-Ingram Cancer Center from MD Anderson to co-lead the Gastrointestinal Cancer Research Program and to develop a program to address the special needs of young adults with cancer.

She advises young people to insist on being checked for colorectal cancer if they have bleeding, pain and weight loss as well as changes in bowel habits, energy levels and appetite. While young adults may not in all cases qualify for insurance coverage for colonoscopies, which are considered the gold standard for colorectal cancer detection and prevention, there are less expensive options.

Jessica Cash

“Honestly, any detection is better than no detection,” Eng said. “It does not matter if it is a colonoscopy or a hemoccult test like Cologuard. Anything is better than nothing.”

Rectal cancers can be detected with a digital exam, she said, but few primary health care providers perform them during physicals.

“A rectal exam should be part of your physical exam if you are having symptoms or are age appropriate for screening, but they don’t do them so much nowadays,” Eng said. “They don’t do them because they think that urologists will complete the prostate exams on men and obstetricians will complete the pap smears for women.”

Eng’s recommendations are the type of information that Waddey wants doctors to receive. A former hospital executive, Waddey organized a 5k walk/run this year that raised funds for colorectal cancer awareness. She has partnered with Vanderbilt to leverage part of those funds for messaging to health care providers.

“A big piece of what I want to do is educate primary care physicians and obstetricians about the signs and symptoms,” said Waddey, a Nashville resident. “A lot of my focus will be on providers, especially with the networks of physicians that Vanderbilt interacts with, not just in Middle Tennessee, but across the state. I feel like we can touch so many people.”

The American Cancer Society in 2018 revised its screening guidelines to recommend that people 45 and older be screened for colorectal cancer, but the U.S. Preventive Services Task Force has not followed suit, which would set the stage for insurance coverage of colonoscopies to begin at age 45 instead of 50.

“I’m glad the American Cancer Society moved it to 45, but I still think it should be younger than that,” said Waddey.

At a more basic level, she said people need to get over any embarrassment about discussing symptoms that may be indicators of colorectal cancer. Colorectal cancer is preventable when people undergo colonoscopies, a procedure that allows a gastroenterologist to simultaneously remove polyps that may be cancerous or precancerous during the screening.

“We have got to talk about it more,” Waddey said. “It’s not easy to talk about your colon, your bowel movements or whatever it may be. But that’s how you create more awareness. It’s an uncomfortable conversation to have, to say ‘Hey, Dad, how many polyps did you have?’ or ‘Mom, how many did you have?’ But these are things we need to share because they are important.”

She urged people to take advantage of colonoscopies when and if they qualify for insurance coverage.

“I never want anyone to be where I sit today,” Waddey said. “If I can do anything to create awareness for young people, so they never have to feel what I feel, that is truly in my heart what I want to do.”

It’s been four years since Cash was first diagnosed with stage IV colorectal cancer. She was lifting weights at CrossFit and training for a half marathon when she noticed the bleeding, so a doctor surmised that it was related to internal hemorrhoids because she was only 31 at the time.

A year later in 2015, after she went back and insisted that she be checked out for the bleeding, she got the diagnosis.

“When I was diagnosed at 32 with rectal cancer, I felt so alone and so scared,” Cash said. “I had never heard of it. Everybody assumed I had breast cancer being a female. Now, I’m like, ‘Do your duty, check your booty!’ I am all about promoting awareness. It can happen to anybody at any age.”

She’s active with Fight Colorectal Cancer, the Colon Club, Colon Cancer Coalition and Colorectal Cancer Alliance. She shared her story last year in On the Rise, a magazine published by the Colon Club that showcased young people with colorectal cancer.

She still has an athlete’s body despite numerous surgeries, 28 days of radiation therapy and multiple rounds of chemotherapy that are still ongoing. The surgeries have included two liver resections, a colostomy, a hysterectomy and ureter reconstruction.

She’s quick with a smile, and her big blue eyes radiate energy. However, she’s been through dark times psychologically.

“It’s hard being young with cancer when all your friends are getting married, having children and their careers are booming,” Cash said. “It’s hard, especially mentally. You go through the ‘why me?’ emotions. All of a sudden, you have to deal with this life-threatening illness when most people your age are going out having fun, going to the bars when I’m home sleeping from chemotherapy.

“But at the same time, as crazy as it sounds, it has been an amazing journey. I’ve met wonderful doctors and all these people through these different organizations. You see that there is still good in this world.”

She can’t help but wonder how different her life would have been had her cancer been discovered earlier.

“I would say to doctors, don’t dismiss it if we have bleeding just because we are young,” Cash said. “We know our bodies best. Don’t dismiss it.”

She’s gotten married since her diagnosis, exchanging vows with Aaron Cash, her longtime partner. They fly from New Hudson, Michigan, to Vanderbilt for appointments, now that Eng is based in Nashville instead of Houston.

Cathy Eng, MD

“I don’t know how I ended up with Dr. Eng, but I am so thankful that I did,” Cash said. “She has been amazing to me. I was going to follow her wherever she went. She thinks outside the box.”

Eng is intrigued by the rising rate of colorectal cancer in young people. She’s committed to understanding why it’s happening and helping those patients with all their needs, including body image, nutrition, wound care and counseling.

“These young patients face different obstacles because they not only deal with psychological and social issues,” Eng said. “They are dealing with body image issues, sexual dysfunction issues and socioeconomic issues. It’s also psychologically more challenging because these individuals have not accomplished all the things they want in life.”