Rises and Advancements in Colorectal Cancer

Colorectal cancer is no longer just a disease of older adults—and the data is raising alarm bells. 

On this episode of The Vitals, host Leslie Schlachter sits down with the Mount Sinai Health System’s leading experts  

To unpack why rates are rising, especially among younger populations, and what you need to know right now.  

Joining the conversation are gastroenterologists Dr. David Greenwald and Dr. Pascale White, along with medical oncologist Dr. Deirdre Cohen. Together, they explore the latest research, evolving screening guidelines, and breakthrough treatments that are changing outcomes for patients. 

From early warning signts to cutting-edge therapies, this episode delivers practical, evidence-based insights that could change lives:  

• The likely reasons why colorectal cancer is increasing in adults under 50;  
• Common symptoms you should never ignore; 
• Screening options—from stool tests to colonoscopy—and when to start; 
• The role of lifestyle, diet, and the microbiome;  
• Advances in treatment, including immunotherapy and personalized medicine; 
• How early detection dramatically improves survival. 

Colorectal cancer is one of the most preventable—and treatable—cancers when caught early. Whether you’re approaching screening age or simply want to stay informed, this conversation is essential listening. 

📞For more information on Mount Sinai’s colorectal cancer treatments or to schedule an appointment with a Mount Sinai physician, click here: https://www.mountsinai.org/care/gastroenterology/services/endoscopy-colonoscopy/colonoscopy/colorectal-screening 

🎧 Subscribe to The Vitals and explore more podcast programming from Mount Sinai for expert conversations on the biggest issues in medicine, research, and patient care: https://www.youtube.com/playlist?list=PLCT7BA-HcHliU8QIXyuk_74L_uH0gyKGt

Transcript

00:00:00:03 - 00:00:24:00
Leslie Schlachter
Hello and welcome back to The Vitals, the Mount Sinai Health Systems podcast, exploring the people and innovations advancing medicine today. I'm your host, Leslie Schlachter, a neurosurgery physician assistant here at the Mount Sinai Hospital. Today we discussed the rising rates of colorectal cancer, particularly among younger adults. It's an issue that's received increasing attention in recent news and in the medical community.

00:00:24:02 - 00:00:45:19
Leslie Schlachter
Colorectal cancer was once thought as primarily a disease affecting older adults, but historic numbers of patients are finding themselves with a diagnosis in their 30s and 40s, and sometimes even younger. Today, we'll talk about why that might be happening, what symptoms people should pay attention to, when to seek screening, and what happens if a screening test reveals something concerning to guide us through this.

00:00:45:20 - 00:01:04:08
Leslie Schlachter
We're joined by three of Mount Sinai experts Doctors David Greenwald and Doctor Pascale White, who are both gastroenterologist and doctor, Deirdre Cohen, who is a medical oncologist treating colorectal cancer. Thank you so much for joining us. Welcome.

00:01:04:11 - 00:01:18:15
Leslie Schlachter
Okay, so we've been hearing lately that colorectal cancer has been affecting younger patients. I mean, I've seen it in the news like Instagram and TikTok. But like what trends are you guys seeing in your practice? Are you also seeing it in younger patients? Absolutely.

00:01:18:16 - 00:01:41:26
Pascale White
I think the one thing that really struck me in the past couple of months is the new Gem article that came out that said, colorectal cancer is now the number one cancer related death in patients under 50 in the United States of America. And this tracks with what we're seeing in our endoscopy practices, patients who are coming in with symptoms in our clinics and saying, hey, this could be a Hemery.

00:01:41:26 - 00:01:49:27
Pascale White
I'm saying, very well, could be something like a hemorrhoid that's benign. But we're seeing trends with younger people being diagnosed with this disease. And so we need to check it out.

00:01:49:29 - 00:01:52:26
Leslie Schlachter
Why? Why is this happening? What do you think is the reason?

00:01:52:27 - 00:02:12:06
Pascale White
Long and short. We don't know. There are different things that we're thinking about at this point. Could it be environmental? Could it be the microbiome? Could it be early antibiotic exposure? All these things that we're trying to look into at this point, but the long is short of it, is that we're working really hard to figure out what's happening.

00:02:12:09 - 00:02:12:15
Leslie Schlachter
Okay.

00:02:12:16 - 00:02:38:20
David Greenwald
So obesity is also been blamed. Absolutely. And diet. But again there's nothing there's no real hard evidence to explain it. But it's definitely a trend that we've noticed. And the sort of the bottom line is that if you're under 40 or 45 and you have a symptom like rectal bleeding, it needs to be checked out and not just sort of said, oh, it's probably a hemorrhoid, this is nothing, or it'll go away, but definitely come seek health care, professional guidance, and probably some sort of investigation to understand why it's there.

00:02:38:22 - 00:02:55:19
Leslie Schlachter
We did a podcast a couple of months ago on the Surgeon General's update for alcohol. With colorectal cancer being one of the cancers that you're at increased risk if you drink alcohol, do we think that alcohol is to blame for this? Maybe. Is alcohol been on the rise?

00:02:55:25 - 00:03:16:04
David Greenwald
So alcohol is a risk factor for colorectal cancer. There are a lot of things that are risk factors. The most important risk factor for colorectal cancer turns out to be advancing age. So although you just mentioned young people again just just the simple fact of getting older is the most impactful reason for getting colorectal cancer. Alcohol itself. There are other risk factors.

00:03:16:04 - 00:03:24:01
David Greenwald
We think a diet that's increased in red meat or processed meats, cigarette smoking, all of those are risk factors for colorectal cancer.

00:03:24:02 - 00:03:31:23
Leslie Schlachter
So cigarette smoking is also a risk for colorectal cancer. Yes. I want you to know I know the answers to some of my questions. I didn't and like I don't resist.

00:03:31:23 - 00:03:34:28
David Greenwald
There are a zillion reasons why cigarette smoking is bad. This is one of them.

00:03:34:29 - 00:03:51:06
Leslie Schlachter
Okay. And you're so you guys are like seeing the patients symptomatic. They come in, we'll get back to, like, diagnostics and stuff. But you're treating these patients correct? What would be your guests are if you were to, like, name your belief for the top three reasons why younger people are getting colorectal cancer.

00:03:51:08 - 00:03:52:09
Pascale White
I think it is.

00:03:52:09 - 00:04:13:09
Deirdre Cohen
Probably a lot to do with diet. Early exposure to antibiotics, and then the sedentary lifestyle that we are seeing. So but again, I think to prior point, we don't really know these are all hypotheses, but I think that they're gaining more and more ground.

00:04:13:11 - 00:04:19:16
Leslie Schlachter
Right this the early exposure to antibiotics. Can you guys just like go into more detail? This is the first time I'm hearing of this.

00:04:19:17 - 00:04:50:17
Deirdre Cohen
Well I think it's more about changing your microbiome. Right. So we all have bacteria that live and breathe, breathe but live on us, with us. And they play a huge part in health and disease. And there can be alterations in that. The communities of bacteria that can lead to dysbiosis and ultimately its downstream effects in terms of immune function and allowing cancers to develop.

00:04:50:17 - 00:04:54:29
Deirdre Cohen
So chronic inflammation is part of it.

00:04:54:29 - 00:04:57:03
Leslie Schlachter
So really like a community disrupter.

00:04:57:04 - 00:05:16:11
David Greenwald
Yeah. Yeah, it can be a community disrupter. I just want to put a little plug in for the use of antibiotics when they're necessary okay. So antibiotic and I know I know you're with us. Antibiotics are really important in in you know, fixing certain bacterial infections that can be very serious. So this is not to say that all antibiotics are bad, but they have to be used judiciously and properly have.

00:05:16:14 - 00:05:21:28
Leslie Schlachter
I agree GI. Are probiotic for when you're on antibiotics.

00:05:22:01 - 00:05:24:19
Pascale White
You're not going to catch me there.

00:05:24:21 - 00:05:30:00
Leslie Schlachter
So like now you tell people to take probiotics or just like have yogurt kefir. Is that like a thing?

00:05:30:05 - 00:05:34:25
Pascale White
No, really. Just in terms of prevention? No.

00:05:34:28 - 00:05:35:24
David Greenwald
Why am I blown?

00:05:35:25 - 00:05:45:01
Leslie Schlachter
I don't know, because I feel like ours there in the world you're supposed they tell you to take they. I don't know who they are right now like they is, I don't know. Instagram and TikTok.

00:05:45:07 - 00:05:45:13
David Greenwald
Yeah.

00:05:45:13 - 00:05:49:23
Leslie Schlachter
Yeah. They tell you to take probiotics and you think you have to, but you are telling us no.

00:05:49:24 - 00:06:05:19
David Greenwald
So the evidence is very weak to nonexistent, depending on what you're looking at for the use of probiotics for when you're taking it abiotic or for irritable bowel syndrome in general, very, very weak. So yeah, TikTok and Instagram say that. But you got to go back to the scientific evidence.

00:06:05:19 - 00:06:09:17
Leslie Schlachter
So this is why we actually have this podcast to say exactly these things. All right.

00:06:09:18 - 00:06:12:02
David Greenwald
So in the probiotics don't necessarily hurt people.

00:06:12:03 - 00:06:12:21
Leslie Schlachter
Just the wallet.

00:06:12:22 - 00:06:21:02
David Greenwald
They cost money. That's exactly right. And that's exactly what I say to my patients, which is this is not going to hurt you, but it's going to separate you from your money. And they understand that.

00:06:21:04 - 00:06:38:13
Leslie Schlachter
Yeah. So sometimes it feels good to probiotics in even if, you know, you're throwing your money out the window up to you. Okay. Yeah. All right. So let's go back to diagnostics. You said if you have a symptom to come in and get checked. So like you said, rectal bleeding, what are some other symptoms that you can look for?

00:06:38:14 - 00:07:04:28
Pascale White
Yeah. Abdominal pain that is prolonged. And we're not talking about the run on the bill. If you went out to eat something and you get a little sick and you have a couple, you know, a bellyache for 1 or 2 days talking about patients who have like chronic for weeks or months on end abdominal pain, patients who have a weight loss that they're not intending to lose, their patients who you mentioned rectal bleeding, their patients who have a change in what their stool looks like, we call it a change in caliber of stool.

00:07:04:28 - 00:07:22:14
Pascale White
So if they looks pencil thin, if it looks smaller than usual, or even if your bowel habits have changed, for example, if you're going to often or having looser stools, or if you're not going off more often enough, like you're having constipation, these are all things that are off your baseline that you really want to have checked out with your physician.

00:07:22:16 - 00:07:44:26
Leslie Schlachter
So you had said that obesity is also a risk factor for colorectal cancer. And now there is medicines out there like all these GLP ones right down upside of GLP one. Hopefully we see a decrease in obesity, downside of GLP ones, change in stool character change in symptoms. What are you guys seeing with that? Are you guys seeing patients coming in and trying to figure out what's what.

00:07:44:29 - 00:08:03:27
David Greenwald
Yeah. So it's a great question actually. So we've actually talked about this a couple of times. The GLP one agonists and other similar drugs. Yeah are incredible for weight loss. They're part of the way they work is they slow down the GI tract the stomach and the colon as well. Mostly the stomach. But so constipation and change in bowel habits is pretty frequent.

00:08:03:27 - 00:08:21:04
David Greenwald
And the concern now is whether people who have some of these early warning signs that Doctor White was just talking about and or taking GLP one agonists or similar drugs are going to confuse the two of them and delay their diagnosis. I don't know that we know that that's happening just yet, but it's certainly a possibility and something we have to be aware of.

00:08:21:05 - 00:08:39:22
Leslie Schlachter
Yeah, I I've been on GLP ones, I have a lot of patients on GLP ones and it's like the constipation is real. Yeah, yeah. It can be actually pretty scary. Yeah. So back to the blood in the stool. So it's blood on the stool like the number one sign of colorectal cancer. Because I feel like that's what we hear.

00:08:39:25 - 00:08:59:18
Pascale White
I mean it's a sign it could be a number of things. Impeachments say blood in the stool. Does it matter the color? Does it matter how frequent? I always say to my patients, it's never normal to see blood in the stool. It could either be from a completely benign or just non dangerous cause, like am right, or a little fissure or cut around the anus.

00:08:59:19 - 00:09:03:29
Pascale White
Or it could very well be a bleeding polyp or malignancy.

00:09:04:00 - 00:09:04:28
Leslie Schlachter
How can you tell a different.

00:09:04:29 - 00:09:11:08
Pascale White
We can't. Which is why we always say when you have a symptom talk to a provider, come in and have us check it out with.

00:09:11:12 - 00:09:17:00
Leslie Schlachter
You need a colonoscopy to evaluate blood in the stool, or is that something that you guys can figure out on just an exam?

00:09:17:02 - 00:09:32:15
Pascale White
We need a colonoscopy. Yeah, we need a colonoscopy. Some patients say, can you do a rectal exam? Like I can do a rectal exam, but that doesn't mean whatever is bleeding is bleeding right now. And so whatever bled at that point may have stopped. But we need to check it out with a colonoscopy with a camera study.

00:09:32:17 - 00:09:36:27
Leslie Schlachter
Can you now walk us through what the options are for colorectal screening?

00:09:36:28 - 00:10:09:10
David Greenwald
Sure. So there are a variety of options, which is really good. At Mount Sinai we talk about choice because there's a choice in colorectal cancer screening options. In fact, our colorectal cancer screening program is called CRC choice anyway. Those choices include looking for blood in the stool, typically called an fit test, or fecal immuno chemical test, which is looking for blood in the stool, a test that looks for blood in the stool, and abnormal DNA, which are little pieces of cells that might be coming off of polyps or tumors.

00:10:09:15 - 00:10:37:21
David Greenwald
That's called fit DNA. It's marketed commercially as color guard. Many people know about it. And then there's colonoscopy, which has become the gold standard over many, many years now because it allows us to both detect abnormalities like polyps, which are little growths, and remove them at the same time to prevent cancer. There are a couple other options. There's a CT, which is a Cat scan of the abdomen, which is reconstructed into a kind of a video that looks like a colonoscopy.

00:10:37:22 - 00:10:57:16
David Greenwald
And there's a capsule as you described, which is exactly what it sounds like. It's like a little magic capsule that's got a CCD chip, like a digital camera chip in it with an antenna and a battery and some lights. And when you swallow the capsule, the battery turns on, the lights turn on, the camera turns on, it starts to take pictures.

00:10:57:16 - 00:11:18:09
David Greenwald
There's also an antenna in there that transmits those images wirelessly to a belt recorder, a hard drive, and then eventually the capsule goes in the toilet. The car drive comes back to us. We download the images. You do not have to fetch the capsule, which is terrific. And then we look at those images and it gives us essentially a different view, just like a colon, like little lots.

00:11:18:09 - 00:11:22:05
Leslie Schlachter
Of like little bomb robots that you send into a bomb room look but not be there.

00:11:22:07 - 00:11:26:13
David Greenwald
Super cool. If we could put little scissors in there and then snip the polyps out, but we hadn't gotten there yet.

00:11:26:15 - 00:11:31:03
Deirdre Cohen
Next, ask what are your thoughts about ctDNA in terms of screening?

00:11:31:10 - 00:11:51:00
David Greenwald
You talking about blood testing? Yeah, yeah. So I was just going to get to that. But yeah but no that's fine. Yeah. So blood testing is also now available for testing for colorectal cancer. There's one that's FDA approved there, some others in the works. And there's another version of it also as well. But they are terrific. Right now it's screening for cancer.

00:11:51:01 - 00:12:06:28
David Greenwald
They are not as effective by any means that screening for polyps. And since we know that in colorectal cancer there's a precursor lesion, an early lesion called a polyp that's not cancerous. And if we take it out people don't get cancer. So that's to me is sort of where we're going with this.

00:12:06:28 - 00:12:11:28
Leslie Schlachter
So so if you're like a negative screening test, you could safely think you're okay, but you're not.

00:12:11:29 - 00:12:23:00
David Greenwald
If you had a negative blood test, for example, you probably don't have cancer, but you may still have a polyp. And we want to get to those polyps. It's the same thing with some of the stool based tests actually.

00:12:23:01 - 00:12:24:19
Leslie Schlachter
So isn't there isn't there like.

00:12:24:20 - 00:12:25:06
David Greenwald
Great question.

00:12:25:06 - 00:12:28:18
Leslie Schlachter
What's what's the blood test that you can screen for. What is it called?

00:12:28:19 - 00:12:30:06
David Greenwald
Grail. Well there's.

00:12:30:08 - 00:12:34:10
Leslie Schlachter
Like there was like when I was in school 20 years ago, there was a blood test for screening.

00:12:34:12 - 00:12:47:18
David Greenwald
Yeah, that was called septum nine. It's it's sort of fallen out of favor. These other tests that we're talking about now are much more sensitive and and specific than those early tests, but they've still got I think they've got a ways to go. No.

00:12:47:18 - 00:13:00:26
Deirdre Cohen
That's great to ask my gastroenterology friends what your thoughts are on blood based testing. Although I suspect in the next 5 to 10 years that there may be far fewer colonoscopies done.

00:13:00:28 - 00:13:14:18
David Greenwald
And I think that would I mean, Doctor White can comment, but I mean, that would be fine with us as long as the sensitivity and specificity which works to try, you know, are perfect or good enough that we're not missing anyone along the way. So, yeah, we'd.

00:13:14:19 - 00:13:16:16
Leslie Schlachter
Be good. Can't clip the polyps, though.

00:13:16:18 - 00:13:31:00
David Greenwald
Well, we would love to get to a place where we could mass screen the whole population with a noninvasive test, like a stool test or a blood test, and then reserve the colon for the people, 30 to 40% of people right now who have polyps, who will benefit from that. So yeah, that would be terrific.

00:13:31:02 - 00:13:39:25
Deirdre Cohen
And I know patients much prefer to have a blood test and their stool. I'm sure you guys struggle right with having patients.

00:13:39:28 - 00:13:42:19
Group
Yes yes yes yes.

00:13:42:26 - 00:13:43:16
Pascale White
The idea.

00:13:43:16 - 00:13:47:24
Pascale White
Of having an invasive procedure or being put under sedation or anesthesia to some people.

00:13:47:25 - 00:13:49:14
David Greenwald
Oh, she's talking about the stool based test over.

00:13:49:14 - 00:13:51:23
Group
A blood. Oh, yeah. Yeah, yeah.

00:13:51:23 - 00:13:53:20
David Greenwald
There's a there's an X factor.

00:13:53:22 - 00:13:54:27
Group
This is.

00:13:55:00 - 00:13:59:06
Leslie Schlachter
As are we talking about you collected in a container and send it to a lab. Or you go in for a rectal.

00:13:59:07 - 00:13:59:26
Group
No, no.

00:13:59:27 - 00:14:00:22
Deirdre Cohen
Collected at home.

00:14:00:23 - 00:14:04:01
Group
And there's a question. No, no, no, that's fine. I just think.

00:14:04:01 - 00:14:18:28
Deirdre Cohen
That it'll be a much bigger uptake. I feel like we could capture a whole lot of more patients for screening who are concerned about colonoscopy and that prep, and then even just collecting stool at home, which is obviously far easier than a colonoscopy prep. So, you know.

00:14:18:29 - 00:14:19:18
Pascale White
But we definitely.

00:14:19:19 - 00:14:21:00
Deirdre Cohen
Have it's not ready yet.

00:14:21:00 - 00:14:42:28
Pascale White
Yeah, we definitely have to be careful. It can't be overstated the fact that the blood tests at this point are not detecting early colorectal cancer. Which one is detected early. You have a higher survival rate up to 90%. And so with patients who have early cancers, who want to find them and potentially have it cured. Right. But these blood tests are not good at that yet.

00:14:42:28 - 00:14:53:23
Leslie Schlachter
So it's just one tool in the toolbox, right. And you use the blood test to follow patients. Move okay. Yes. So once they're in treatment, we're getting determined, I promise. Oh that's fine.

00:14:53:25 - 00:14:55:29
David Greenwald
It's a different blood test. That's your phone.

00:14:56:03 - 00:14:57:00
Deirdre Cohen
There's a different body test.

00:14:57:06 - 00:15:10:23
Leslie Schlachter
So what are the recommendations right now? Let's just talk about the general healthy public. Then we can talk about people that have like obvious risk factors, like, I don't know, all sort of colitis or Crohn's and then people with family history. So what's the screening recommendations.

00:15:10:23 - 00:15:35:01
Pascale White
So right now is 45 for everybody. So we like to say 45 is the new 50 for patients who need to know that the age went down to 45 because we're seeing a uptick in early colorectal cancer. So it's 45 for all. These are for patients who are at average risk. So patients who have no family history of colorectal cancer, patients who have no personal history of polyps, patients who have no symptoms at all.

00:15:35:01 - 00:15:47:21
Pascale White
So they're not anemic, they're not losing weight or having blood in the stool. These are patients who are going to come in and say, I'm asymptomatic, average risk. We're going to screen you at 45 patients who have any other risk factors. They're going to be screened earlier.

00:15:47:23 - 00:16:03:17
Leslie Schlachter
So for patients who have a primary care doctor I know how our EMR works. Something will come across their screen saying ding ding 45. Send them for a colonoscopy. But like, how do you capture patients that like don't have their yearly PCP or follow their care? How do we make sure that they're getting it?

00:16:03:19 - 00:16:35:02
David Greenwald
Okay, so there has been an enormous amount of work done on outreach to the public to make sure that this message is getting to everyone, and it's getting to everyone in different languages, in different populations, with different messaging to the different populations, because we know that the messaging that reaches one population won't necessarily reach the other. So there are national organizations that were all involved in that have put forth, put together really amazing public relations information to try to get that word out that this is a preventable disease.

00:16:35:02 - 00:16:59:08
David Greenwald
Colorectal cancer is largely preventable if we can take polyps out, if it's not preventable. As Doctor White was saying, it's in detected early, it's treatable. So it's beatable. And that's the message we're getting out there. So we have to just keep getting that message out. And having said that, the screening rate in New York City right now is about 69%, which means that 31% of the eligible population hasn't been screened.

00:16:59:09 - 00:17:12:11
David Greenwald
And around the country, it's not many different than that. And the rates are even lower in the groups that have lower insurance or less insurance or federally qualified health centers. The screening rates are in the 30s and 40% right now, so we've got a lot of work to do.

00:17:12:12 - 00:17:19:04
Leslie Schlachter
Are these is it call and ask me, which is the gold standard. Is that covered by patients who have Medicaid. Yeah.

00:17:19:06 - 00:17:19:28
David Greenwald
Yes, absolutely.

00:17:20:00 - 00:17:20:16
Leslie Schlachter
There should be.

00:17:20:17 - 00:17:23:14
David Greenwald
You know, with no co-pays and no deductibles. Okay.

00:17:23:16 - 00:17:41:26
Leslie Schlachter
Well, I guess this would be a good time just to, like, pause for a second. So if you are new to The Vitals, please make sure that you scan the QR code below. We want to make sure that you guys follow us and get all this information moving forward. And hopefully if you can't stay for the whole episode, also scan the QR code below to make an appointment to see one of our gastroenterologists.

00:17:41:26 - 00:17:58:25
Leslie Schlachter
If you're 45 or up and haven't had a colonoscopy okay, so let's let's keep going. So you you have a patient there getting their colon polyp whatever. Can you tell right then and there during the colonoscopy, whether that looks like something cancerous or not.

00:17:58:27 - 00:18:17:21
Pascale White
You can tell if something looks malignant most of the time. But because we don't know, we have to remove them and said, I'm off to the pathologist. So if we're finding a big tumor, yes, some things are pretty obvious, but these polyps that we're taking out, we send them off to the pathologist to confirm if they're precancerous or not, because not all polyps are precancerous.

00:18:17:24 - 00:18:22:12
Pascale White
Is there some polyps that don't turn into cancers? It's the precancerous ones that we want to find and remove.

00:18:22:12 - 00:18:28:05
Leslie Schlachter
And then the ones that have the precancerous like the polyps, you just follow them close more closely with colonoscopies moving forward.

00:18:28:05 - 00:18:37:26
Pascale White
It depends on the type of precancerous polyp. It depends on the size. It depends on the number. We find we have guidelines that tell us when to come back for these colonoscopies.

00:18:37:26 - 00:18:46:08
Leslie Schlachter
So now we have a patient with cancer. Yeah. Like what kind of cancer is colorectal cancer said adenocarcinoma. What are we dealing with.

00:18:46:10 - 00:18:49:27
Deirdre Cohen
Yes it is and I don't know. Carcinoma gland for main tumor. Correct.

00:18:49:28 - 00:18:54:24
Leslie Schlachter
Okay. And so what are the treatments. So are there is there a surgery radiation. Chemo.

00:18:55:00 - 00:19:27:05
Deirdre Cohen
Yes is the answer. It really depends. It's very stage dependent right. So if it's a stage one colorectal cancer for example that's treated with surgery alone. So most of those patients never see me which is wonderful. They have over well over 90% survival rates for stage two. Typically it's mainly a surgery. Again, we do look at ctDNA to help us prognosticate their risk of recurrence and whether chemotherapy would be helpful to lower that risk of recurrence.

00:19:27:05 - 00:19:55:00
Deirdre Cohen
But for the most part, stage two patients are not getting chemotherapy, and surgery alone is curing them. It's where we get into stage three and four, where there's more multimodality therapy, including surgery, chemotherapy and radiation in the setting of rectal cancer. So that's where we really use radiation therapy. And there is a distinction between, you know, biomarkers within colon cancer.

00:19:55:00 - 00:20:05:14
Deirdre Cohen
So and certainly gastroenterologists can also chime in here in terms of tumors that are mismatch repair deficient or microsatellite unstable.

00:20:05:16 - 00:20:08:06
Leslie Schlachter
Can you bring that down five notches for yes that.

00:20:08:06 - 00:20:09:06
Pascale White
Is a biomarker.

00:20:09:06 - 00:20:36:04
Deirdre Cohen
It's basically a mutation that can happen either even heritage it from mom or dad. And then it's called Lynch syndrome or it's sporadic. And basically it's a error in DNA repair, but it actually allows for the tumor to produce more antigens. And so these tumors are much better behaving. And they also respond to immunotherapy, which I know is a big hot topic.

00:20:36:06 - 00:20:46:28
Leslie Schlachter
You wouldn't. So once the pathology comes back and you can do some genetic workup on the actual tumor itself, you then can find out whether or not they're candidates for immunotherapy versus just like chemotherapy.

00:20:46:29 - 00:21:02:17
Deirdre Cohen
Yeah. So we do a lot of testing on the tumor to help us understand the biology of the tumor. So including whether they would be good candidates for immunotherapy. And you know what what treatment they would best need.

00:21:02:18 - 00:21:07:24
David Greenwald
And this is way different than it was like ten years ago. I mean, this didn't none of this even existed, which is.

00:21:07:24 - 00:21:10:21
Pascale White
So much more personalized medicine.

00:21:10:23 - 00:21:39:15
Deirdre Cohen
So we're really looking and understanding what's driving the tumor and, you know, having more targeted approaches. And we're also, you know, backing off from some of our more aggressive therapies in that setting. So for example, for mismatch repair deficient or MSI high rectal cancer, we're now able to treat these patients only with immunotherapy and forego surgery and radiation, which is huge in terms of quality of life and functional outcomes.

00:21:39:21 - 00:21:53:07
Leslie Schlachter
I know, I know, you're the oncologist, you're not the surgeon. But like you said, first stage one and stage two surgery can be curative. Can you just tell us a little bit about what that is? Is that like a big surgery with a bag. Is it something smaller? Sure.

00:21:53:07 - 00:22:07:26
Deirdre Cohen
So typically you know for colon cancer it's they're taking up part of the goal. And so a Hemi collected me whether it's on the right side or the left side. And there's no bag involved. So they are, you know, put back together if.

00:22:07:26 - 00:22:09:28
Pascale White
You will reconnect. Correct.

00:22:10:00 - 00:22:22:12
Deirdre Cohen
And they have complete, you know, normal function. I mean there's a little change early on, but generally people live a really full and normal life following surgery.

00:22:22:14 - 00:22:34:04
Leslie Schlachter
Okay. And then so is it like more of like when. Because when I think colorectal cancer I can't help it. I worked in urology for years, so I had patients with stoma like who are the patients that are getting the bags.

00:22:34:09 - 00:22:55:29
David Greenwald
Most of the patients with colorectal cancer are not getting bags unless they come in fully obstructed and blocked, and then the bag is actually a temporary measure, while the while the the rest of the situation is taken care of and then eventually it's again, the tumor will usually be resected, taken out, and then the colon reconnected. In the vast majority.

00:22:55:29 - 00:22:56:29
Leslie Schlachter
Of mechanisms.

00:22:56:29 - 00:23:05:02
David Greenwald
It's a healing mechanism. Yeah, there are lots of patients who get bags for other reasons, diverticulitis and so forth. But in terms of colorectal cancer, it's pretty rare.

00:23:05:04 - 00:23:05:08
Pascale White
Yeah.

00:23:05:10 - 00:23:16:19
Deirdre Cohen
I think, you know, the the only time would be a very low lying rectal cancer. And even then we're trying to avoid that with chemotherapy and radiation.

00:23:16:21 - 00:23:19:12
Leslie Schlachter
How long does treatment usually last.

00:23:19:13 - 00:23:51:02
Deirdre Cohen
That's also kind of depends on the stage. So certainly for metastatic it's sort of indefinite. It really depends. Also if there's limited metastatic disease what we call oligo metastatic disease where we can surgically remove all of the metastases versus if it's widespread. And then sort of treatment continues until as long as patients tolerated and the tumors responding. But for typically for stage three where it's surgically resected and there are lymph nodes that are involved with cancer, we give about six months of chemotherapy on average.

00:23:51:02 - 00:23:53:21
Leslie Schlachter
And do you have any clinical trials right now that are going on?

00:23:53:22 - 00:24:21:12
Deirdre Cohen
We do have several clinical trials going on. So we have a study looking at basically using ctDNA which is circulating tumor DNA. So looking at sort of fragments of cancer cells or the DNA of the cancer cells in the blood and adjusting treatment based on that. So escalating treatment if the the CTA is positive in the blood or de-escalating if it's negative.

00:24:21:12 - 00:24:50:10
Deirdre Cohen
So really trying to avoid over treating patients who are going to be cured with surgery alone and avoiding chemotherapy, because certainly chemotherapy can have some long term side effects. And then escalating and trying to cure more patients who, you know, may benefit for a more intense regimen. We also have treatments in the metastatic setting. So more some studies looking at bispecific antibodies in combination with chemotherapy.

00:24:50:10 - 00:24:51:21
Deirdre Cohen
And I don't know if this is two.

00:24:51:22 - 00:24:54:12
Pascale White
No no it's good. It's good. Watch.

00:24:54:15 - 00:24:59:06
Deirdre Cohen
And then we have a couple of bispecific antibody treatments in the metastatic setting.

00:24:59:06 - 00:25:06:04
Leslie Schlachter
Right now I would imagine the patients are looking for more of like the immunotherapy route than the standard chemo route.

00:25:06:06 - 00:25:20:03
Deirdre Cohen
Well I think chemotherapy still is still the backbone for treatment of colorectal cancer. We're not quite ready to give that up. So a lot of our studies are adding immunotherapy agents in combination with chemotherapy.

00:25:20:04 - 00:25:24:01
Leslie Schlachter
Maybe you guys can get your little video robots to spit little.

00:25:24:03 - 00:25:24:18
David Greenwald
Yeah.

00:25:24:19 - 00:25:27:14
Pascale White
So we actually did things at a polyp.

00:25:27:16 - 00:25:40:17
David Greenwald
We actually have other parts of the GI tract where we put chemotherapeutic agents directly against the tumor like in the bile duct. So yes. And if we can get our little capsule to direct itself perfectly, that would be terrific. You can work with us on that.

00:25:40:23 - 00:25:57:18
Leslie Schlachter
So you guys are gastroenterologists. You're an oncologist. I guess the only person we're missing here is a colorectal surgeon. But is that like typically the pathway? How would this how this works? And is there a connection back. Do you need surveillance colonoscopies. How does it work once you're kind of like in the colorectal pathway?

00:25:57:20 - 00:26:14:05
Deirdre Cohen
Well, I just add that I think someone who's very important in this whole pathway is the PC, which I think we alluded to. Right. Looking for anemia. Right. Which I think when I think about my patients who have been diagnosed with colon cancer, a lot of them present just with new newfound iron deficiency anemia.

00:26:14:05 - 00:26:15:05
Leslie Schlachter
After their primary. And.

00:26:15:06 - 00:26:20:28
Deirdre Cohen
Oh, well, there's yeah your hemoglobin is now ten. And so then they're referred to to my colleagues.

00:26:21:02 - 00:26:44:17
David Greenwald
And even more important is the primary. I mean that's very important. But even more important is the primary care physician. Just saying you need to deal with colorectal cancer screening because a lot of people shy away from this because they're embarrassed about having a colonoscopy. They're embarrassed about playing around with their stool for the stool based testing. There's all sorts of reasons why people have avoided colorectal cancer screening, but turns out to be really beneficial.

00:26:44:19 - 00:27:08:12
David Greenwald
So one of the few cancers that we can show where screening and then eliminating polyps, we've actually decreased the rate of colorectal cancer in this country pretty dramatically over the past 30 years. So the primary care physicians and other health care providers who are providing primary care, them telling a patient you need to get screened, it turns out to be the single most important factor in getting that patient screened.

00:27:08:17 - 00:27:18:16
Leslie Schlachter
Yeah. No, I love that. I have a primary care here at Mount Sinai, and I'm not going to say her name, but she's not like the most warm, fuzzy PCP. But she is like, this is what you have to do.

00:27:18:19 - 00:27:20:01
Group
Like who you are.

00:27:20:03 - 00:27:29:20
Leslie Schlachter
Just like gives me a bullet point list of what has to get done. And if certain things are done, the office is calling being like, why did you cancel this? And I love it. That's what they should.

00:27:29:21 - 00:27:30:26
Group
Also good.

00:27:30:29 - 00:27:57:15
Deirdre Cohen
This is the team with surgery as well as radiation. And I mean we have what we call tumor boards where we're presenting patients and we're reviewing in addition to with pathology radiology, interventional radiology. So it's a big team. But I think after the completion of treatment, the core group of surgery, medical oncology and gastroenterology continue.

00:27:57:20 - 00:28:07:10
David Greenwald
The people who come in either for their colonoscopy or with a stool based test that's positive. And that's really important that if the stool based test is positive, those patients need a colonoscopy.

00:28:07:10 - 00:28:11:26
Leslie Schlachter
So the patient doesn't even need to see you for the stool based test, they can send it and then be like, no.

00:28:11:26 - 00:28:16:22
David Greenwald
In fact, on the Super Bowl, the color guard people were advertising just I love that. Yeah, yeah.

00:28:16:23 - 00:28:17:29
Leslie Schlachter
So just picking up a CVS.

00:28:18:00 - 00:28:18:25
Group
Well, yeah, sorta.

00:28:19:03 - 00:28:19:22
David Greenwald
Really it's a mail.

00:28:19:22 - 00:28:21:29
Group
On things but yeah Instacart.

00:28:22:04 - 00:28:34:13
David Greenwald
But anyway once once those once. You know if any of those tests are positive then we do work with our colleagues on staging, as Doctor Cohen was saying. And then we referred them typically to our oncologist to manage along with the surgeon if that's relevant.

00:28:34:13 - 00:29:00:23
Leslie Schlachter
So basically colonoscopy, positive pathology, MRI, Cat scans. Yes. Staging. Yep. You maybe maybe not. Maybe just colorectal surgeon. Correct? Yes. Okay. Got it. Yeah. And I think you just brought up a really good point before. And for those of you guys listening, one of the things that can be really stress inducing is when you go to a doctor, get diagnosed with something, you wonder like, should I get a second opinion?

00:29:00:23 - 00:29:18:01
Leslie Schlachter
Should I get a second opinion? Especially in New York and major cities, you can feel like you need to get multiple opinions from people. And one of the great things about a place like Mount Sinai, we are an academic institution and we have multidisciplinary teams. So what they talked about is a tumor board. And you guys said your tumor board is probably similar to ours.

00:29:18:02 - 00:29:42:20
Leslie Schlachter
So GI medical oncology, radiation oncology, colorectal pathology, radiology. Everybody reviews complex cases for sure. But sometimes non complex cases where it's like should we do this. Should we do that. And then there's a group consensus that comes out of the tumor board. And by default you're getting like over ten opinions clean ones is it. And that's a big benefit.

00:29:42:20 - 00:29:52:00
Deirdre Cohen
And in fact we for every rectal cancer patients not just complicated ones, every single rectal cancer patient is presented at our multidisciplinary conference.

00:29:52:00 - 00:29:52:29
Group
So yeah.

00:29:53:00 - 00:30:05:04
Leslie Schlachter
That's that's really important because like if you're getting an opinion out of Mount Sinai, then you know, you're getting multiple opinions that came together as one. Are you guys using artificial intelligence at all in colorectal cancer?

00:30:05:07 - 00:30:06:07
Pascale White
That's a great question.

00:30:06:09 - 00:30:07:16
Group
We are so we absolutely are.

00:30:07:17 - 00:30:25:00
David Greenwald
So there are we're in baby step mode right now. But it's a big step where we're using it. So the the easiest to explain example is that we're using it during our colonoscopies to look at the screen. So when a colonoscopy we're looking at a video image of the inside of the colon. And as I said we're looking for polyps.

00:30:25:01 - 00:30:43:21
David Greenwald
30% of women have polyps. 40% of men, when we screen them, have polyps. So we can use artificial intelligence to look at the TV screen. And it puts a little green circle or an arrow pointing at something and says, hey, look there, and that there might be some residual stool, or it might be a polyp that I saw, or it might be a pop I didn't see.

00:30:43:22 - 00:30:54:01
David Greenwald
So that's the way we're mostly using artificial intelligence right now. It's terrific increasing the yield in polyp detection. And we're still studying whether it actually affects outcomes or not.

00:30:54:04 - 00:30:59:24
Leslie Schlachter
So far like your when the little arrow goes up on yours. Do you ever go oh I didn't see that.

00:30:59:24 - 00:31:01:04
Group
Thank you. Yeah.

00:31:01:06 - 00:31:07:26
David Greenwald
So I've seen demos and. Yes absolutely. Yeah. You sort of say oh and we've been doing that for years also with the other people in.

00:31:07:26 - 00:31:08:14
Group
The room.

00:31:08:15 - 00:31:13:08
David Greenwald
So we have technicians and nurses in the room and we ask them to actively participate.

00:31:13:13 - 00:31:13:26
Leslie Schlachter
I other.

00:31:13:26 - 00:31:18:14
David Greenwald
Intelligence, other intelligence. But now we're using computer artificial intelligence. It's very cool.

00:31:18:15 - 00:31:35:29
Leslie Schlachter
Yeah. That is really cool. Yeah. No, that's really helped me. Thank you. In neurosurgery, when we order scans, the AI radiology reads it, and then we'll send something out like. So let's say it's not in the list for the radiologist to read for another couple of hours. If there's something that picks up, it moves it to the top of triage, which is really helpful,

00:31:36:01 - 00:31:44:16
Leslie Schlachter
Yeah, yeah. No, it's really, really great. What are some of the biggest misconceptions out there about colorectal cancer that we should talk about. Stressing that.

00:31:44:16 - 00:31:50:07
Pascale White
It's no longer a disease of older people. Younger people are getting colorectal cancer and.

00:31:50:07 - 00:31:52:01
Leslie Schlachter
Not say it again. It's the number one.

00:31:52:02 - 00:32:12:12
Pascale White
It's the number one cancer death. And patients under the age of 50 in the United States of America very big deal. And they didn't expect that to happen so soon. It was projected that this would be the case in 2030. It is now the case now. So this is a trend that is most definitely alarming. And we want everyone to know about that.

00:32:12:14 - 00:32:32:27
David Greenwald
There's a myth that colorectal cancer is only a man's disease actually equally affects men and women. There's a myth out there that if you don't have a family history, you don't need to be screened. That's not true. Family history is important, but it's not the only thing. And most colorectal cancer occurs in people with no family history. And then the last big misconception, I think, is that if you have no symptoms, you're fine.

00:32:32:27 - 00:32:41:10
David Greenwald
But again, as we said, this is a preventable illness. If a preventable disease, if we can find it and we're looking for people without symptoms who have polyps.

00:32:41:11 - 00:32:42:09
Leslie Schlachter
We got to get the polyps out.

00:32:42:09 - 00:32:51:03
David Greenwald
We got to get the polyps out. This is very much akin to cervical cancer, where perhaps smears find cancer before it's cancer. And then you can do something about it and prevent it.

00:32:51:05 - 00:33:14:16
Pascale White
I think the other myth out there is that colorectal cancer comes in a particular race or particular gender. There are a lot of disparities in this disease. There are patients who are getting diagnosed with this disease at far higher rates. For example, American Native Alaskan Indian patients have now the highest incidence of colorectal cancer in the United States.

00:33:14:19 - 00:33:34:19
Pascale White
Second, that is for African Americans. So a lot of disparities here in terms of screening disparities in terms of survival disparities, not everyone is getting screened. And we really need to make a concerted effort to reach those populations that are dying of this disease at higher rates, to really get the message out there.

00:33:34:22 - 00:33:36:08
Leslie Schlachter
What about you for myths.

00:33:36:09 - 00:34:01:11
Deirdre Cohen
I would say. I mean, I think you guys covered it very well, but from my perspective, I would say that it is not a death sentence. So we can still cure you if you are to be diagnosed with colon cancer. So there are really, really new advanced treatments out there that are curing more and more patients even in, you know, metastatic stages.

00:34:01:11 - 00:34:01:26
Deirdre Cohen
And it sounds.

00:34:01:26 - 00:34:09:02
Leslie Schlachter
Like you guys aren't trying to bulldoze patients with treatments. You're trying to do, like the least amount that you need to be correct, not as aggressive.

00:34:09:03 - 00:34:19:25
Deirdre Cohen
That is. Yes, it is all about precision medicine and really focusing on the biology of the tumor and giving no more or less than what is called for.

00:34:19:28 - 00:34:39:21
Leslie Schlachter
I think it's always been there, but I think it kind of lifted a little bit more during Covid. Was this mistrust of healthcare professionals, pharmaceutical companies, like some sort of conspiracy conspiracy? Do you see that with any patients when it comes to chemo, that it's poison or that there's like there's got to be reasons that you're pushing drugs on them?

00:34:39:21 - 00:34:41:08
Leslie Schlachter
Is that a part of your practice at all?

00:34:41:08 - 00:35:07:09
Deirdre Cohen
I think there is a level of questioning about because of the side effects of chemotherapy. Right. So the chemotherapy kills good, kills the cancer cells. But it also side effects are due to damaging some of our normal healthy cells. And the way we give it is on a certain cycle schedule so that those healthy cells can get better.

00:35:07:09 - 00:35:38:07
Deirdre Cohen
And this is not terribly toxic to patients. But I essentially build trust, I think is very important, as you mentioned earlier, and explain that, really explain the studies that after surgery, this number of patients who get chemotherapy recur versus this number of patients, which is much higher, who don't get chemotherapy. And there's a clear benefit, and that I wouldn't be giving it if it wasn't, you know, effective.

00:35:38:10 - 00:35:50:17
Deirdre Cohen
And I think it's a batter of showing the data and reassuring patients. I think more than than I think most patients are mainly concerned about the side effects. More than that, it's.

00:35:50:18 - 00:35:52:12
Leslie Schlachter
Not like mistrust, mistrust.

00:35:52:19 - 00:36:08:14
Deirdre Cohen
It's more about the side effects and whether they're going to tolerate it. And it is the chemotherapy worse than the disease. And I always explain to every one of my patients, like, my job is to never allow the treatment I'm giving you to be worse than your disease. That's not the goal here at all. I'm here to make you better.

00:36:08:21 - 00:36:25:26
Leslie Schlachter
Yeah. I mean, because we see I see that in my world of neurosurgery where sometimes people are just like, nope, I don't want to go through that. And I just will let nature take its course and patients can make that decision. But that's so nice to hear that from a medical oncologist. Like, my goal is for the treatment to not be worse than the disease.

00:36:25:28 - 00:36:26:19
Leslie Schlachter
I love that.

00:36:26:20 - 00:36:47:12
Deirdre Cohen
And I think in colon cancer, it is a disease. Even in advanced setting where survival is, we're talking years. So it's not as nihilistic as most of my patients do not choose comfort care, although that is always part of the discussion. If we can't cure it, that is an option to have supportive palliative care only. And that's, by the way.

00:36:47:14 - 00:36:52:26
Leslie Schlachter
Like palliative care for colon cancer does not sound fun. It sounds obstructive.

00:36:53:03 - 00:36:58:07
Deirdre Cohen
Well, I mean, I think palliative care is part of treatment. So I wouldn't say that actually.

00:36:58:10 - 00:37:03:16
Leslie Schlachter
Meaning just choosing palliative care that I mean, you say you don't you don't get that that often.

00:37:03:17 - 00:37:09:19
Deirdre Cohen
No we don't we don't not not without having had some treatment initially. Yeah.

00:37:09:21 - 00:37:42:08
Pascale White
I think I would just want to mention in terms of the mistrust in the medical community, we can't ignore the fact that there are some people in this country that did undergo atrocities that really mishandled their trust in the medical system. And so to handle these communities with care, with understanding, with empathy, and to be able to have a discussion about side effects, to be able to have a discussion about treatment protocols, to be able to explain to this community to build their trust is absolutely critical.

00:37:42:14 - 00:38:00:04
Leslie Schlachter
Yeah. Great. Agreed. Would you guys be able to each share a story about a patient that, you know, like a big save or maybe like something that was like a heartwarming story, something that the viewers could maybe be like, yeah, I got to go in and get screened.

00:38:00:05 - 00:38:00:16
Pascale White
I have.

00:38:00:16 - 00:38:01:09
Leslie Schlachter
A story. Okay.

00:38:01:15 - 00:38:21:00
Pascale White
So top of mind, and I think you heard this story, Dave. At last conference, there was a patient African-American man. He was in his 40s, and I saw him on my clinic list and I said, okay, I'm going to go in. I have the statistics. I know, because a lot of the times they're very apprehensive about getting screen, especially the young men.

00:38:21:02 - 00:38:33:28
Pascale White
So when I went in there, he looks at me and says, are you Doctor White? I said, I am Doctor White and he said, I'm definitely getting my colonoscopy with you. And I said, why? He said, because you have your Jordans on.

00:38:34:00 - 00:38:34:19
Leslie Schlachter
Yes.

00:38:34:19 - 00:39:00:04
Pascale White
And it hit me that the connections that we make with our patients is far reaching than our degrees. It's far reaching than our training. It is the ability for the patient to connect with their physician, to build that trusting relationship. And I had no idea that my Jordans would have this big impact on this patient. He felt, you know, but he felt as though I could understand where he was coming from.

00:39:00:05 - 00:39:19:08
Pascale White
That patient ended up getting screened. I found the tiniest and I mean, to this day, I can't even believe I saw it and it didn't look like anything, but it was a pre-cancerous, aggressive polyp. And if he didn't come in, I don't know what it would have turned out to be.

00:39:19:09 - 00:39:20:11
Leslie Schlachter
Hearing your thoughts.

00:39:20:13 - 00:39:46:14
Pascale White
I think about it all the time. I am wearing my Jordans every Tuesday in clinic for colorful kids, or wearing his mom in honor of him, but it's one of those things where you never know how you're going to connect to the patient. You never know how that patient is going to decide to get screened. And these are the moments where you say, this was a life saving procedure for you, and please go out there and tell everyone that, you know, to get screened, because if you didn't, this could have and, you know, had a different ending.

00:39:46:14 - 00:39:48:20
Leslie Schlachter
That's a good social media story right there.

00:39:48:23 - 00:39:50:03
Pascale White
I did I did actually.

00:39:50:05 - 00:39:52:08
Leslie Schlachter
Good, good.

00:39:52:11 - 00:40:09:00
David Greenwald
So I have a similar story, but I'll, I'll make it a little bit different. It was also a young man very recently. And I could do one from like every week. But he was in his late 40s. He had postponed doing his colonoscopy for a couple of years because he said that he was freaked out by the prep.

00:40:09:00 - 00:40:13:00
David Greenwald
So I just want to touch briefly on the fact that the prep is not as bad as everybody thinks.

00:40:13:02 - 00:40:14:12
Leslie Schlachter
I think we need to talk about the prep.

00:40:14:15 - 00:40:33:20
David Greenwald
You will come back to that. How about that? But this gentleman finally came in. So in 48. So he was three years behind our recommendations. He was perfectly prepped. Everything was good. And when I was done, you know, I told him that I had found six polyps and none of them were scary looking to me, but that we would send them off to the lab and so forth.

00:40:33:20 - 00:40:55:22
David Greenwald
And he looked very, very disappointed, like he had somehow failed, that he was supposed to have a perfect colon. And so I said to him, no, actually, this is exactly why we're doing what we're doing. And you didn't do anything wrong, but you had these polyps and we took them out. And much like Pascal, Doctor White was saying, like, you know, this potentially like he's just going to continue on, you know, in his life.

00:40:55:22 - 00:41:10:08
David Greenwald
And maybe we've prevented him from getting colorectal cancer. That has amazing impact on him and his family. You know, ten, 20, 30 years from now. And I actually remind the nurses and the tests that I work with when we do stuff like that, what we're doing. Right. So that's my heartwarming story.

00:41:10:08 - 00:41:15:00
Leslie Schlachter
For the that is, he walked out with a hop in his step because he had a squeaky colon.

00:41:15:01 - 00:41:23:03
David Greenwald
Yeah, but he didn't even realize how good it was. Sorry. And the animal was great. And let's come back to the prep, please.

00:41:23:05 - 00:41:45:06
Deirdre Cohen
So I would say a little different in the sense that I treated a patient with 80 year old gentleman who was diagnosed basically from a dermatologist because he had a fistula. So in fact, the cancer fistulas through his skin from the cecum and was was leaking essentially. And he had seen all these doctors. No one knew what it was.

00:41:45:06 - 00:42:12:18
Deirdre Cohen
He finally got an imaging and had a biopsy and was found to have colon cancer. And he was about to have this huge surgery when we realized, appropriately, that we tested for the biomarker that I mentioned for this marker mismatch repair, and it was deficient, which meant the tumor basically melted away with immunotherapy. So he didn't need any surgery, he didn't need any chemotherapy.

00:42:12:18 - 00:42:15:03
Deirdre Cohen
And he is thriving doing so.

00:42:15:06 - 00:42:16:27
Leslie Schlachter
He's had official repair.

00:42:16:29 - 00:42:26:01
Deirdre Cohen
No he didn't have anything. Just that love on his own. What it was his own body healed it his own immune system. So so that's why I say there's there's.

00:42:26:01 - 00:42:31:18
Leslie Schlachter
Hope in treatment. So back to the prep. I've had a call and ask to be. I've had two.

00:42:31:19 - 00:42:33:10
David Greenwald
Good.

00:42:33:13 - 00:42:49:29
Leslie Schlachter
I had hemorrhoids a decade ago. Okay. Yeah. But my my great man Ari Greenspan is my gastroenterologist. And he said, I'm really sorry, but this is what we got to do. And that's what we did. I did not have a good experience with my prep, if you catch my drift. Did not like it and it scared me. Okay.

00:42:50:00 - 00:42:53:00
Leslie Schlachter
So like please tell me the prep has changed because that was not fun.

00:42:53:00 - 00:43:10:12
David Greenwald
So I don't know what you had and we're not going to talk about that right now unless you really, really want to. Will everybody drink stuff. So most of the preps right now tastes better than the preps that the comedians like to make fun of. And I mean, their entire routine can be about colonoscopy preps and it works.

00:43:10:14 - 00:43:30:16
David Greenwald
But the preps that we're using, for the most part right now are a powder that mixes with some better tasting liquids. So either it's a sports drink like Gatorade or Powerade or sugar free Powerade crystal like coconut water or a flavored solution that comes with a commercially available preparation that also tastes better. We're also using lower volumes than we used to use.

00:43:30:16 - 00:43:51:05
David Greenwald
So previously people used to drink something called Golightly. It was like four gallons, the four quarts or a gallon of seawater. Terrible. Yeah. I mean, I've tried it. It's terrible. So we've replaced that with things that are much easier to take. And because it's lower volume and easier to take, easier tasting, people tend to, at the end of it say, oh, that wasn't so bad.

00:43:51:06 - 00:43:52:09
David Greenwald
So you need to try again.

00:43:52:11 - 00:43:58:13
Leslie Schlachter
Yeah, yeah, I'll let you know my next line. So they're just like better tolerated.

00:43:58:14 - 00:44:05:17
David Greenwald
Yeah. And I really think I've done a couple of colonoscopy preps myself also. And they were not bad. I don't know if your experience and your experience or your patients experience.

00:44:05:17 - 00:44:09:12
Pascale White
Only one. And it was not that bad. And I actually prepped while I was scoping.

00:44:09:14 - 00:44:10:21
David Greenwald
So I go.

00:44:10:23 - 00:44:12:17
Leslie Schlachter
Oh, you did your on a scope day.

00:44:12:17 - 00:44:13:25
Pascale White
I did my preference school day.

00:44:14:01 - 00:44:14:16
Leslie Schlachter
Okay. Bye.

00:44:14:17 - 00:44:15:09
David Greenwald
It's what we do.

00:44:15:10 - 00:44:18:11
Leslie Schlachter
Right. Do you have to prep for the video robot.

00:44:18:13 - 00:44:20:25
David Greenwald
For the capsule? I mean, there is a prep involved in that.

00:44:21:00 - 00:44:21:10
Leslie Schlachter
Because it.

00:44:21:10 - 00:44:24:22
David Greenwald
Means, well, the colon needs to be as clean as it can be.

00:44:24:26 - 00:44:38:16
Leslie Schlachter
Got it? Okay, so as we're finishing up, whether you want to prevent your risk of colorectal cancer or prevent it from recurring, is there anything that patients have control of that they could do to decrease the risk?

00:44:38:20 - 00:45:03:23
Deirdre Cohen
Yeah. So I think what is what I tell all my patients when they're completed their course of treatment and they're moving into surveillance is to keep moving. So exercise is really, really important to lower the risk of recurrence. So is healthy eating. So we talk about sort of low fat low processed foods red meats, high fruits and veggies, sort of what every doctor tells their.

00:45:03:23 - 00:45:05:12
Leslie Schlachter
Patients low red meat or high red meat.

00:45:05:13 - 00:45:06:13
Deirdre Cohen
Low low low.

00:45:06:17 - 00:45:10:02
Leslie Schlachter
Because then you went to fruits and veggies. So I just wanted to share it with comma or semicolon.

00:45:10:03 - 00:45:11:25
Deirdre Cohen
Thank you for your ideas. Yes.

00:45:11:25 - 00:45:12:14
Leslie Schlachter
Hi.

00:45:12:14 - 00:45:35:21
Deirdre Cohen
Hi greens, low meats if any, and avoid the processed foods. We also make sure that everyone's vitamin D is at at a good level and avoiding alcohol. You know, I would say in moderation if at all. And certainly avoiding smoking.

00:45:35:23 - 00:46:02:20
Leslie Schlachter
Okay. Yeah. I mean, if you think like to me, I'm not in your world. But to me, common sense says decades ago people were buying real food and prepping it at home. And like eating out minimally and processed foods were just starting to come out. Now, it's like most of the foods people eat is processed, and people aren't necessarily buying whole foods and making dinner or their food every day.

00:46:02:21 - 00:46:07:15
Leslie Schlachter
To me, it just seems like an obvious connection. Yeah, but we're just not saying it yet because we can't prove it yet.

00:46:07:16 - 00:46:24:11
Deirdre Cohen
There's a very strong hypothesis in terms of looking, you know, when you look globally at rates of colorectal cancer. So we have a very strong correlation between ultra processed foods and risk of cancer.

00:46:24:11 - 00:46:33:15
Leslie Schlachter
So and then can you just define exercise for us. Because exercise to some people might be they just walk back and forth to work every day. So like what exercise are you recommending.

00:46:33:15 - 00:47:03:06
Deirdre Cohen
Exercise. Just move your body. You know, it's not so prescriptive. There was a study looking at prescriptive exercise in terms of meeting with a physical therapist twice a week initially and then once a week subsequently. For patients with stage three colon cancer, versus giving patients just information and encouragement to exercise. And there was a significantly lower risk of recurrence for those patients who, you know, had to show up and meet with a therapist.

00:47:03:06 - 00:47:12:13
Deirdre Cohen
But it's not this specific amount of exercise. I really think it's the consistency for for patients or for all of us.

00:47:12:15 - 00:47:17:28
Leslie Schlachter
Okay. What about you guys? Anything preventative that you want to add?

00:47:18:01 - 00:47:40:25
David Greenwald
The thing I would talk about is barriers. And I want to break down barriers. So if we can talk about all the different barriers to people getting colorectal cancer screened, they include financial barriers. And we've tried to eliminate those financial barriers. So colonoscopy for example, is now again free from co-pays and deductibles. So there's no financial barrier. The embarrassment factor.

00:47:40:25 - 00:48:01:16
David Greenwald
We really don't want people to be so embarrassed by stool based tests and that they just don't come. So we had a slogan that we put on taxi kits around New York City a number of years ago that said, don't die of embarrassment. There are real life barriers, like getting somebody to take care of your kids or your elders that you're caring for so that you take the time to get the call.

00:48:01:16 - 00:48:16:11
David Greenwald
And there are a zillion barriers like that. We need to break down each one of those barriers, and they're different, as I said earlier, for different communities. And then we can sort of increase the screening rate in New York City to 70%, 80% and beyond.

00:48:16:13 - 00:48:34:01
Leslie Schlachter
Do you guys participate? Because I know that there the Mount Sinai Medical School, the medical students see patients in the uninsured clinic. Do you guys participate in that from a GI perspective? That way, uninsured patients can at least get in the door and then eventually get the care they need.

00:48:34:02 - 00:49:02:23
Pascale White
Yeah, absolutely. A lot of us see patients at 102nd Street, which a lot of our fellows are trained at that location, as well as the other faculty practice associates. And so we do see patients who come from right here in our area, in our backyard, at any star where we we can serve them, to see them in the clinic, see them in the office, make sure that they're have choices for their screening, and make sure that they know that choice exists.

00:49:02:25 - 00:49:16:00
David Greenwald
And I'll add to that, we do provide colonoscopies for the patients from that hop clinic that you're talking about who have screenings. Yeah, and they need a colonoscopy. We bring them absolutely in no charge. No. Every everything is taken care of.

00:49:16:01 - 00:49:17:18
Leslie Schlachter
Yep. That's great. That's great.

00:49:17:19 - 00:49:18:03
David Greenwald
The way it has.

00:49:18:03 - 00:49:22:26
Leslie Schlachter
To be. Yeah. It should, it has to be. Thank you guys so much for being here. I really appreciate your time.

00:49:22:28 - 00:49:25:10
Group
Thank you. Thank you.

00:49:25:13 - 00:49:54:15
Leslie Schlachter
That's all for this episode of The Vitals, I'm your host, Leslie Schlatter. Subscribe to The Vitals and the Mount Sinai Health Systems other video podcast programing on YouTube, Apple Podcasts, Spotify, or wherever you get your podcasts. To learn more about colorectal cancer treatments or to book an appointment with the Mount Sinai Expert. Scan the QR code below on your screen, or click the link in the description below to get in touch with the show, or to suggest an idea for a future episode, you can email us at Podcast at Mount Sinai.