Dr. Thaïs Aliabadi, OB-GYN; Co-host, SHE MD Dr. Kimmie Ng, Founding Director, Young-Onset Colorectal Cancer Center, Dana-Farber Cancer Institute; Associate Professor of Medicine, Harvard Medical School Moderator: Erika Fry, Fortune
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00:00Thank you all for being here for this conversation.
00:03Dr. Ng, I want to begin with you.
00:05You're a clinician and a researcher focused on GI cancers
00:08and the rise in young-onset cases in particular.
00:12While there's still a fraction of all cases that are increasing,
00:15and it's a bit of a mystery as to why, right?
00:19Can you tell us what you're seeing
00:21and what we do know about why this is happening?
00:24So there is a silver lining about colorectal cancer
00:27in that overall, and especially in people over the age of 50,
00:30there's been a decline in incidence and improvement in survival
00:34largely due to increased compliance with screening guidelines
00:37and also improved treatments.
00:39But this improvement has not been seen in people under the age of 50,
00:43where it has been increasing by about 2% per year
00:46ever since the mid-1990s.
00:48And in fact, the problem is so severe now
00:51that colorectal cancer is actually the leading cause
00:54of cancer-related death in men under the age of 50
00:58and expected to be the leading cause of death in young women
01:01by the year 2030.
01:03And we do think it's probably some combination
01:05of environmental exposures that is causing this uptick,
01:08but we don't know exactly which ones.
01:11Wow. Thank you. We'll come back to that.
01:14Dr. Kim, you know, is this something that we're seeing more broadly
01:19with other cancers?
01:21And in terms of, you know, figuring out what's driving this,
01:26what are the challenges?
01:28You know, this is a really concerning pattern that we've all seen.
01:32Someone who's done lung cancer in their past
01:34but now oversee a lot of cancers,
01:37this is the epidemic that is smoldering underneath us.
01:40We are not noticing it enough, and now it's becoming apparent.
01:44When you walk through our clinics now,
01:46you will see people in their 40s and their 30s
01:49showing up with new cancer diagnoses.
01:51In fact, the American Cancer Society reported
01:54that it was the 50 and under age group
01:57that had the increasing rate of cancer, not the older folks.
02:01And we did our own study here in Orange County in Southern California
02:05where we looked at L.A. County, Riverside, San Diego,
02:08as well as Orange County, and Orange County,
02:11where Newport Beach, Huntington Beach, Irvine
02:13is a very highly educated population,
02:16we had the highest rates of cancer in those under the age of 50.
02:20So we've got to do something about this.
02:23I've seen patients in my own clinic in lung cancer over 10 years ago
02:27who were 40, 30 years old, and it's not because of smoking.
02:32So something is happening.
02:35Dr. Ali Abadi, this is personal for you.
02:38You had breast cancer yourself.
02:40Olivia Munn, the actress, credits you for saving her life
02:43for the role you played in her breast cancer diagnosis.
02:46In both those cases, they were near misses,
02:49not detected in mammograms,
02:52but caught after you pushed for more thorough testing
02:55based on your breast cancer risk assessment score.
02:58You know, why was that the case?
03:00Why are these things not, like,
03:04why are we not doing that screening well enough?
03:07First of all, thank you for having me.
03:09I've been in women's health for now over, I don't know, 30 years almost,
03:14and the first thing I noticed is that women, in general,
03:18get dismissed when they go to the physician.
03:20Our complaints are dismissed, and every time we open our mouth,
03:24they tell us we're exaggerating our symptoms,
03:27it's PMS, it's anxiety.
03:29So that's the starting point of a woman going to a physician.
03:34When it comes to breast cancer,
03:36there's a lot of false information out there.
03:39I personally had no family history of any cancers,
03:44and I was still diagnosed with breast cancer.
03:46An average American has a 12.5% chance of getting cancer.
03:51So if I told you, breast cancer,
03:53so if I told you this plane had a 12.5% chance of crashing,
03:57would you board it?
03:59But when you tell a woman that you have a 12.5% chance
04:02of getting breast cancer, they're like, it's not a big deal,
04:04I don't have it in my family.
04:06Even if you don't have it in your family, you start at 12.5.
04:09Now, if you're tall, if you had children after 30,
04:13if you have dense breasts, if you've had family history,
04:16if you're overweight, you add your risk factors
04:21and you get a risk score.
04:23If that risk score goes above, it's 20% or above,
04:26that means you fall into the high-risk category
04:29and you have to start your imaging as early as 30, not 40,
04:34and you have to add MRI to it,
04:36which is exactly what I did for myself and Olivia Munn.
04:39Olivia had a negative mammogram, negative ultrasound,
04:42but because her lifetime risk was 37%, I added an MRI.
04:47All her friends were telling her, why is your doctor so paranoid?
04:51And, you know, with my paranoia,
04:54she had three cancer lesions on her right and one on her left breast.
04:58Wow.
04:59And you were telling me as we came on stage, the CDC changed their...
05:04Not CDC, the U.S. Task Force, because I heard you say it.
05:07They were talking, and they're like,
05:09the U.S. Task Force changed their guideline.
05:11I'm like, who do you think did it?
05:13I call it the Olivia Task Force, and I texted her,
05:17since 2016, the U.S. Task Force was recommending mammograms at age 50,
05:23and it was driving me crazy.
05:25Olivia comes out with her story mid-March.
05:28On April 30th, I wake up in the morning,
05:31they had changed their guideline to 40 every two years,
05:34and they said average risk this time,
05:37meaning if you're high risk, that means you need additional images.
05:41I texted Olivia, and I said, this is an Olivia Task Force,
05:44so thank you for that.
05:48That's great to hear.
05:51What are the challenges in detecting these cases early for younger patients,
05:57especially since they may not be entitled to screening at a younger age?
06:03The delays in diagnosis for young people presenting with symptoms
06:07that we commonly see with colorectal cancer is just a severe problem.
06:11There is an average delay of about six months to a year
06:14before somebody even goes to seek medical attention for their symptoms,
06:18and two-thirds report having to see two or more physicians
06:21before being correctly diagnosed.
06:23That's because there's a lack of awareness,
06:25both among people, young people, as well as the providers seeing them,
06:29that colorectal cancer can happen in a young and otherwise healthy person.
06:33There needs to be an increased awareness about what these symptoms are,
06:37and not a dismissal of symptoms when they happen.
06:41Either of you have other things to add on what we can do to better prevent?
06:46I have a personal story with my own colonoscopy.
06:49I'm 53 years old.
06:51I wanted to get my colonoscopy at age 48.
06:54I went to my local gastroenterologist.
06:56He said, no, it's not going to get covered.
06:58You're going to have to wait.
06:59I waited 49, not covered, 49 and 11 months.
07:03I get a phone call, we can do you now.
07:05Excellent.
07:06Had a colonoscopy.
07:07It was fine.
07:08Before I turned 51, the guidelines switched to 45.
07:12So am I five years late now, or did I just get it in time?
07:16That's what frustrates me about these guidelines for lung cancer.
07:20For years, the Preventive Task Force recommendation was not to screen for lung cancer.
07:26It's because we don't have any evidence or data yet to support it.
07:29That doesn't mean we shouldn't do it.
07:31We've got to do something proactively through our research, through our clinical trials.
07:35Two of the initiatives that we've opened up here in Orange County at City of Hope,
07:39through philanthropy, not because the NCI is going to fund it or anything,
07:42but philanthropic organizations, we opened up a pancreatic cancer screening program
07:47where in the first 10 patients who came in, we diagnosed a 78-year-old sprite lady
07:53who's probably going to live to 110 now after her cured whipple when we found it.
07:58Second is a stomach cancer screening program.
08:01If you're of Asian or Latino descent, especially Asians, you come over from Asia,
08:07you're getting screened for gastric cancer.
08:09You move to the United States, now we don't screen for it.
08:12It makes no sense.
08:14So we opened up a study now where we're screening our AAPI population for this cancer.
08:19And the third one I'm going to open this year is a thyroid cancer screening program.
08:22Now, again, if you go to the task force and it says thyroid cancer screening,
08:26they'll say not recommended, may be harmful.
08:29Well, it's because we just haven't established the level one data
08:33or the pilot data that we need to find this.
08:36So it shouldn't stop our research.
08:38And I hate it when people say it's not recommended.
08:41Well, no, it just means it hasn't been proven yet.
08:44We have to continue to pursue this.
08:46And if I may add, the age at which to begin colorectal cancer screening was lowered from 50 to 45.
08:52And most young patients getting diagnosed with colorectal cancer are in their 40s.
08:56But if you look at the statistics, the rate of rise is actually steepest in those in their 20s and 30s
09:01who are still not eligible for screening.
09:03So a lot of work needs to be done to figure out how to best screen those really young individuals.
09:08I want to add one thing, which is very important,
09:11especially when you talk about cancer in these young patients.
09:15Make sure if you have family history of any cancers, I don't care what it is,
09:20if it's pancreatic, if it's prostate, you're a woman, it doesn't matter.
09:23Breast, ovary, colon, do a genetic test.
09:27I use the Myriad MyRisk test.
09:30You can do it at home.
09:31You can literally order the box, spit in the tube, send it back.
09:35They check for 48 cancer-causing genes.
09:37It's so important because a lot of these younger patients especially have it in their family.
09:43They do carry a gene.
09:44They could carry, I'm not saying all of them,
09:46but you don't want to miss at least the ones that carry the gene.
09:49In my office, starting age 25, if anyone has family history of cancer, I do order a genetic test on them.
09:58And you just want to make sure that's the low-lying fruit.
10:02You don't want to miss those patients at least in your practice.
10:05And you'd be surprised how many people walk around without genetic testing.
10:10If you have one family member with pancreatic cancer, insurance will pay for it.
10:14If you have one family member with prostate, one family member with breast under 50,
10:18two family members above 50 with breast, two family members above 50 with colon,
10:23one under 50 with colon, I mean, almost everyone gets approved.
10:27So take advantage of that.
10:29With appropriate genetic counseling as well.
10:31That's very important to have somebody be able to explain those results to you.
10:35And I want to turn to the audience.
10:37Any questions?
10:39Just raise your hand.
10:40Okay.
10:41I see one out there.
10:46Hi.
10:47Emily Sherberth with APCO Worldwide.
10:49Well, I am the person you speak of.
10:52I was diagnosed with breast cancer at 48.
10:56Just had my lumpectomy, going through radiation in a few weeks.
10:59And throughout, I did the 86 gene genetic testing.
11:05It was all negative.
11:06My mother had breast cancer, though.
11:07She got it in her mid-50s.
11:09So throughout my whole entire journey, nobody talked to me about my diet,
11:13nobody talked to me about my alcohol consumption or my exercise
11:17or any of my lifestyle factors.
11:19And I'm convinced that that was a big part of what led to me developing cancer
11:24at 48.
11:26So talk to me about, or talk to all of us, really, about, you know,
11:29why is that?
11:30Why isn't that diet and lifestyle and exercise, you know, I mean,
11:34I saw a surgical oncologist, I saw an oncologist, you know,
11:37at all these doctors, part of my care, not one of them mentioned diet.
11:42I think part of the problem is when we go to medical school,
11:45and I'll completely be honest with you, I think we can all speak to that,
11:48no one sends us to a nutrition class.
11:51They don't teach us about diet, lifestyle, right?
11:54We just learn to treat the disease,
11:56and we forget about everything else that surrounds it.
11:59I agree with you.
12:00I mean, processed food, lack of exercise, obesity alone is linked to 13 cancers.
12:07So you're right, and until, you know, we, I mean,
12:10more and more we're learning about diet and health and not smoking
12:15and obviously avoiding alcohol, but we don't know.
12:19I mean, there's so many factors.
12:21I don't smoke.
12:22I don't drink.
12:23I've never done drugs.
12:24I've never been overweight.
12:26I don't have family history.
12:27I don't have a gene mutation.
12:28I got breast cancer.
12:29So I think, as she was saying, I was the poster child of an American woman
12:33who was not supposed to get any cancers.
12:35I got it when I was 48.
12:37So there's so much more to it, I think.
12:39So when I moved, I was recruited to City of Hope just three and a half years ago.
12:43We're building, we just built our second campus in Orange County.
12:47Orange County's got the sixth largest county in the country, 3.2 million people.
12:51My very first recruit to come to the center is a guy named Richard Lee.
12:57He's an integrative oncologist.
12:59He's internationally known.
13:01He has spent time on a Fulbright scholarship over in Taiwan
13:05learning about holistic lifestyles therapies.
13:09I recruited him.
13:10We started an acupuncture clinic, a massage therapy clinic.
13:13We had other programs ready, and we were fortunate enough to meet some donors
13:18who were ready to join our mission in just what you say,
13:22to treat the mind, body, soul, and not just the disease.
13:25Treat the person.
13:27And so the Cherng family, Andrew and Peggy Cherng,
13:31gave us $100 million to set up the Cherng Family Center for Integrative Oncology
13:36at City of Hope.
13:37And what we're going to do with this is basically a drug development institute,
13:42but for naturopathic compounds.
13:44We're going to test aromatherapy, art therapy, music therapy, tai chi,
13:48white button mushrooms, cannabis.
13:50Actually, he's the first person in the country to get an NCI grant
13:55to study cannabis in patients who have neuropathy afterwards.
13:58So all of these things you've mentioned is so important.
14:02That's what we're going to integrate, not into just those who are diagnosed,
14:06but also in the survival and cured patient population,
14:10but also in the preventative population as well.
14:13So I hear you loud and clear.
14:15It's the mission of what we're doing.
14:17We're armed with resources and brain and smart people who are coming to join us,
14:22and we're going to make this a nationwide program.
14:24So I salute you there.
14:26And I don't think it's a coincidence that breast cancer and colorectal cancer,
14:30the two most common cancers in young people,
14:32are the most strongly linked to diet and lifestyle.
14:34We started our Young Onset Colorectal Cancer Center
14:37with the goal to really guide patients after their cancer diagnosis
14:40about what they can do in survivorship to decrease the risk of recurrence
14:44and have them live healthier lives.
14:46And that does include exercise and avoiding red meat
14:49and avoiding alcohol and not smoking
14:51and all those things that are too often overlooked, unfortunately,
14:54when survivors are being counseled.
14:57Real quick, we have one question in the back.
15:00Hi, Alicia Bozzano from Hopkins Medicine.
15:04I don't want us to just throw the U.S. Preventative Services Task Force down the river.
15:10There was a reason that they didn't originally do that,
15:13and it's because of false positives as well.
15:15So a lot of these conditions, for example,
15:19cervical cancer, we've done tons of pap smears on women,
15:23and subsequently a lot of procedures
15:26and a lot of money spent on all those procedures
15:29for women to get their cervixes cut out,
15:32and now they don't actually need them cut out as much
15:34because we know the natural history a little bit more
15:37and there was a lot of false positives.
15:39Similarly with breast cancer, there are questions about that as well.
15:42So I wonder what your response is in terms of
15:46how do you address false positives?
15:48And in the future, you mentioned MRI, but how does AI play into this as well?
15:53Let's start backwards. Thank you.
15:55I think AI plays a huge role.
15:57One of the centers that I refer my patients to
16:00basically, last year, they implemented AI to read their mammograms,
16:06and I was speaking to the CEO of the company,
16:09and he was telling me that in the past six months,
16:12AI picked up 500 lesions that the radiologist missed.
16:17So even in my case, when my mammogram, ultrasounds, and MRI were all negative,
16:22I had no cancer, but because my lifetime risk was high,
16:25I asked for a double mastectomy,
16:27and after I did it, they found cancer in my breast tissue.
16:31Not on the left where they were doing all the biopsies,
16:35but on the right, and it was read as completely benign on all three images.
16:40So I think AI will bring a huge value.
16:44I think our false positive rates will go down,
16:47and when it comes to the U.S. task force, you know when...
16:50Sorry, I'm really sorry. We are completely out of time.
16:52I'm sorry we couldn't get to more questions,
16:54but thank you all for being here and for sharing your responses with us.
16:58Maybe you can connect in the hall, but thank you.