Clinical Challenges in Early Onset Colorectal Cancer

Hello to all the behind the knife listeners. My name is Janet Alvarez. I'm a current general surgery resident at New York Medical College's Metropolitan Hospital Center. First, I'd like to introduce the rest of my team as we will be working closely together to keep you informed on the most relevant and UpToDate colorectal cancer specifics.

Dr. Winnie Ombre is a current general surgery resident at Weill Cornell Medical Center and New York Presbyterian Center. Dr. J Joshua Smith is the current chair of the Department of Colon and Rectal Surgery at MD Anderson Cancer Center. Dr. Phil Bauer is a graduating colorectal surgical oncology fellow at Memorial Sloan Kettering Cancer Center, soon to be a new attending at the Ohio State University.

We have a couple guest speakers joining us today, Dr. Andrea Ick, a gastrointestinal medical oncologist at Memorial Sloan Kettering Cancer Center. Also the

section head of Colorectal Cancer, the founder and co-director of the MSK Center for young onset colorectal and gastrointestinal cancers. And she was recently named to the Time 100 Most Influential People in Health for 2024.

2025. Dr. Nancy Yu, a professor at the Department of Colon and Rectal Surgery at MD Anderson Cancer Center. Co-director of the Clinical Cancer Genetics Program. Clinical medical director, colorectal service line. Thank you so much for joining us today. What is so important about this talk today? Colorectal cancer is the third leading cause of cancer death for both men and women, and the second leading cause of cancer death overall.

While the incidences and mortality of colorectal cancer has been declining in the us, the incidence of early onset colorectal cancer, AKA. Cancers developing in patients less than

50 years of age has increased worldwide. The American Cancer Society estimates about 154,000 new cases in 2025 alone. The etiology of this increase is unknown.

Early onset colorectal cancer has shown to manifest as predominantly left-sided or rectal tumors, and patients tend to present at advanced stages. Though this may be attributed to delay in diagnosis. A selection bias. Since patients less than 45 years of age are not being screened today, we will be discussing early onset colorectal cancer in the context of two cases.

First, I'd like to review the screening recommendations for colorectal cancer. Yeah, so the US Preventative Services Task Force, as well as the American Cancer Society recommends screening me gain at age 45 for our average risk individuals. So this of course excludes patients with a family history of colorectal cancer or those with a personal

history of cancer, IBD or another hereditary syndrome such as FAP or Lynch that would require a screen to start sooner.

Our screening modalities can be divided into direct visualization or stool-based tests. And direct visualization of course, includes colonoscopy and flexible sigmoidoscopy, and also can include CT colonography and our stool-based tests most predominantly now includes fecal immunochemical tests with DNA or fit DNA, also known as Cologuard.

So it's important to note some of the differences in sensitivity for detecting cancers and adenomas with these modalities. Colonoscopy, which we all know is our gold standard, has a 95% sensitivity for the detection of colorectal cancers. FE fit, DNA test has a 92% sensitivity. And then terms of detecting adenomas, colonoscopy has the highest sensitivity.

Detecting adenoma is less than five millimeters. And you know, of course

we believe that direct visualization is the ideal screening, but you can also argue that any test that the patients are able and willing to complete is the ideal screening. There are some parts of the country and, and the world where resources are limited in colonoscopy is not available there.

And so that's when some of these other modalities really come into play in a careful screening paradigm. Now, I will say that this is, again, is for average risk individuals and those with increased risk due to one of the factors we mentioned above, such as family history would be starting screening at age 40 or 10 years prior to the age of diagnosis for one of their first degree family members.

But unfortunately, there's a large proportion of young onset patients that do not have a family history and would be considered average risk. And these patients, of course, would not be screened. So they almost always present the symptoms like the two cases we're gonna present for healthcare. Thanks for that Dr.

Bauer. So let's jump into our first case. We have a 43-year-old male with new

onset rectal bleeding. He denies abdominal pain and has no family history that he knows of and no personal history of cancer. He is generally a happy and active individual and has no medical comorbidities. Dr. Smith, can you describe what further workup this patient would require?

Sure. So, a complete workup certainly consists of a full colonoscopy to better evaluate the possible tumor location, and then a biopsy and then analysis of the entire colon. Okay, great. So this patient undergoes a colonoscopy, and the gastroenterologist finds an ulcerated irregular mass at four to five centimeters from the anal verge and extending to the second valve of Halston.

A biopsy is taken and the pathology shows a proficient mismatch repair adenocarcinoma. What would be the next steps in the staging for this patient? So typically what we would do is a

dedicated rectal MRI or a pelvic MRI, with rectal protocol in this case. In then additional standard staging tests would include CT, chest, abdomen, pelvis to evaluate for any distant metastasis.

And then lab tests would include a big. Basic metabolic panel including tumor marker which would be A-A-C-E-A. Excellent. We get all of the results back for this patient's workup, and it indicates he has a clinical T three N one rectal cancer with no distant metastasis. Our patient then meets up with the rest of his team, which comprises a medical oncologist, a radiation oncologist, and a colorectal surgeon to finalize his treatment plan.

Based on the recently published Oprah study, it is decided in a multidisciplinary team session that he will undergo chemoradiation first, followed by consolidation chemotherapy, followed by restaging. We call this treatment regimen, total neoadjuvant therapy in

which the patient receives all the treatment upfront prior to potential surgery.

Now, in our next podcast, we'll discuss total neoadjuvant therapy or the watch and wait treatment strategy. But for now, Dr. Smith, can you provide us a brief overview of treatment options for this patient? Sure. Janett. And then for this patient, it would also be important, and we'll talk about this at the end of the.

Podcast, but if he hadn't started a family, we'll talk about fertility and preservation of sperm if need be, if he hadn't started his family. But we'll get to that at the end of the the session as it relates to more precise therapy for this patient and then fertility preservation. For cancer and also for colon cancer.

In some cases surgery is the mainstay of treatment for non-metastatic core stage zero to three cancer. And for clinical T four, those with bulky nodal disease or extravascular

invasion some of those patients will benefit from upfront or neoadjuvant treatment. Unresectable disease may be treated with systemic chemotherapy, and that may be plus or minus chemoradiation for rectal cancer.

Then adjuvant chemotherapy may be used in high risk colon cancers. The treatment for metastatic colorectal cancer depends on risk resectability location of the lesions, and then tumor mutational profile can play into it. And this can be related to what mutations are noted, including K-R-A-S-B-R-A-F, nras or HER two positive tumors, and can include surgery, radiation, chemotherapy, immunotherapy in some cases, and are targeted therapies based on the mutational profile.

Of course there are ongoing studies using targeted therapies in the neoadjuvant setting for unresectable or metastatic colorectal cancers, including immune checkpoint inhibition for mismatch repair deficient tumors, cetuximab encorafenib plus Cetuximab and FOLFOX for B-R-A-F-V 600 E

mutant tumors and panitumumab.

Or an anti EGFR monoclonal antibody for specific in the context of RAs wild type tumors. And these are current based on current data and accepted recommendations for advanced or metastatic colorectal cancer. The current treatment paradigm for recal cancer is OnOne drastic changes as many know to improve response to treatment and increase organ preservation rates.

Early stage rectal cancer can of course be treated with upfront surgery and selected cases, but neoadjuvant chemoradiation and chemotherapy can also be used to optimize tumor response and allow organ preservation depending on the tumor site. Now, the treatment of early stage rectal cancer is certainly complex, and we can certainly spend another entire episode on that topic alone.

So prior to recent landmark studies in the field, the standard of care for locally advanced rectal cancer are stage two and three. Locally advanced or rectal cancer was preoperative chemoradiation, followed by total mes, rectal excision, and then adjuvant

chemotherapy. The current treatment paradigm, however, has been total neoadjuvant therapy including a patient receiving chemotherapy and chemo radiation prior to any consideration of total meso, recal, excision, or organ preservation, and potentially watch and wait if the patient achieved a clinical complete response or the tumor at resolved based on MRI endoscopy and an exam the Oprah trial led by Dr.

Garcia Aguilar. Demonstrate the safety and efficacy of this watch and wait approach, along with establishing the consolidation approach or chemotherapy after long course chemoradiation as the optimal sequence for long-term organ preservation. This watch and wait surveillance strategy allows patients who have a clinical complete response to total neoadjuvant therapy, the opportunity to preserve the rectum.

And of course, this is with close surveillance. The ongoing Janus trial is studying consolidative chemotherapy. In the context of TNT and this overall

strategy using a chemotherapy intensification, the idea meaning triplet chemotherapy versus doublet after long course chemoradiation with the overall goal of improving clinical complete response rates to increase organ preservation in addition to improving disease-free survival rates after long course chemoradiation.

And this trial is, is currently ongoing across the us. Thank you so much Dr. Smith for that. In-depth summary, how would you then determine a patient's response to treatment at the restaging? So at his restaging, there'll be assessment of tumor response by exam, endoscopy and MRI, along with restaging by CT chest abdo pelvis, which will get further guide decision making for whether or not a watch and wait approach or a surgical approach should be pursued as we move forward.

Great. So our patient's biopsy results or immunohistochemistry staining show that

he has an MMR proficient tumor. Dr. Bauer, can you explain the significance of MR proficiency? Sure. So mismatch repair proteins are enzymes that correct errors in DNA replication. And so it's important to remember that when you're doing immunohistochemistry staining for, mR, you're testing the tumor itself. You're taking this off with a tumor biopsy. And so a positive screen would be a loss of expression of mlh one, ms. Or PMs two, MSH two or MSH six. And what that tells you at that point is that. Either the tumor has this Mr deficiency mutation, or the patient may have a germline MR deficiency.

However, you can't prove that until the patient undergoes genetic testing. So anyone that would screen positive in the setting, we would prefer to a genetic counselor to have that discussion, hopefully undergo genetic testing. But again, it's possible that a patient will just have somatic mutation leading to their MMR deficiency.

And this is

important 'cause recently Dr. Icks team at Memorial Sloan Kettering published and updated their updated data on their phase two clinical trial utilizing GE staab, an immune checkpoint inhibitor for MMR deficient colorectal cancer. So, Dr. Sik, I'd love bring in if you could tell us a little bit more about the study and where we stand and the results so far.

Sure. Absolutely. So the idea behind the study actually originated. When we noticed that when we were utilizing total neoadjuvant therapy for locally advanced rectal cancer, a subset of patients just didn't respond or actually progressed on our induction chemotherapy with FOLFOX at the time. And so when we looked back, we noted that they were mismatch repair deficient, and at that point.

Immunotherapy was approved for metastatic disease with MIS metro repair deficiency or MS I high status. And so when we then used immunotherapy, we saw, you know, fantastic responses in these tumors. So then the idea was

to bring immunotherapy into the total neoadjuvant paradigm and actually use it first.

And we chose just Astar, which is a PD one monoclonal antibody. So single agent and treated patients with mis metric or deficient locally advanced rectal cancer by immunohistochemistry. But then did do confirmation with next generation sequencing to ensure that they were MSI high. And with that, what we published recently was a expanded cohort.

So we had 49 patients who completed six months of daab. And all 49 had a clinical complete response just to immunotherapy alone. So we were able to omit chemotherapy, radiation, as well as surgery in, in those patients. And they were followed just with non-operative management. And then what we also published is when we saw these early responses in, in locally advanced rectal tumors, we wanted to expand to all solid tumors that were mismatch repair deficient, which is well probably.

You know, on the

conservative side, two to 5% of all early stage solid tumors, but it's certainly higher in, in tumors like of the endometrium of the colon. Mismatch deficiency is about 10 to 15% in early stage disease. And so when we treated everyone broadly, 82% of patients were able to have a clinical complete response to daab alone.

And we're able to undergo organ preservation or non-operative management. And this includes upper tumors as well as, so, gastric tumors, hepatobiliary, as well as colon, rectum, GU and GYN. And so 82%. Needed only immunotherapy achieved the clinical complete response. But really when we looked at it by tumor type, 65% of the non rectals achieved the clinical complete response.

So there's a bit more work that needs to be done to get, to improve the clinical complete responses outside of the rectum. But the rectum is clearly very, very sensitive when it's mis metric or deficient.

Excellent. Thank you so much for that, Dr. Ick. It's very exciting for our patients, especially like you mentioned the DMMR patients.

Now, I wanted to ask Dr. Ek and Dr. Yu, do you know of any potential genetic differences in early onset colorectal cancer? I can start. I would just piggyback. Oh, we just talked about, I think the biggest and the most exciting difference is that. The prevalence of MMR deficient tumors are so much higher among the younger patients, and this is largely because of Lynch syndrome, where the molecular signature is mismatched repair Deficient tumors is the most common hereditary predisposition syndrome.

And so, when we do look at all of our young patients. As a cohort, up to maybe 20% of those patients may harbor a hereditary predisposition syndrome, and Lynch is the most common. So because of

that, we do see a high proportion of the mismatch repair deficient tumors among the young patients. So it's super important that we don't miss them because their treatments, as we just talked about, is so exciting at this time.

I think aside from the mismatch deficient tumors, though, when we look at the proficient tumors between the older and the younger patients, there are not drastic differences. We, you know, studies, some studies have shown small differences in particular genes or the mutation prevalence of particular genes, but certainly nothing that really translate to a difference in terms of treatment.

But I'll let Dr. Ek add. I would, you know, echo exactly what Dr. Yu has just said. I think the, what we believe for the most part is that once the tumor develops, it very likely follows the typical adenoma to carcinoma pathway. And once all the genetic mutations are in place, then. As we compare, at least the genomics, we don't see any significant

differences as well as the responses to treatment and the overall outcomes.

But there are still a lot of questions I think that remain, you know, to be answered with this in terms of potential reasons for these early adenomas. You know, there's a association with a birth cohort effect. It's occurring. Globally. So it's not limited you know, to one region or to the United States alone.

This is really a global phenomenon. A rise in in early onset GI cancers, actually even outside of the colon. Dr. Bauer, would you be able to comment on any differences in rates in terms of race and ethnic populations? Unfortunately, minority populations, including. Black Hispanic slash Latino, American Indian and Alaskan natives have been known to have a higher risk for developing colorectal cancer.

When we look at stage adjusted colorectal cancer mortality, it's also higher in the black population. Reasons for this are not

entirely known, but it can be attributed to to disparities of care such as lower screening rates. Limited access to healthcare, which would be a direct result of socioeconomic status, can also be associated with exactly where people live.

And of course this is especially concerning for our low socioeconomic status patients has been associated with worse outcomes, which further emphasizes the importance of understanding the patient's external, social and economic picture of the complete picture for their, for their care. In terms of looking at just the United States, the incidence of colorectal cancer seen high rate in Appalachia, as well as parts of the Southern United States and the Midwest.

This possibly the differences in colorectal cancer risks as well as access to quality healthcare. And we do note that from 2015 to 2019, we stayed with the highest incidences colorectal cancer was Mississippi, and that was 46.5 per 100,000 persons Dr. U and

Dr. Ick, do you know of any modifiable and non non-modifiable risk factors?

I can take the start. So over the years, obviously we've been studying risk factors for colorectal cancer as a whole, and so there are established risk factors for colorectal cancer. We know there are obviously very high risk. Patients, and these are patients with hereditary predisposition and also medical predisposition.

So typically patients with inflammatory bowel disease. But then there's also lifestyle risk factors. And these have included obesity, smoking, I. Alcohol use and type two diabetes. Family history is also important. What I would say is that all the known studies have studied colorectal cancer risk factors as a whole, and we're really needing studies that are highly enriched for younger patients to really be able to tease out.

Particular risk factors for young

patients. This is obviously in the area of active research and so there are many proposed risk factors as we speak. And these include demographic risk factors, environmental risk factors, socioeconomic status, diets, lifestyle, and most recently gut microbiome just to name a few.

Yeah. I would also, you know, agree with, with that and, and I think the, the most exciting and most important thing is that there is now a lot of active. Research in this area, you know, many funding mechanisms, et cetera, which always help. And because we really don't know, and some of the typical risk factors for average onset colorectal cancer really don't fit when the highest rise in early onset colorectal cancer is in sporadic, so non hereditary.

In patients in their twenties to thirties. So you could think of, you know, even exposures or high risk. Typical high risk factors just, just don't quite fit when someone is diagnosed with

colorectal cancer at 25. So it's very likely an environmental factor, or actually most likely a combination of potentially lifestyle changes and environmental factors.

I feel it's safe to say that again, this research is still ongoing and there's still a lot to discover, but we can safely emphasize the importance of a healthy diet and level of activity as there has been evidence showing that these are modifiable risk factors as you touched upon. One recently published study in the New England Journal of Medicine, which was also presented at ASCO 2025, showed improved disease-free survival and overall survival in patients with resected colon cancers, treated with adjuvant chemo who had been stuck to a structured exercise regimen, which only further supports a healthy lifestyle.

All right. That was a really great discussion about our first case, and I think we're ready to jump

into our next case. So our second case is a 3-year-old woman who develops bleeding parum during pregnancy. That was initially attributed to hemorrhoids, and this delayed her presentation to her PCP. Upon further workup including a colonoscopy, she was found to have a clinical T three N zero rectal cancer and is planned to receive chemotherapy, possible radiation and possible surgery.

So. She's interested in having more children and wants to discuss fertility preservation options with her treatment team. So Dr. Sig and Dr. Yu, if this patient comes in, how are you gonna counsel these patients on the potential effects of treatment for colorectal cancer? And, you know, you've both established young onset programs at your institutions.

How does that look when patients come to the center and you know, how many different specialists are they seeing and how is that facilitated for these young patients? I think this is, this is one of the most

important things you know to highlight whenever we meet someone with rectal cancer. So first of all, we're seeing more and more young patients as we've been discussing with rectal cancer and, and unfortunately, this patient is kind of a typical example, and so there's.

Many things that go into treatment of rectal cancer. Of course, the ultimate goal is cure, but to cure with at least amount of morbidity and survivorship is critically important, and especially in young patients, and especially in in young women. So this is, for us, always a multidisciplinary approach. Even from an oncologic perspective.

So from the very beginning I'm a medical oncologist, so it's medical oncology, radiation oncology, as well as. Our colorectal surgeons that are involved in this discussion with the patients in terms of. Goals where they are, fertility preservation, sexual health, et cetera, is always critically important.

So the first thing that we touch on as part of our young onset center is, you know, fertility. Do we need, do we, are

we thinking about fertility preservation? Is there a discussion of. Potential, like harvesting always in the context, of course, of the extent of the disease and the need to start treatment.

But that's a, that's a very, very important first discussion that we have. And then of course, as a multidisciplinary team, I. With rectal cancer, you look at the ex, the staging of the tumor, the location of the tumor, and then make a decision. We think about total neoadjuvant therapy. What is our ultimate goal?

Is it to potentially try to omit radiation for fertility preservation, for sexual health preservation, or do we try to think about. Intensifying total neoadjuvant therapy to pursue non-operative management, for example, if the tumor is very low and the patient would require a permanent colostomy. So those are just some of our, our initial discussions.

Yeah, definitely. I think these patients are, they're very challenging in many ways and I think that's why I personally really enjoy treating these patients

or working with them. I think one challenge is that when they come to the office with the diagnosis, they often don't know what they need.

They don't, they don't know what questions to ask and they don't, sometimes they don't know all the questions that they need to be thinking about, not only immediately, but also in the long term. So I really think that the patients need definitely multidisciplinary input, but I think what they really could help.

That's something that they can really benefit them is actually a quarterback. And so I think one of the oncologic disciplines, one of the providers. End up serving in that role, end up being the quarterback that has the guide to shared decision. Making discussion with the patient helps raise these questions that Dr.

Just raised, but then also help guide the balanced discussion and help interpret. All the different discussions about toxicity and benefits that each of the disciplines may be

providing, and then pull in resources that may, that the patient or the family may need to support them through this whole journey.

So, I think, you know, I think both Dr and myself. Our lucky work. We work in major institutions where there are established programs to support these young patients with colorectal cancer, where there are mo multiple resources that we are able to pull in for them. But I think kind of a coordinator or quarterback to help them walk through their journey is super helpful for these patients.

Great. Thank you Dr. Ec and you for those really incredible insights and as was discussed. Certainly pelvic radiation, cytotoxic chemotherapy, and surgery all come with their own set of adverse effects and complications. And pelvic radiation certainly associated, is associated with infertility, premature ovarian failure, sexual

dysfunction in both men and women.

The known adverse effects of radiation certainly is prompted trials to explore omission of its treatment in locally advanced rectal cancer, and we often think of treatment deescalation in organ preservation. Whenever it's feasible, and these are important strategies to think about as we consider patient's quality of life, their sexual health, and then their both short-term and long-term fertility.

As Dr. Ek, Dr. Yu and Dr. Smith we're all discussing their various forms of fertility preservation that I wanted to quickly get into. They range from. GA embryo cryopreservation hormone suppression during chemotherapy, as well as surgical techniques. Ovarian function suppression with GnRH agonists have been shown to reduce ovarian toxicity during chemo, though the underlying mechanism is not certain.

Some studies have showed high rates of ovarian function preservation in patients with lymphoma, breast cancer, and other

malignancies further supporting this method. Ovarian tissue transposition requires removal of the entire ovary or cortical biopsies, followed by cryo preservation. It's typically done laparoscopically.

Now, the ovary or tissue is then transplanted back when the patient is ready to become pregnant. Due to the risk of receding cancer cells, it is not recommended in patients with blood cancers, ovarian cancer, high risk of ovarian cancer, or cancers with high risk of ovarian metastasis. Thanks, Janet. As we all know, radiation treatment can damage reproductive organs, and so ovarian and uterine transposition techniques have been created to move these organs away from the radiation field.

So this is pretty exciting. But the ovaries can be transposed either medially or laterally. It just kind of tacked up. And this is typically done laparoscopically. And there's a lot of studies that have shown high rates of preserved ovarian function after transposition. And this does

allow for functional ovaries post-radiation therapy.

However, the problem is the uterus may still be damaged by radiation compromising fertility for that patient. So current research is looking into the efficacy of uterine transposition as a means of fertility preservation, and this technique entails mobilization of the uterus, which is then sutured into the upper abdominal wall with a cervical stoma creation at the site of the umbilicus.

There have been reported successful pregnancies after uterine transposition and reversal. However, this is still early on and there's a paucity of cases and data related to the outcomes here. Now, despite these varying fertility preservation techniques, reproductive healthcare needs are still an unmet need among early onset colorectal cancer survivors and their families with few patients pursuing fertility preservation.

As Dr. Yu mentioned, sometimes these patients present to their clinic and they're not sure what questions to ask. Ask

barriers include lack of appropriate counseling, financial impact of their cancer diagnosis, and of course the very costly fertility preserving procedures. As of 2024, only 21 states, including DC, have mandated fertility coverage laws with only 15 of those laws, including IVF coverage and 17 of those laws covering fertility preservation services by igenic or medically induced infertility.

Thankfully, there are advocacy groups like Livestrong Fertility that lessen the financial burden of fertility preservation for cancer patients. Dr. And Dr. Yu, you both, you know, started centers for, you know, screening the treatment of young onset GI patients with young onset GI cancers. Do you have any tips or high level advice for institutions or providers that are looking to start a center like this at their institution?

Yeah, sure. I mean, I think, you know, the, the

goal of the center is really twofold. One part was research focused to kind of have a prospective registry to try to identify these patients and collaborate and figure out why we're seeing this rise in early onset cancers. But then the, the second and equally important part was to provide support services and really to introduce all of the ancillary services that were already.

Available at our institution, but that you might not think of, you know, immediately as the patient is sitting in front of you and needs to start treatment. So things like social work, all of our patients meet with the social worker and they found that actually to be the most rewarding. And then as I mentioned before you know, for fertility.

As well as sexual health, integrative medicine, nutrition, kind of these services that, that do exist, but again, that they're not kind of in a, in a one all in one place for the patients. And so I think in terms of starting, it's obviously always tricky from an administrative perspective, but really what's important is to have one administrator.

And it doesn't, you know, a

program manager, let's say, and it doesn't have to be, they don't have to be clinical, but to kind of help capture these patients and then alert the. Oncological team, whether that's the surgeons or the medical oncologist or even the radiation oncologist, that this is a young patient and that these are the services that we have readily available.

There's been a couple papers that, that were published now on these centers as well, and the oncologist for reference as more and more centers have, have opened throughout the US. Yeah, absolutely. I think very similar goals for the center. I would add to that. For us, I think one of the other goals is to really decrease variation in care and introduce a standard pathway for the patients.

Because what was happening is because not all the patients walk in having a comprehensive list of needs or asks. It was left up to the provider to respond to that list, and so we really wanted to create a standardized, comprehensive list to showcase what's available so

that when a patient's. Sometimes they'll, you know, when they go through the list, it actually jock their, their memory and then they realize, oh yeah, this is something I need.

And so I think to meet them where they are is one of the things, one of the ways that we do that is really using, taking advantage of the. The Epic and the electronic medical record system. So we're able to create a standardized order set that includes just the entire battery of console services, so that makes it easier for the providers to refer the patients.

I think the other goal that. I know Dr. Sik also shares is just creating a community for these patients and also being able to empower them. And so we do a lot of public education and I know like we run a annual patient conference where the participants and we invite the patients to, to come and we invite experts.

To, it's very similar to what we're doing right now, which is just to kind of share knowledge and then it gives

a social hour for the patients to meet each other and build some community, and so that they don't feel like they're alone, that there is a whole group walking through their journey with them.

Wonderful. Thank you so much for that insight and again, for taking the time to discuss with us and just spread this information. Thank you. This is gonna be infinitely better because you were both here. Thank you so much.

Thank you both. Thank you so much. Thank you so much. Incredibly helpful. Thanks so much. Thank. Thank you. Thanks, Dr. Sombre. Will now provide us with a recap of our discussion, quick hits, the incidence of colorectal cancer and those below the age of 50 continues to increase. The etiology is likely multifactorial, including diet, alcohol, obesity, the gut microbiome, activity levels, and environmental contributions.

Optimal care of these patients requires a

multidisciplinary team and ideally a care coordinator. All young onset patients should be referred to a genetic counselor to discuss germline testing. Finally, discussions of long-term fertility and prioritizing reproductive health are particularly important in this patient population.

Thank you so much to Doctors Ick and you for joining in this episode to all the listeners who tuned in and of course did Behind the Knife for hosting us. Be sure to dominate the day.