Cancer Care Connections
Cancer Care Connections
Gastrointestinal Cancers: Screening, Early Detection, and Risk Reduction
Dr. Yue Zhang breaks down the complex world of GI malignancies, explaining how colorectal, pancreatic, liver, esophageal, and stomach cancers each present unique challenges. She explains why these cancers are often detected too late—when treatment options become limited—and how proper screening can dramatically change outcomes.
While screening guidelines continue evolving, Dr. Zhang emphasizes that personalized risk assessment should guide decisions about when and how to screen. First-degree relatives with GI cancers, certain genetic mutations, chronic conditions like cirrhosis or acid reflux, and lifestyle factors all influence individual risk profiles. For many, a combination of regular physical exams, appropriate screening tests, and attention to warning signs like unexplained weight loss or chronic digestive issues can make the difference between early intervention and limited treatment options.
Despite these challenges, Dr. Zhang remains hopeful about the future of cancer care: "Throughout the years, our cancer care has advanced dramatically. I see my patients living longer lives. I have more tools, more medications, more clinical trials." She concludes with powerful prevention advice: maintain a healthy weight, eat fresh foods, exercise regularly, avoid smoking, limit alcohol, and perhaps most importantly—prioritize your health.
Dr. Yue Zhang earned her medical degree from Peking Union Medical College and gained her Master of Public Health in both epidemiology and biostatistics from Boston University School of Public Health. She completed her internal medicine residency at the North Shore-Long Island Jewish Medical Center in New York, and Hematology/Oncology fellowship at Yale-New Haven Hospital in Connecticut. She became an assistant professor of medicine afterwards and worked at the academic center at Stony Brook University Hospital (SBUH) in New York. During her time with SBUH, Dr. Zhang gained expertise in gastrointestinal cancer care and treatments for genitourinary cancer patients. She was the principal investigator for multiple clinical trials, published numerous papers in peer-reviewed journals, and was invited to speak at many professional conferences, editorial boards, and advisory boards. She is highly respected by her peers for continuously providing education to medical students, residents, and fellows, and has received many awards for her excellent patient care.
Dr. Zhang was recruited by the physician team at Virginia Oncology Associates due in part to her cutting-edge knowledge and expertise in treating pancreatic cancer, colorectal cancer, liver cancer, renal cell carcinoma, and other cancer types.
Dr. Zhang believes in personalized medicine and is passionate about curing cancer. A good quality of life for cancer patients and their individual needs are her highest priorities.
Thank you for listening! If you're interested in hearing more from Virginia Oncology Associates, make sure to subscribe to Cancer Care Connections on Apple Podcasts, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com.
Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at VirginiaCancer.com. or find us on Facebook or Instagram at Virginia Oncology Associates.
Intro: 0:05
Welcome to Cancer Care Connections. On this episode, Cheryl spoke with Dr. Yue Zhang, a medical oncologist and hematologist at Virginia Oncology Associates. Dr. Zhang breaks down the large class of gastrointestinal cancers and provides insight into the importance of screening and early detection to catch these cancers while they're easiest to treat.
Cheryl: 0:25
Dr. Yue Zhang began working at Virginia Oncology Associates in 2020. She is highly respected by her peers for continuously providing education to medical students, residents, and fellows, and has received many awards for her excellent patient care. Dr. Zhang was recruited by the physician team at Virginia Oncology Associates due in part to her cutting-edge knowledge and expertise in treating pancreatic cancer, colorectal cancer, liver cancer, renal cell carcinoma, and other cancer types. She believes in personalized medicine and is passionate about curing cancer. A good quality of life for cancer patients and their individual needs are her highest priorities. Dr. Zhang, thank you so much for talking with us today.
Dr. Zhang: 1:13
Thank you for the invitation.
Cheryl: 1:15
I would love to hear more about how you got into medicine. I know this is your passion. How did you get into this?
Dr. Zhang: 1:22
It turns out it was the most competitive field at that time when I entered college and I did very well during my academic years. It became a pathway for me to go as a way to improve myself. The second part is I was very young, at age 17, to get into the eight-year medical program. I find biology very interesting and led me to the medical field.
Cheryl: 2:00
Wow, that's fascinating and it led you here to Hampton Roads. How do you enjoy your time here?
Dr. Zhang: 2:08
It's wonderful. I love working with people here. We have a huge patient population who are very kind and really they need help. They are very trustworthy and I really appreciate our patients and my colleagues. We work together as a community.
Cheryl: 2:30
Oh, I love that. I love that, and I know patient care is so important to you. Today we want to talk about cancer, in particular, gastrointestinal cancer screening, early detection, and ways to reduce risks. So I think the way I'd love to start is to have you help us understand exactly what gastrointestinal cancers are.
Dr. Zhang: 2:55
It's a big variety of diseases. I love this subgroup of disease. Cancer has blood cancer and solid tumors. For solid tumors, we have GI malignancies. GI malignancies have been sub-grouped with many common diseases: colorectal cancer, pancreatic cancer, liver cancer, esophageal and stomach cancer. They are the most common malignancies from GI cancers. And then there are, you know, rare cancers such as appendiceal carcinoma, GIST (gastrointestinal stromal tumors), anal cancer, bile duct carcinoma, and small bowel carcinoma. They are a wide variety of diseases. They have different etiologies, treatment plans, and prognoses, and we manage them very differently. So I enjoy taking care of patients with this disease. They are mentally challenging for me. They have not only symptomatic management; there are many different chemo regimens, immunotherapy regimens, target therapy regimens and there are many interesting clinical trials. I can see throughout the years, my patient's life expectancy and quality of life are improving.
Cheryl: 4:19
You mentioned that this group of cancers is mentally challenging, and when you talk about all of the different kinds of cancers that are involved in gastrointestinal diseases, no wonder it's mentally challenging. Can you talk a little bit more about that, especially given the pain that these cancers cause to patients?
Dr. Zhang: 4:42
Yeah, so when you lump gastrointestinal malignancies, they are the biggest patient population. We know about colorectal cancer. We know the incidence of pancreatic cancer keeps going up. That being said, this type of disease, sometimes presents itself at a later stage. Sometimes we can catch them early, we can make them preventable. The problem is, once patients have a large disease burden, metastatic disease, we tell patients unfortunately we cannot cure them, and also because of that patients suffer from a lot of symptoms: such as GI symptoms: nausea, vomiting, diarrhea, constipation, and horrible pain. There are many associated conditions. We treat patients with chemotherapy, and chemotherapy can cause GI symptoms on top of everything, and that could be really challenging for patients and also for our healthcare providers.
Cheryl: 5:54
We have a lot to talk about today, and I want to start with screening because you were just talking about it. In many cases, people find out too late and then, when they find out too late, it becomes much too late to do something impactful about it. So how important are these screenings and when would somebody think about getting those screenings? What is kind of a red flag to look for?
Dr. Zhang: 6:21
I think that's such a wonderful question. Screening is very dear to my heart and as an oncologist, I love my patients. I want to help them and I tell them that I'll hold their hand and try to fight back against the cancer and to preserve their quality of life. But I'd rather see them in the grocery store, I'd rather them be my neighbor, my friend, and see them on the playground or somewhere. Early detection and intervention are very, very important. They can prevent serious health situations and the consequences associated, as we mentioned earlier. They can cure cancer. They can save lives. And that is really a part of the screening. As I mentioned earlier, if we can find the disease at the very beginning, we do not have a huge burden of disease, and that could be physical and financial for the individual and healthcare system. Also, very importantly, beyond life expectancy, we talked about quality of life. We'd rather catch it earlier, and take care of it before things become really hard for everyone.
Cheryl: 7:47
You've talked with many, many patients over the years. Why do some people keep from getting screened? What are some of the barriers to screening for some people?
Dr. Zhang: 7:51
Throughout the years I found there are many barriers and troubles. Some patients just simply tell me it is very inconvenient. They don't have time for a colonoscopy, for instance. They need to take off work, need to arrange a driver, and when you hear about there being a bowel prep, some people just feel like it's very inconvenient. Some other people have concerns about insurance coverage, they have financial concerns, and there's a group of patients who told me they're just fearful. They feel like what if it's truly cancer? That means that I have to change my lifestyle, and maybe have to have treatment, surgery, or other procedures. That's, you know, on their mind.
Dr. Zhang: 8:37
I want to say, from a medical part, not all diseases have very effective screening methods and the guidelines are still developing. Also, as I mentioned, the diseases are different. There are some incidents improving and some instances decreasing. And patients are different.
Dr. Zhang: 9:00
They have different risk factors, they have a different family history, they have genetic differences, and then there are different environmental situations and overall health statuses. Some patients have so many comorbidities, that it probably does not make too much sense for them to do intensive screening. Other patients, even though they're younger, their first-degree relatives already developed, say, pancreatic cancer. They want to go for it. So this is a big variation of situations but certainly, there are multiple barriers. I think one part is to encourage our patients to do so and the other part, as a health care provider, I want to do our duty to bring this attention to all our patients. We are trying to bring this attention to our community and basically, we're here to help you. God forbid there's something that happens, but most importantly, we hope to prevent it and send you to do a very appropriate screening.
Cheryl: 10:11
I can tell that screening is something that you are very, very passionate about, especially since you see so many patients who may have benefited from getting screening a little bit earlier, so I want to talk more about that. In general, what are some of the screenings that we all need to be aware of?
Dr. Zhang: 10:33
So for the general population, we're talking about patients who do not have a particular personal or family history of cancer risk, we follow the American Cancer Society's guidelines. One important thing, we are talking about GI malignancy, what we know is colorectal cancer screening saves lives. There is a big update for age change to start screening from age 50 to age 45 as the guideline. As I can tell you, even in my clinic there are younger and younger people developing cancer. Despite the fact we changed the guideline from 50 to 45, unfortunately, I have many young patients. They are in their 30s, they're in their early 40s, and the youngest one I even have is in their 20s. It's very devastating and I see it in my clinical practice and also there's data to support that the average age of diagnosis is becoming younger and younger. For instance, the average diagnosis was age 72 in 2002 and in 2019, the age already changed to 66. So this certainly needs to be brought to the attention to our society, to everyone. Take care of yourself, your family, your friends, and your loved ones.
Cheryl: 12:07
It's a message you need to keep saying. It's a message we need to keep saying.
Dr. Zhang: 12:10
Yes, that's why I think it's very important for us to make it very loud and clear.
Cheryl: 12:17
So this colorectal cancer screening is, as you mentioned before, it's the colonoscopy, is it not?
Dr. Zhang: 12:22
So there are various ways to screen for colorectal cancer. Colonoscopy, oftentimes, is the preferred and encouraged method. As we mentioned before, people have different choices. A colonoscopy can go in directly and then if we see a polyp, the GI doctor can take it out. It's generally believed, that when a polyp develops, it takes several years; it could even up to 10 years to develop cancer. So you are not only identifying the problem, you're taking care of it. It's more preventive. However, there are some elderly patients and some people have other situations.
Dr. Zhang: 13:05
There are different ways to screen. There's stool testing, there's different stool cards, and now they are becoming a little bit fancier to do DNA testing. It's a way of finding the cancer in the early stage, but colonoscopy is still the standard. Some patients do the compromised way called sigmoidoscopy and basically, we screen the lower part of the rectal, anal, and colon parts, and then combine it with some other testing. So there are a variety of methods. I think our GI colleagues have more to say, but the message to the public is that it's not just a colonoscopy, There are multiple ways to screen.
Cheryl: 13:52
Definitely something if you are of age, if this is something that is on your radar, talk to your healthcare provider to find the best way for you. Are there symptoms to look for, even?
Dr. Zhang: 14:09
Well, a lot of colorectal cancer, at the beginning, might not have any symptoms. A lot of GI cancers, in general, don't have any symptoms. We talk about pancreatic cancer, right, it's so lethal. I want to say the data shows over 85% of patients, when they present, are already past the surgical option. They are no longer a surgical candidate because the cancer is already spreading. With colorectal cancer, there are some patients who never really have dramatic bowel movement changes, then things happened and they were shocked by the colonoscopy results. They said that was just my very first colonoscopy screening. Some people can have symptoms.
Dr. Zhang: 15:01
We talked about GI malignancy. GI malignancies oftentimes have GI symptoms. As I mentioned, some people have dramatic bowel movement changes and upset stomachs for upper GI patients. They can develop some bleeding. It could be very hard for regular people to recognize it because it could be just one episode of dark stool. But if patients have dramatic weight loss for unexplained reasons, they have developed abdominal pain, there's unexplained anemia, they're generally fatigued for no clear explanation, I think those are things I would bring to the attention and engage in conversation with a primary care physician.
Cheryl: 15:51
Clearly, if there were symptoms that hurt, stomach pain, or sharp pains, that would be a signal. But what you're saying is sometimes it could be something isolated that you should also pay attention to. So let's go back to pancreatic cancer and how lethal that is. Are there screenings available for that?
Dr. Zhang: 16:13
That's a very good question. Pancreatic cancer is going to become the top three lethal diseases and it will cause the most deaths by 2030, with the incidence rate being high, and the outcome being poor. As we all know, the guideline is developing. It's not matured yet, but everybody is working on this field, trying to find a tailored way. Pancreatic cancer screening is not as universal yet as colorectal cancer. It's only limited to patients with high-risk features, such as some family history, especially first-degree relatives. Generally speaking, you have a two to three-fold elevated risk if your mom or your dad has a diagnosis of pancreatic adenocarcinoma. Certain families are clustered with multiple malignancies. This raises some concern for potential germline gene mutations, such as Lynch syndrome and BRCA mutation. There's not only an increased risk of pancreatic cancer, but there are other common malignancies such as colorectal, breast cancer, and ovarian cancer. So the guidelines still focus on those particular groups of patients.
Cheryl: 17:43
Let's move to liver cancer and talk about ways to screen this type of cancer and maybe ways to reduce risks.
Dr. Zhang: 17:51
Liver cancer is a huge problem nationwide and worldwide. In the United States, there's a large association with alcohol intake. Internationally there are a lot of diseases caused by hepatitis B and hepatitis C infections. That being said, liver cancer generally is a progression of disease development. Generally, it starts with liver fibrosis at one point. As the liver becomes more damaged, it causes liver cirrhosis. A cirrhotic liver is a risk factor for liver cancer. Even if we're taking care of one spot, another spot in the liver can become cancerous.
Dr. Zhang: 18:45
So, with that being said, how do we screen it? If a patient has those risk factors, family history, or they have some symptoms, generally, through your primary care doctor or gastroenterologist's office they start doing a physical exam, taking a family history and potentially scheduling an ultrasound every half a year or yearly. Some offices, depending on the risk, do a CAT scan or MRI as the early detection part. If it was detected early enough and a lot of area can be intervened by our wonderful interventional radiologist doctor or surgical oncologist, they can just either ablate that area or resect it out without the need for us to start systemic regimen right away. As you heard from me earlier, even for those patients, we still need to continue intense screening to look out for other areas. But in general, this is a challenging case because patients oftentimes have cirrhotic liver and develop cancer. It's a combination of situations to deteriorate patients' health.
Cheryl: 20:12
In this case, and maybe, as we were talking about pancreatic cancer as well, when would they sit up and say I should probably talk to my healthcare provider?
Dr. Zhang: 20:20
For general screening guidelines, I encourage everybody to have a primary care physician do their annual physical exam, and based on that, it depends on their family history, and personal history. General guidelines: there are guidelines for general cancer screening. Now I'm focused on GI malignancies, but there are mammograms and there are lung cancer screening guidelines. So those are driven by a guideline that is a very standard of care for healthcare providers. That's the first layer. The second layer comes with your personal family history and if there are multiple cancers in your family. Do you have first-degree relatives who have a cancer diagnosis or personal previous exposure to chemotherapy, radiation therapy, or certain toxins? Obesity nowadays has become more common and that's increased a lot of esophageal cancer. There are certain lifestyle choices, alcohol, and smoking, as we already know is correlated with lung cancer, but smoking as a matter of fact is correlated with multiple other GI malignancies as well.
Dr. Zhang: 21:42
The third layer is if you have developed symptoms. As you asked earlier, if there are any red flags for you; you see blood in the toilet, you drop weight for no reason, you start being nauseous persistently. Those are the things that need to get medical attention. I think those are the three layers. Again, everybody's different. I find many of my patients are busy taking care of their families, their children, their parents, and their work, but unfortunately, they ignore their own health. I find that it can be challenging. People think this is just a hemorrhoid. You know, I never pay attention, or one day I may have had some viral infection. My stomach has not been feeling well for over a year. So those are the things I think you need to pay attention to for yourself or your family.
Cheryl: 22:43
Dr. Zhang, that was so helpful. We have a lot of caregivers who listen to this show and may be in that position. busy, busy, busy, busy, taking care of everyone in the household and this symptom or this screening or this situation they're thinking about for another day, another year, because they're so busy, and I think people can definitely relate to feeling this way. There are other things that are more important than themselves. I wanted to get to one last cancer, as we're talking about GI diseases: stomach cancer screening and risk reduction. What can you offer for that?
Dr. Zhang: 23:23
Gastric cancer not only has a genetic component to increase risk but there's also an environmental risk factor as well. So Asian countries such as Korea and Japan, have much more intense screening procedures than the United States. The United States has universal screening, which is different from those countries as their incidence rate is higher and partially related to their lifestyle. Here in the United States, as I mentioned, there are certain dietary changes and fortunately, we have refrigerators. Once that was invented, it saved a lot of gastric cancer. But you know, fresh foods, fresh vegetables, those are things that decrease the risk of gastric or esophageal cancer.
Dr. Zhang: 24:18
I mention obesity, partially because of acid reflux and GERD, and with the frequent irritation, Barrett's esophagus develops and causes one of the most common sites, called the GE junction, to become cancerous. So we have a GI doctor to do an endoscopy, basically, a tube put down the throat, to take a look at this area more intensely and hopefully capture any changes earlier. Also, as I mentioned, smoking, alcohol intake, and h pylori, which is a bacterial infection, can be treated with antibiotics. This is still a little bit controversial, but gastric cancer has increased risk. For certain families, there are certain gene mutations that can pass from generation to generation, and for those families we even need them to start screening in their 30s or even younger age.
Cheryl: 25:28
You've shared with us such important information, Dr. Zhang. You have been in this business for a while, helping patients, helping them through some very difficult times. Is there hope? Is there also some hope that you can share?
Dr. Zhang: 25:43
Absolutely, oh absolutely.
Cheryl: 25:44
Please do. Share some hope.
Dr. Zhang: 25:46
I'm very optimistic, as my team always jokes with me. I'm the perfect fit for treating pancreatic cancer as I'm always so positive. I want to say it's devastating, it's absolutely devastating and it's life-changing. People lose jobs and cannot take care of their families. They have to rearrange their life and everything. But through the years, cancer care has advanced dramatically.
Dr. Zhang: 26:18
I can tell my patients, just throughout the years of my practice, I see patients live longer lives. I have more tools. I have more medications. I have more clinical trials. I have more hope for my patients. On top of life expectancy, our supportive care team has improved dramatically as well. There are multiple ways to support our patients symptomatically. Sometimes it could be even real life, financially or psychologically. There are multiple ways. I think it's always challenging, absolutely challenging, whenever we talk about cancer. It's a serious conversation. We need to be really tailored individually, but overall, I think, people are living longer, living better lives throughout the years and I have hope in my heart. I think it will be better every year.
Cheryl: 27:14
And for people who are listening, this is a great episode to share with friends, family, and people maybe you're concerned with about the importance of screening, and the importance of taking steps to reduce risks. Any last words, Dr. Zhang? Anything that you want to share with patients who may be listening? Family of those patients or caregivers?
Dr. Zhang: 27:38
Number one, get the age-appropriate screening. That's number one. I can not say that enough. The second part is your risk factor adjusts your screening, possibly more intense screening. If there's hepatitis it's being taken care of right away and there's treatment, there's a cure for hepatitis C. If you enjoy alcohol, maybe cut down a little bit and monitor your liver. Give the liver a break intermittently.
Dr. Zhang: 28:09
Colorectal cancer depends on family risk. If you have acid reflux you probably need to consider whether or not you need an endoscopy earlier. If the symptoms are persistent, we can eradicate h pylori to decrease the risk of gastric cancer. If patients have recurrent pancreatitis or some first-degree relative has pancreatic cancer, engage with your primary care doctor. If the primary care doctor feels uncomfortable there are oncologists, there are GI doctors. We're more than happy to help our patients with that perspective.
Dr. Zhang: 28:51
Most importantly, I want to say live a healthy lifestyle. We cannot control our genes, but we can control our lives to some degree. Maybe try to avoid smoking. I mentioned earlier fresh vegetables, fruits, healthy food, and protein-rich food. Eat a balanced diet. Exercise is big. Exercise can reduce a lot of cancer risk and even in my patients who have been cured of colorectal cancer, I strongly encourage them to exercise because there's data showing a significantly decreased risk of recurrence. Exercising routinely, keeping a healthy body mass and muscle, trying to avoid obesity, and sleeping hygiene is always something I want to mention to my patients. Very importantly, keep a good spirit and healthy relationships. Try to have a happy life. I think that's something we can do. There are special cases for immunization, such as HPV infection. Those types of things are a little bit different, but I overall encourage a healthy lifestyle. Everybody is an individual, everybody has a different belief.
Cheryl: 30:19
Eating better, moving more, and living a healthier life. Dr. Zhang, thank you so much.
Dr. Zhang: 30:25
What a nice summary from you, Cheryl.
Cheryl: 30:27
That was awesome, thank you.
Exit: 30:34
Thank you for joining us today on Cancer Care Connections. Today we explored the complex world of gastrointestinal malignancies, specifically colorectal, pancreatic, liver, and gastric cancers. Dr. Zhang encourages everyone to live a healthy lifestyle, including eating a balanced diet, being physically active, limiting alcohol consumption, and maintaining a healthy body weight. These positive lifestyle choices help prevent many cancers. While screening guidelines continue evolving for gastrointestinal cancers, Dr. Zhang emphasizes that personalized risk assessment should guide decisions about when and how to screen. Remember, screening and early detection help catch cancer when it's easiest to treat.
Don't forget to subscribe to our podcast via Apple Podcasts, Spotify or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com. Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at virginiacancer.com or find us on Facebook or Instagram at Virginia Oncology Associates.