Why is colorectal cancer so bad in Ashland County?

ASHLAND — Something wasn’t right. 

Jeff Rose suffered from stomach cramps and other abdominal pains off-and-on through most of his 40s. Symptoms would last three or four days and then vanish, causing a medical mystery that persisted for the better half of a decade. 

Doctors first assumed it was his appendix; so they removed it. When pain returned, they pointed to the gall bladder. Tests disproved the theory. 

Years passed, and symptoms came and went. He pushed through, rarely calling off work and sometimes taking Ibuprofen to mask the pain.

One day in May 2022, however, he could tell he had a fever. Still, he finished out his 6 a.m. to 2 p.m. shift. He took some pain meds and they worked — until they didn’t.

That night, he couldn’t sleep through the “horrendous” pain that started from below the rib cage to his belt line. 

“It would cramp really bad, and then — I don’t know how else to describe it — it would spider web. Get bigger. I couldn’t find a way to sleep that night, it hurt so bad,” he said. 

That morning, he broke protocol by calling off work. By 7:30 a.m., after his wife had left for her job, the pain and fever hadn’t relented. So he woke up his daughter, who at the time lived at home with them. 

“I had her drive me to the ER in Wooster,” he said.

There, doctors recorded a 102-degree fever and a high white blood cell count — pointing to an infection. The source? A perforated colon. Imaging revealed tumors, too.

Rose, 49 at the time, was in surgery early the next morning. Surgeons expected to find stage 4 colorectal cancer. They were wrong; the cancer hadn’t spread to lymph nodes or other organs. 

But the news wasn’t all good, either.

Surgeons removed more than a foot of his bowels. He stayed in the hospital for five days, recovering, and grappling with the reality that chemotherapy would begin weeks later.

Rose, now 52, is one piece in a grand jigsaw that has puzzled experts across the United States in recent years: why are younger adults coming down with a type of cancer historically thought to afflict older people? 

One in five cases of colorectal cancers diagnosed today occurs in people younger than age 55. In 1995, that rate sat at one in 10, according to a study published by the American Cancer Society. 

Colorectal cancer rates have improved over time.

But those trends haven’t extended to Ashland County. In fact, colorectal cancer rates are worsening locally — and it’s getting deadlier.

The data is alarming to the local medical community, which has organized to learn more about the troubling phenomenon.

Digging into the numbers

Ashland County recorded 340 new cancer cases from 2016-2020. Colon and rectum cancer made up 10.5% of those diagnoses. That’s behind breast, prostate and lung and bronchus cancer diagnoses.

But colon and rectum cancer accounted for 13.5% of all cancer deaths within the same time period, behind only lung and bronchus cancer.

The grimmest data point, however, is perhaps the fact that colon and rectum cancer incidence and mortality rates surpass state and national trends.

In other words, more people are getting it and more people are dying from it in Ashland County compared to other areas of Ohio and the U.S.

“It’s concerning,” said Dr. Mehrdad Tavallaee, an internist at University Hospitals with 28 years experience. 

But the irony, Tavallaee said, is colorectal cancer's 90% survival rate when detected early through colonoscopies and other tests.

So why are Ashland County’s colorectal cancer patients going undetected?

Dr. Mary Ellen Gaeke said the answer is found in screening rates. Gaeke is a general oncologist at Ashland’s UH Samaritan Infusion Center. A traveling doctor since 2022, she’s practiced since 1980.

She pointed at the fact that only 48% of Ashland County’s residents who are between the ages of 50 and 75 have screened for it. That's roughly 22 percentage points behind the rates of both Ohio and the U.S. Clearly, Ashland County is behind in this regard, she said.

“That’s where we need to put our efforts,” she said.

Determining risk

Patients are getting younger

Early-onset colorectal cancer — defined as cancers occurring before age 50 — are still considered rare. But those who are getting the disease are getting younger, research has shown.

In 2002, for example, the average age for a colorectal cancer diagnosis was 72.

By 2019, it was down to 66. That’s because new cases in people under 55 nearly doubled, from 11% to 20%. The National Cancer Institute reported early-onset colorectal cancer is now the leading cause of cancer death in people 20 to 49 years old.

Experts, by in large, agree: screening should happen before 50. The data is clear, and the local anecdotal stories support it. 

Dr. Gaeke said gone are the days when a doctor sees a patient with some rectal bleeding and constipation and prescribes medicine for hemorrhoids. (Hemorrhoids are inflamed veins in the anus and lower rectum that can cause constipation and rectal bleeding.) 

“We used to say ‘use stool softeners …’ and do no rectal exam or colonoscopy. But now, since we see this incidence (in colorectal cancer) increasing in the younger generation, that would be inappropriate. We better find out it’s not cancer,” Gaeke said.

Tavallaee had a patient in his 20s come in recently with constipation and blood in his stool. He performed a colonoscopy and found polyps.

A colon polyp is a small clump of cells that forms on the lining of the colon. Most of them are harmless, according to the Mayo Clinic. But it's those polyps that can, if not removed, develop into cancer, Tavallaee said

Angela Woodward, the executive director of Ashland County Cancer Association, was 42 when she was diagnosed with breast cancer. She’s been cancer-free for 13 years. She empathizes with clients who are younger, a trend she bears witness to more often than ever.

“I had young children at home,” she said. “I remember that day when I was diagnosed, thinking ‘Oh my gosh, are my children going to be without a mom?’” 

ACCA is a nonprofit in Ashland that offers wrap-around services to local cancer patients. Woodward said the organization helps up to 350 clients every year, and the clientele within the 0-40 age group is has grown slightly since 2022, according to data provided by ACCA.

More information, screening is needed

The local health community needs more information to know how to curb local rates.

"We really have to spend more time digging into this and figuring out what's going on," said Vickie Taylor during a June meeting with Ashland County Board of Commissioners.

"It's not going to be a quick study. It could be the environment, it could be something else."

The Ashland County Health Department launched a survey in early June to collect demographic information from residents, including their history on colorectal cancer screening. 

The aim is to develop messaging around the importance of screening, either through stool samples or via colonoscopies.

When asked, the health department declined to offer specific details — like how many people have responded — about the status of the survey.

"This is an open, ongoing survey so we will not be able to provide information regarding the survey with it still being open. I don't know that we have a date set for when it is going to end," wrote Jill Hartson, a health department spokeswoman, in an email. 

In the meantime, the experts encourage those with average to moderate risk to screen. Colonoscopies are the "golden standard," but there are other ways to find polyps and other related complications.

"(Colonoscopies) can detect cancer at the earliest stage," Tavallaee said. "It can prevent cancer from happening, too. The majority of (colorectal) cancers start with a tiny polyp, and they start growing over time. It takes up to 10 years for a polyp to become cancerous."

Other screens include take-home tests. Free tests like these are available through the Ashland Christian Health Center, said Cheryl Benway, the organization's executive director.

Benway secured a $30,000 grant through the Samaritan Hospital Foundation in November 2023 to provide take-home tests to its uninsured and under-insured clients. She said the organization feels blessed to be able to provide this service free of cost, which eliminates a possible barrier to those who don't have insurance or whose insurance doesn't cover that type of test.

Another way to screen, Tavallaee said, is called the fecal immunochemical test (or FIT), checks for hidden blood in stool. Blood in stool can be an early sign for cancer, polyps, ulcers and hemorrhoids.

What's causing this?

No one knows for certain. But there are theories, ranging from genes to diets and environmental pollutants.

"Things like obesity, inactivity, genetics — those are things we know about," said Gaeke, the oncologist from UH Samaritan.

One researcher, Dr. Victoria Seewaldt, has pointed to weight, labeling colorectal cancer "the disease of obesity."

Others point to diet.

One 2017 study, for example, underscore high intakes of red and processed meats and alcohol increasing the risk of colorectal cancer.

The same study revealed decreasing rates when coupled with a diet of mostly fruits, vegetables and whole grains.

A January 2024 study investigated the impact of environmental factors on our gut's microbiome.

Another, from 2022, focused on triclosan, a chemical from the 1960s used as an anti-bacterial agent in things like soap and toothpaste. The Food and Drug Administration banned it in household products in 2017, but it can still be found in commercial pesticides.

Others point to microplastics and their role in damaging the colon's mucus barrier, like this 2023 study.

Why this is happening locally, though, remains a mystery. The information is simply lacking.

"We have no data," Gaeke said.

A colonoscopy evangelist

Rose lives with his wife in Lake Fork, a small unincorporated area in Mohican Township. They've occupied the same house for 29 years. His cancer is in remission; he returned to work in October 2022. There, he’s turned into a bit of a colonoscopy evangelist. 

“Everybody thinks the colonoscopy thing is taboo … but (colorectal cancer) is nothing to fool around with,” he said.

He said several of his coworkers have since gotten colonoscopies.

Rose has also encouraged his daughter, 26, and son, 21, to be more aware. They are at a higher risk now, so doctors have recommended they start getting screened every two years starting at age 30.

Though his cancer is in remission, he returns to Wooster’s James Cancer Center for blood work every four months. He gets two colonoscopies every year. In between those, he gets a CT scan.

The last CT came back good, he said. The last colonoscopy revealed six or seven polyps, which doctors removed.

They were all benign. 

But chemotherapy wreaked havoc on his liver. It's why he's abstained from drinking alcohol since October (except for a beer he shared with his son when he turned 21). He also watches what and how much he eats, avoiding ultra-processed foods as often as possible.

The condition of his liver concerns him, but he's cautiously optimistic.

"The liver can regenerate," he said.