Colon Cancer is Increasing in the Young: What you Need to Know

Colorectal cancer is usually considered a disease of older adults, but now nearly one-third of rectal cancer diagnosis are younger than age 55 with the biggest increase in diagnoses being seen in people ages 20-29. Colorectal cancer is the leading cause of cancer death in men younger than 50, and it ranks second only to breast cancer in women younger than 50. 

This week we talk about what has changed that may account for this trend, what symptoms to pay attention to, and how to advocate for yourself to get a timely diagnosis.

In this Episode:

• 01:41 - Recipe of the Week: Macaroni and Corn Casserole
• 03:59 - Arlington Cemetery: Preserving the Mementos Left at the Graveside
• 09:17 - Colorectal Cancer and the Rise of Early-Onset Disease
• 44:07 - Navigating a Strained Relationship at a Relative's End of Life
• 55:35 - Outro

Transcript

Colon-Cancer-is-increasing-in-the-Young-What-You-Need-to-Know

This podcast does not provide medical nor legal advice. Please listen to the complete disclosure at the end of the recording. Hello and welcome to Everyone Dies, the podcast where we talk about serious illness, dying, death, and bereavement.

I'm Marianne Matzo, a nurse practitioner, and I use my experience from working as a nurse for 46 years to help answer your questions about what happens at the end of life. And I'm Charlene Everett, an actor in New York City, and here to offer an every person viewpoint to our podcast. We are both here because we believe that the more you know, the more prepared you are to make difficult decisions.

So welcome to this week's show. Please relax, get yourself some cold tea and cake, and thank you for spending the next hour with Charlie and me as we talk about colon cancer and its rise in young adults. Like the BBC, we see our show as offering entertainment, enlightenment, and education, and divide it into three halves to address each of these goals.

Our main topic is in the second half, so feel free to fast forward to that ragtime free zone. In the first half, Charlie has the story of keepsakes left at Arlington National Cemetery. Keepsakes left at Arlington National Cemetery.

In the second half, I'm going to talk about colon cancer that is increasing in people under age 50 and are tending to be more aggressive tumors when diagnosed. And in our third half, Charlie has a question for discussion about loyalty. Well, mashups are all the rage and our recipe this week is macaroni corn casserole, which is an ultimate carb mashup.

We're always ones to push the boundaries and this mac and cheese is no exception. This is melty, gooey goodness that one can only achieve with a duo of white cheddar and gruyere cheeses. Then up the ante with crumbled bacon and pretty little corn kernels, ready to pack a punch of sweetness to every bite.

Bon appétit! So, Charles, how are you? Well, you know, I'm concerned here. As you said, it's a pretty little corn kernels. So, you know, isn't that a form of discrimination? Why do they have to be pretty? I mean, can't we just use corn kernels as long as they're well and healthy? No, they just are.

You can't get a corn kernel that's not pretty. It's just part of the genre. So, there's no pressure on corn themselves, right? No, it just comes naturally.

It just comes naturally. It's like, boom, they pop out of that, you know, off the cob and they're just adorable little things. I see, I see.

You know, I know you're from New York City and, you know, you might not see how cute they are. Speaking of cute, though, I don't think we usually think of Willie Mays as cute. Willie Mays died.

Yeah, that was quite a while ago, though, right? Yeah, what's it, four weeks ago now? The great Willie Mays. Yeah, he started his career here in New York when the New York Giants played here. Of course, out in San Francisco in his last two years, right? Two years was back in New York playing with the Mets.

Well, if you can make it there, you can make it anywhere, Charles. That's what they say. I've heard that.

What a catchy title. I know. So, Mary Ann.

Well, rest in peace, Mr. Mays. Yes. So, in our first half, Section 60 at Arlington National Cemetery is the 14-acre burial site of American casualties from the Iraq and Afghanistan wars and counterterrorism missions everywhere, though there are a few graves sprinkled in of World War II and Vietnam veterans who either died of old age or whose bodies were discovered overseas after many years of being missing in action.

Besides the rows of tombstones, families and friends leave mementos and trinkets, tokens that arouse memories that were sentimental to the person buried there or the visitor. They range from predictable things like flowers or their unit insignia to the less predictable, like childhood toys, half-finished bottle of Jack Daniels or a quilt. You can see characteristics of the individuals from what is left on their graves.

They tell a story. There are some headstones that don't have anything on it and that can make you wonder who this person was and why no one had left anything. Rod Gaynor is the cemetery's historical curator, and when he walks through Section 60, he collects and tags the keepsakes with the date and plot number.

The keepsake collection totals 3,250 that have been gathered over the last 15 years from Section 60. Each is packed in a transparent red plastic bag placed inside a white corrugated cardboard box and locked out of sight in a climate-controlled underground corridor not far from the Tomb of the Unknowns. Among them is a wooden plaque bearing the names of two Marines killed in 2005, a diamond cross necklace.

There are letters, photographs, patches, and pins, a high school football helmet, even an old Nintendo Game Boy. Unfortunately, Arlington Cemetery has no plan for the long-term storage of Section 16 mementos and it lacks the space and budget to properly conserve and display them. The boxed archives are not official U.S. government property, therefore they are ineligible for taxpayer funding.

Arlington Cemetery's dilemma over how to permanently care for these objects is similar to the one experienced by the National Park Service in the early 1980s when the Vietnam Veterans Memorial opened on the National Mall and mementos began to appear at the site. The decision was made to preserve them in 1984 and the full collection, which now numbers in the hundreds of thousands, was moved to the National Capital Area's Museum Resource Center in Landover, Maryland. It is not available for public viewing, though some items can be seen online and occasionally shared with museums like the Smithsonian.

The Wall that Heals, a mobile exhibit, also includes some replicas of mementos. As with many things, what to do with these artifacts comes down to funding and the cost to taxpayers, which is a question we don't have an answer to. What do you think, Marianne? Well, you know, I appreciate that they're picking all this stuff up, but I also think about we don't have an unlimited amount of money for things, and you didn't mention how much any of this is costing, but if they have a full-time curator and they're storing stuff in the bags and the boxes and the air, climate control's got to add up, Charlie.

And you think about people who don't have internet access or air conditioning in this awful heat and, you know, people say, oh, you're going to sound like a liberal, but it's like, is that really what you want to spend your money on? Or is that what I want to spend my money on? Yeah, yeah, good point, good point. Folks, please go to our webpage for this week's recipe for macaroni corn casserole and additional resources for this program. Everyone Dies is offered at no cost, but is not free to produce.

Please contribute what you can. Your tax-deductible gift will go directly to supporting our non-profit journalism so that we can continue to remain accessible to everyone. You can also donate at www.everyonedies.org, that's every, the number one, dies.org, or at our site on Patreon, www.patreon.com, and search for Everyone Dies.

Marianne? Thanks, Charlie. From 2000 to 2020, the frequency rate of colorectal cancer, which is cancer of the colon and the rectum, decreased by nearly half. However, among people younger than 50, the rate rose from 6 per 100,000 people to more than 8 per 100,000 people, which translates into an increased rate of 1 to 2% per year for the last 30 years.

The biggest increase is being seen in people ages 20 to 29. Colorectal cancer is the leading cause of cancer deaths in men younger than 50, and it ranks second only to breast cancer in women younger than 50. Colon cancer used to be a disease of old people, and now, as nearly one-third of rectal cancer diagnoses are younger than age 55.

You know, as always, Charlie, let's start with a bit of anatomy. The colon and rectum, or you might hear it called the colorectum, along with the anus, make up the large intestine, which is the final segment of the gastrointestinal system. The large intestine is sometimes called the large bowel, which is why colorectal cancer, or as I'm going to call it from now on in this talk, CRC, is sometimes referred to as bowel cancer.

The function of the large intestine is to absorb water and electrolytes from digested food and eliminate feces. Waste pass from the colon into the rectum, which is the final six inches of the large intestine, and is then expelled through the anus, which is the last one inch of the system. Even though they're close to each other, cancers of the anus are classified separately from those of the rectum because they usually originate from different cell types and have different characteristics.

CRC almost always starts with the growth of a polyp, which is a non-cancerous growth that develops on the inner lining of the colon or rectum. Polyps are common and are detected in about half of average risk people 50 years or older who have a colonoscopy, with higher frequency in older age groups and among men compared to women. Note that the age recommended for the first screening colonoscopy is age 50.

I assume you've had one by now, Charles? Oh, and by the look on your face. I do have an appointment though, but no, foolishly, I have not. I've had rectal exams, but not a colonoscopy, no.

So a rectal exam, what they're checking is your prostate. That's what the rectal exam is for. So it's looking for changes, enlargements of the prostate.

But the colonoscopy, this is, you know, with a camera on the end of it, that after some wonderful drugs that put you to sleep, they put this in and they can go up and they can look to see how the cells look. And if they see any polyps, this is like one of the good things about a colonoscopy is if they see any polyps, which are considered to be precancerous colon cancer lesions, they can just snip those right off and get rid of them. And so it lowers your risk both by seeing what's in there and also getting rid of any polyps that are there before they can grow and invade and become cancerous.

So don't be like Charlie listeners. If you're age 45, get your colonoscopy. Insurance covers that.

Note that the age recommendation for a first screening colonoscopy has recently changed from 50 to 45. So fewer than 10% of polyps are estimated to progress to invasive cancer, a process which usually occurs slowly over 10 to 20 years, as more likely as polyps increase in size. Once the polyp progresses to cancer, it can grow into the wall of the colon or rectum, where it may invade blood or lymph vessels that carry away cell waste and fluid.

Cancer cells typically spread first into nearby lymph nodes, which are bean-shaped structures that help fight infections. They can also be carried by blood vessels to other organs and tissues, such as the liver or lungs, or directly into the membrane lining of the abdomen. The spread of cancer cells to parts of the body distanced from where the tumor started is called metastasis, and the extent to which cancer is spread at the time of diagnosis is described as its stage.

So in CRC, there are four stages, and the first is in situ, which are cancers that have not begun to invade the wall of the colon or rectum. They're kind of just sitting there right on the outer lining. Then there's local, which is cancers that have grown into the wall of the colon or rectum, but have not extended through the wall into nearby tissues.

There's regional, where cancers that have spread through the wall of the colon or rectum and have invaded nearby tissues or that have spread to nearby lymph nodes. And then there's distant, cancers that have spread to other parts of the such as the liver or lung. Early CRC often has no symptoms, which is one of the reasons screening colonoscopies are so important.

As a tumor grows, it may bleed or block the intestine. So the symptoms, the things you might see are bleeding from the rectum, blood in the stool or in the toilet after you've had a bowel movement, dark or black stools. Now you get dark or black stools from what's considered to be old blood, so blood that's further up the colon.

If there's bleeding further up the colon, what you'll see in the toilet or on the toilet paper is a dark or black stool. If it's a brighter blood, it's lower in the colon or in the rectum. Another symptom you might see is a change in bowel habits or the shape of the stool, like a more narrow stool than usual.

People can have cramping, pain or discomfort in the lower abdomen, an urge to have a bowel movement when the bowel is empty, constipation or diarrhea that lasts for more than a few days, decreased appetite, and unintentional weight loss. And what I mean by unintentional weight loss is you're not on a diet, you're not trying to lose weight, but you notice that your clothes are getting loose. And I've said this before, I'm always puzzled by people who notice that their weight is going down, but they don't do anything about it.

And you know, I'll see people, you know, you see people that somebody you haven't seen in a while and their clothes are hanging on them, you know, and you kind of hope that they'll say, oh, I'm on Ozempec or I'm on some diet. And, you know, depending on your relationship, if you say, oh, you lost some weight. Yeah, you know, last two months I've lost 20 pounds, which is a fair amount of weight.

My question always to that is, oh, were you trying? And they'll say, no, it just happened. And then, you know, the bells are going off in my head. If it just happened, that's typically not normal.

Something's going on. You know, you could be depressed and you're not eating, but it can also be something else. So if you have unintentional weight loss, please go see your healthcare practitioner.

So what are the risk factors for colorectal cancer? In the United States, 55% of all CRCs are attributable to lifestyle factors, including an unhealthy diet, insufficient physical activity, high alcohol consumption, and smoking. And you might say, you know, can you come up with a different list for any of these diseases? And the fact of the matter is, no. This list kind of goes just about across all diseases and cancer types.

So these behaviors are traditionally associated with high income countries because, you know, the more money you have, the worse that you can eat. And this is where the CRC rates are highest. Numerous studies have documented that people with healthy lifestyle behaviors have a 27 to 52% lower risk of CRC to people compared without these behaviors.

That's impressive. 27% to 52% lower risk. Risk factors are divided into modifiable and non-modifiable.

Non-modifiable factors that increase risk are related to things that you can't do anything about, like your hereditary or medical history. It can include personal or family history of CRC or precancerous polyps and a personal history of long-term chronic inflammatory bowel disease. Most people at increased risk because of a medical or family history should begin CRC screening before age 45.

Up to 30% of people diagnosed with CRC have a family history of the disease. 30% have a family history. The most common hereditary risk factor for CRC is what's called Lynch syndrome, which accounts for about 3% of all CRCs.

People with Lynch syndrome also have an increased risk for many other cancers, including endometrial, ovarian, small intestines, stomach, urinary bladder, and female breast. What it is is that these individuals have a mutation in certain genes that hinders the cell's ability to correct errors introduced during DNA replication. These mistakes result in additional mutations that can ultimately lead to cancer.

I've only seen one person with Lynch syndrome, and they had, I think, three or four different primary types of cancer. And it's just this genetic anomaly that results in an increase in cancer. Chronic inflammatory bowel disease, IBD, is a lifelong condition usually diagnosed in early adulthood, in which the gastrointestinal tract is inflamed over a long period of time.

People with IBD have almost double the risk of developing CRC, colon-rectal cancer, compared to people in the general population. The most common forms of inflammatory bowel disease are ulcerative colitis and Crohn's disease. Cancer risk increases with extent, duration, and severity of disease, but has decreased over time, likely due to the increased use of medications to control inflammation and screening surveillance to detect pre-malignant lesions.

People who have type 2 or adult-onset diabetes have a slightly increased risk of CRC that appears stronger in men than in women. Regarding modifiable risk factors, these are things that you can do something about, that you are in control of. So modifiable risk factors are physical activity is strongly associated with a reduced risk of colon cancer, but not rectal cancer.

Studies consistently show that the most physically active people have about a 25 percent lower risk of developing colon tumors than the least active people. Being physically active from a young age may further lower risk. People who are the most sedentary, meaning that they spend most of their hours of the day sitting, have a 25 to 50 percent increased risk of colon cancer compared to those who are the least sedentary.

However, sedentary people who become active later in life may reduce their risk. So that's motivation to start moving it. Check out our other podcasts about the benefits of movement and start lowering your risk.

Excess body weight increases the risk of CRC, even among those who are physically active. Compared to people who are normal weight, obese men have about a 50 percent higher risk of colon cancer and a 25 percent higher risk of rectal cancer. And obese women have about a 10 percent increased risk of colon cancer and no increased risk of rectal cancer.

Our diets have long been suggested as being linked to CRC occurrence. It's not only through excess calories and obesity, but also directly linked through specific dietary elements. For example, diet has a large influence on the composition of the gut microbiome, which is the trillions of microorganisms, including about a thousand different strains of bacteria that inhabit the large intestine.

Diets with greater amounts of certain foods, such as refined carbohydrates, processed sugar, red meat, have a higher potential to increase inflammation and are associated with increased CRC risk. In November 2009, the International Agency for Research on Cancer reported that there is sufficient evidence to conclude that tobacco smoking causes CRC. In the U.S., about 12 percent of CRCs are attributed to current or former cigarette smoking, with CRC risk in current smokers about 50 percent higher than that of people who've never smoked.

An estimated 13 percent of CRCs in the U.S. are attributable to alcohol consumption. Very heavy drinking, more than three drinks per day, was associated with a 25 percent higher risk. There's extensive evidence that long-term regular use of aspirin and other non-steroidal anti-inflammatory drugs, or you might know them as NSAIDs, lowers risk of CRC.

The reduction in risk appears to be stronger among individuals younger than age 70 and without excess body weight. The American Cancer Society currently does not recommend the use of NSAIDs for cancer prevention in the general population because of potential side effects, namely serious gastrointestinal bleeding. Decisions about aspirin use should be made after discussion with your healthcare practitioner.

That gives us an overview of CRC in general, but what are the differences for young adults? A 2019 study documented that among early-onset colorectal cancer patients, which is defined as those under 50 years of age, with rectal bleeding symptoms, the average time from symptoms to diagnosis was 271 days. Think about it. 271 days.

That's almost a year. By then, nearly half the patients' cancers had already metastasized. In early-onset CRC patients, lower awareness of CRC, lack of screening, an under-appreciation of symptoms, and reluctance to seek medical care may contribute to delayed diagnosis and an advanced stage of diagnosis.

Also, healthcare practitioners are not looking for colon cancer in people in their 20s and 30s. Remember I said it's a disease of older people. The increase in colon cancer in younger people needs to be known by younger people and those that love them to help them get an earlier diagnosis.

So parents and grandparents who are listening, take a look at the people that are in their 20s and 30s and 40s in your life, and if you hear anybody talking about the symptoms that we talked about, cramping, abdominal pain, unintentional weight loss, but primarily the first symptom that people will see is bleeding when they go to the bathroom. If that happens, you really need to say, get to your healthcare practitioner. And if your healthcare practitioner says, it's probably just hemorrhoids.

No, but that's what's being said because you don't look at a 22-year-old and think colon cancer. Well, except this has always been a disease of people over the age of 50. So now CRC is divided, it has two names, early onset CRC, which is for people under the age of 50, and late onset CRC is for people over the age of 50.

And we never had that mark on the sand. So that's where the responsibility comes to us as patients or parents to say, what's going on? What are they doing about it? And no, we're not waiting six months for you to get a colonoscopy. That's how it's going to be diagnosed.

The reasons for the increase in early onset CRC, remember early onset is people younger than 50, but the biggest rise has been in those, what did I say, 21 to 29. So there's a greater exposure to potential risk factors, such as a Western style diet, obesity, physical inactivity, and antibiotic use, especially during the early prenatal to adolescent periods of life. These exposures can not only cause changes in colorectal epithelial cells, but also affect the gut microbiome and immunity.

The upward trend of early onset CRC in most Western countries since the 1980s seems to reflect a birth cohort effect, which means that historical changes in certain risk factors might have differentially affected each age group, like what we're talking about is a birth cohort, which is considered generally about a 10-year period, with increased risks being carried forward to a later time. So evaluation of early life exposure in relation to future risks of early onset CRC may include their mother's lifestyle while pregnant, including diet, disease, and medications. Around the 1950s, a global shift started in diet toward higher consumption of processed meats, fast foods, edible oils, refined grains, high fructose corn syrup, and sugar.

The global prevalence of childhood and adolescent obesity has increased more than five-fold in recent decades, along with reductions in physical activity. Exposure to substances such as antibiotics was increasingly more prevalent in the past several decades. Prenatal and perinatal practices, which is the time that before you get pregnant and while you're pregnant, have also changed with increased use of reproductive technology, cesarean sections, bottle feeding, which might have unforeseen long-term effects on offspring.

In adolescence, the rate of inflammatory bowel disease, an established CRC risk factor, has increased dramatically, and the occurrence of type 2 diabetes has also sharply increased. So these are the considerations researchers are trying to unpack related to why early onset CRC is increasing. Here's what you need to know for your own health.

If you experience pain in your lower abdomen, blood in your stool, or unexplained weight loss, or if you feel that something is off and your symptoms are just not going away, you need to get checked out. Go to your healthcare practitioner, but know they probably aren't going to think colon cancer because of your young age. If you have any of these symptoms, speak up and don't give up until your doctor gets to the root cause.

Nearly one-third of people diagnosed with early onset CRC have a family history or genetic predisposition, and having a conversation with your relatives is important. The Colon Cancer Coalition has developed a script you can use to bring up colon and rectal cancer questions in conversations with relatives, which may help you determine whether you should be screened 10 to 15 years earlier than the current recommended age. The link for this script is in the show notes.

Early onset colorectal cancer tends to be more aggressive. It's often diagnosed later in the course of the disease when it's harder to treat. Sometimes it's misdiagnosis, diverticulitis, or hemorrhoids, or some other problem.

Don't let your fear of what the diagnosis may be by ignoring pain, blood in your stool, or weight loss. Listen to your body, even if you believe you're healthy, and advocate for yourself. Doing nothing is not a good option.

The life you save could be your own. Charlie, questions? Um, yeah. So, okay, so, you know, I understand what you said about the difference between a rectal exam and a colonoscopy.

Should people have both? Well, men. Should men have both, or just, you know, focus on the colonoscopy? 45. Well, it depends on how old you are and what symptoms you're having.

Um, at age, yeah, is the recommended time for the first colonoscopy. So, the statistic I read, oh, cripe, what was it, like 40% of people at age, you know, at age 50 don't get their colonoscopies done. And that's, um, I don't know, to my worldview, I think that's irresponsible.

Because like I said, it's great drugs. I mean, if you do nothing else, go for the drugs. The prep is not fun, but they now have pills that you can take so you don't have to drink the stuff.

And so if you have a problem with drinking the stuff, ask if they can order the pills for you and if your insurance covers it. Um, and then you, you go and honestly, they do give you nice drugs and you just kind of go to sleep. I find it very pleasant, um, that part of it.

And you wake up, it's all over and, um, generally they'll take pictures of your colon. So you get to take home pictures of your colon, put them on your refrigerator and everybody can see how, how the lining of the inside tubes look. And that's it.

I mean, it, you're, you're not sore afterwards. Um, you don't know what's happening. Uh, it's, you know, the, the prep is the worst part.

And like I said, if you take the pills, even that's not bad and just do it. I mean, you know, we've probably all done worse. Just do it.

And don't put off that screening at age and you're listening to this and you haven't had a colonoscopy, book one, because like I said, it's like a two, it's a twofer. They go in and they look at those cells, but also if you have any polyps, they'll just clip them right off. And, you know, get, you know, help lower that risk that way.

Got it. No reason to put it off. So how long does, when somebody has this procedure done, what you're looking at an hour or a half hour for, from beginning to end? Oh, let me think.

Oh, I think it's probably the procedure itself is maybe 10, 15 minutes. Okay. I mean, it doesn't, it doesn't last long.

And then, you know, you, you wake up usually, you know, back in the screening room, you know, the pre-op room and they just make sure that your blood pressure is everything. Okay. You have to have a driver to drive you home.

You're not allowed to drive yourself. I don't know what it's like in New York, but you can't like take a cab or an Uber. No, no, it's the same thing.

You cannot. I've, there've been a few friends who I, just that, after the colonoscopy, I went and I picked them up. You know, they were all fine, but just to your point, yeah, nobody's allowed out without, you know, someone there, you know, to go out with them.

And it's, I mean, it's not, let me tell you, colon cancer treatment is far worse than getting a colonoscopy. So, so, so then after that, you, I mean, how often do you go or do you just then rely on rectal exams? What do you, what? Rectal exams are not going to help with colorectal cancer. Rectal exams are only done on men for prostate cancer.

What they're doing when they put their finger up the rectum is the tip of the finger can feel the prostate and the prostate should feel smooth and it feels sort of like a heart shape. You know, it's got a lobe and then like a little dip and then another little, so what they're feeling, is it smooth? Can you feel that little dip? Is it enlarged? That's what the rectal exam's for. It has nothing to do with colorectal cancer.

So how often to get a colonoscopy and also how often? What they'll tell you is, you know, if they find any abnormalities, if they find any polyps, they'll say, I want to do another one three years or they'll say, I want to do another one in five years or they'll say, I want to do another one in seven years. So it depends on what they find when they're looking around with that camera. They'll tell you.

Oh, okay. And what I do is I just, I just write it in my calendar. Next colonoscopy will be 2028 or whatever, you know, because I don't rely on them to see.

Other people will say, oh, well, they'll call me in five years. Yeah. Don't hold your breath.

Put it in your calendar for when your next one is and then that year, when that year rolls around, make your appointment. I don't rely on systems to manage my health. Okay.

Yeah. No, no, no. I agree.

And so, okay. So that's, so I got it about how often for a colonoscopy and how often for a rectal exam. Generally doctors will do that whenever you have a physical.

So if you have a yearly physical, generally they'll do it then. Okay. Um, there was, was, you know, while you were speaking something else.

Oh, okay. So with this, I mean, is it generally just men or does this affect women as well? Colorectal cancer. It affects both.

Um, it affects, um, men more. Yeah. So it's leading, leading for men and the second leading cause, um, for women after breast cancer.

Okay. So why do, why do men get more PR about this than women? I didn't know it was so high up for, for women. Why does most of the scientific research be done on white men? I don't know, Charlie.

I see your point. Yes. They're just making all these waves about, they're so excited that they're finally, after all these years doing a study, a long longitude and a longterm study on black women.

Yeah. I remember reading about that. Yeah.

So, you know, these, the marginalized groups, um, you know, we've talked about those in the past is that they're not on the radar. I mean, you could add a lot of, a lot of reasons. They're not on the radar.

Researchers may tend to be white men, at least that was true for a long time. So they study, they study their own populations. You know, why is there more research on prostate cancer than breast cancer? Don't get me started.

Yeah. Yeah. And, and to your point also, um, yeah, there's just more research now on this, you know, women in general that, uh, it's long last, you know, the men folk realize, you know, they're not built the same way.

Isn't that something? And, and to that I say, vive la difference. Well, it's like back when the Framingham, um, study came out, which was the big, uh, heart disease study that was all white men. And that's when, you know, the recommendation of a baby aspirin a day, you know, to lower your risk of heart disease, but that had never been studied on any minority people or on women.

So they took a recommendation from a study of white men and kind of applied it across, but we only know that it had an effect for white men. And it's like, well, let's throw it at other groups and see if it sticks. And it didn't.

I, oh, well, well, now we have you to thank for letting us know. Thank you for me to rant about things. Yes.

That's why I'm here Good. In our third half, we have the following question from the New York Times, uh, to talk about. My father's brother was going through a rough patch financially.

So my father offered him a room in his house. My uncle moved in, but they fought frequently over my uncle's insistence that my father should be more religious. After months of tension, my father finally asked my uncle to leave and my uncle stopped speaking to him.

Later, he was diagnosed with cancer. My father made many attempts to repair their relationship, but my uncle wanted nothing to do with him. Now we have learned that my uncle is terminally ill.

He has invited the whole family, except for my father to gather for one last Passover. I am torn. It feels wrong to exclude my father, but it also feels wrong to refuse a wish of a dying man.

Thoughts? Hmm. I like when you go first. What are your thoughts? Um, jeez.

Well, um, I had to tell you the truth. The first thing that came to my mind was, you know, that this, you know, religious person who wants the entire family around and he lies dying, except for his brother. And, you know, religiosity is nice in theory.

But, you know, we're controlled by emotions. So in this case, I think Mr. Religion should practice what he preaches and not cut out his brother. You know, and the other thing with it too, you know, he's putting his nephew in the middle of it.

And that ain't nice. That's what I think. How does he put, how's the nephew in the middle? Explain that to me.

Well, because, um, the nephew is invited, but the nephew's father, this guy's brother, is not. So now the nephew has to, oh gosh, like respect his father and not go to see his uncle or respect the uncle, go see the uncle for the last time and basically, you know, leave his father out of it. So that's what I mean.

To me, it looks like he's also putting his nephew in the middle. Who is, you know, the nephew loyal to? The uncle or the father? It's a Seder meal. And my thought is, is that the uncle can invite whoever he wants.

Right. And the people that he invites have a choice whether to go or not. And, you know, with people who are at the end of life, you've got, you know, it may in fact be the last Seder meal that he's, that he'll be alive for.

And I was, I had, I have a friend who's saying always is that the nice thing to do is the right thing to do. And the nice thing would be for the, for the nephew to go with the family and celebrate that Seder meal. And if that were my child and my brother or my sister is mad at me and they don't want to invite me, but they've invited my child, then I would want my child to go and represent us and, and to give support to the family and to sort of be the bigger person and, and show up for that meal.

And if my brother or sister said, no, I'm just too angry at you. What I, I'd probably do is send them a letter and say, I love you. I'm sorry that this disagreement got in between our, our relationship.

I'm sorry, you're so sick and I'll respect what you decide, but I would like to be able to be with you. And if my sibling was like, no, you're going to rot in hell and I don't want you around then. Okay.

I mean, I, I can only be responsible for me. I can reach out to them and, and do the nice thing. It doesn't hurt me to, to be kind to my siblings, even when they're being jerks.

I mean, isn't that what kind of adult behavior is? And if, and if they're going to include my, my child, well then that's great. Why, why shouldn't, why should my child feel a, that they're in the middle or that it's a question of loyalty to me or loyalty to, to another family member? It's a meal. I mean, it's not, it's not a hill I need to die on.

Hmm. So I would, I would say, you go, you represent our family. You, you tell them you love him and you tell them I love him too.

That's nice. That's nice. Yeah, but I know, but I'm not, you know, I'm not, you know, I'm not a nice person.

That's not about nice. It's just about. Okay.

So what's the word? Okay. It's, so what, what is it about? Not practicality. It's what word am I looking for here? It's about, I don't know, doing the right thing.

No, it's not. That's what I'm saying. The right, the right thing to do is, you know, the nice thing to do is the right thing to do.

The nice thing to do is to go to the darn meal. In fact, it'd be even nicer to make, you know, like a strudel or something and, and give it to your kid and say, take this. Our mom used to always make it, you know, or whatever.

I like that. Excellent. Now.

I don't, I think, I think, let me just say this though. I think that a lot of times we run into issues when we look at it as a black or a white either, either you support me or you support your uncle. Well, wait a minute.

There's a lot of gray in between those two points and doesn't need to be black or white. And I think in most cases it does not. Right.

But people may get into black and white. Yep. You're right.

Yes. So, so what does, what does the author say? Well, he says this, I appreciate your sharing the backstory of this conflict between your father and your uncle. Context is always helpful.

Now I urge you to set it aside. It is not your job to repair the relationship between these men or to judge them. In my experience, sibling relationships are often more layered and complex than any one story can convey.

Creating some emotional distance here may also help make your decision about attending Passover easier. On a purely humane level, there is no conflict between sympathizing with a man who is dying and feeling bad about your father's exclusion from what may be a last gathering. I can also imagine your discomfort at feeling disloyal to your father.

That's a lot of emotion to layer onto one day. Still, I would attend your uncle's Seder. And I would tell your father that you feel sorry about his exclusion.

Let him know that you love him and think he has been a good brother to your uncle. Your father already knows what a difficult situation this is. I doubt he would want you to boycott the Seder for him, and I bet he will be proud of your compassion.

So, Marianne, along the lines what you were saying. Yes. All right, very good.

I just, I think by talking about these kinds of situations that maybe our listeners can look for a middle place instead of setting up camp in either the black or the white area. Yeah, because really everything, most things, I mean, there is a gray area. It's not all or nothing, um, despite how things are in the country.

It's not black and white. Oh, it absolutely is not, you know. Yeah, yep.

And, you know, even if you take it to the point of saying, and we don't get political here, we've probably raised enough tensions talking about death and dying. Yeah. But look at, you know, look at what's best for your country.

Don't even, I don't know, don't even look at the people who, who, the personal characteristics of the people who are running for office so much as how do, how do they behave relative to supporting our democracy in our country and supporting our economy and supporting our, um, position in the world is, is what I try to think about. Yeah. But we shouldn't even go down that road.

Let's not. Let's just close the show for the week. Stay tuned for the continuing saga of Everyone Dies and thank you for listening.

This is Charlie Navarrete and from the television show, Doc Martin, a lot of my patients say they find a rural environment very relaxing. Of course, they also like it as a place to hide the bodies. And I'm Marianne Matzo and we'll see you next week.

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