Natalie Phelps first started suspecting that something wasn’t quite right in January 2020. Nearly eight months pregnant at the time, her midwife attributed the pain she was experiencing to pregnancy or maybe hemorrhoids.
But things didn’t improve after she gave birth at the end of February. The pain got worse, and she noticed irregular bowel movements and mucus in her stool.
Her primary care physician wasn’t concerned because at age 38, she was considered too young to have colon cancer. Instead, Phelps was referred to a therapist because her doctor thought that postpartum depression could be causing her symptoms.
A gastrointestinal specialist thought it might be Crohn’s disease or colitis. She was too young for a routine colonoscopy, but because of her symptoms, the GI doctor performed the procedure. When Phelps awoke from the anesthesia, she learned that she had a tumor in her rectum. Additional testing confirmed it was cancer and had spread to her liver.
“I thought I was an unlucky person—a rare one in a million young patient to get cancer,” she says. “As I've gone through treatment and connected with others online and through nonprofits, I’ve learned how much colorectal cancer is on the rise in young people in their 20s, 30s and early 40s. I'm not a rare patient but part of a growing problem with a shifting demographic.”
Dr. Mukta Krane, Phelps’ colorectal surgeon at Fred Hutchinson Cancer Center, says it’s unclear why colorectal cancer is impacting more people at younger ages. “We’ve seen a pretty significant increase in less than a generation,” she says. “Most of us who do research in this area think it’s likely due to environmental causes, but it’s hard to pinpoint what they might be.”
Colorectal cancer still mostly affects people over 50, but diagnoses in younger people have been climbing. Because of that, the recommended age for a person’s first screening colonoscopy was lowered to 45 from 50 in May 2021.
“Natalie still would have been too young to be screened based on that alone,” notes Dr. Krane. “We can't forget that colorectal cancer can happen to younger people. We have to be really responsive to patients when they are telling us that they think something is wrong.”
If younger people complain of abdominal pain or rectal bleeding, doctors may chalk it up to gastroenteritis or inflammatory bowel disease. “When patients under 40 have symptoms that are hallmarks of colorectal cancer in an older person, it’s not uncommon for them to be attributed to benign causes,” says Dr. Krane.
Rectal bleeding of any kind should be further investigated with a colonoscopy or a FIT test—a fecal immunochemical test, also called a fecal occult blood test—that looks for signs of blood in the stool. Persistent pain or bloating and changes in bowel habits such as the urge to go more frequently should also be checked out; thinning stool, for example, can result from a tumor narrowing the space where stool collects.
The most common type of colorectal cancer is adenocarcinoma, which originates from a polyp, underscoring the importance of screening colonoscopies. “If we’re screening people frequently enough, we should be able to detect disease as a polyp when it is typically pre-cancer and we can remove the whole thing,” says Dr. Krane.
In Phelps’ case, it took months to reach the correct diagnosis in part because her primary care physician attributed her symptoms to pregnancy and childbirth. “Natalie’s case highlights that the medical community can underestimate people’s symptoms, particularly women’s,” says Dr. Krane. “Her diagnosis came after the birth of her second child and was thought to be related to that, as well as her pregnancy and the stress of being a new parent.”
By the time she sought out Fred Hutch, Phelps was diagnosed with stage 4 rectal cancer. She came to the Colorectal Cancer Specialty Clinic, where she saw not only Dr. Krane but a handful of other specialists who would also be involved in her care. “It was very clear that the doctors there work as a team and communicate very efficiently,” says Phelps.
The multidisciplinary clinic also offers patients the option to participate in clinical trials as well as other novel investigational approaches. “Patients not only get the team approach, but they are also screened for eligibility for clinical trials and surgical innovations that may help with their care,” says Dr. Krane.
Coordinating with other medical, surgical and radiation oncologists, plus experts in genetics, the multidisciplinary team at Fred Hutch recommended a combination of chemotherapy and radiation before surgery.
Phelps began chemotherapy in the fall of 2020, with a 5-month-old baby and a 3-year-old son. Her treatment was complicated due to COVID-19, but the Bainbridge Island resident was fortunate to have friends who moved out of their Seattle home so Phelps and her family could move in to be closer to Fred Hutch. After four months of chemotherapy, she started radiation therapy. In the spring of 2021, she had surgery to remove the tumor.
The surgery was complicated and arduous, lasting 18 hours and involving four different surgeons. Dr. Krane removed the primary tumor, while another surgeon addressed the cancer’s spread to her liver and a gynecologic surgeon removed the cancer that had invaded her vaginal wall. A plastic surgeon led the reconstruction efforts.
Phelps began chemotherapy again last fall to treat a liver metastasis, followed by liver surgery. In January, a new liver metastasis was discovered, but it was too small to be removed surgically. Her primary tumor has not returned, and her disease is stable.
In the future, Phelps may need additional surgery or chemotherapy. Immunotherapy could also be an option, as could a liver transplant and consultation with the Cancer and Organ Transplant Clinic, a multidisciplinary clinic at Fred Hutch specializing in both organ transplants and oncology that is the first of its kind. But Phelps hopes to remain stable for a long time.
“I feel great now and I’ve used this time to make as many memories as possible,” says Phelps. “I’m feeling really happy emotionally and good physically. I don't know what the future will hold, but I’m so grateful for the time I have now.”
This weekend, Phelps will spread her message of patient advocacy at the Walk to End Colon Cancer. Phelps helped organize the Oct. 8 event—Fred Hutch is a sponsor and both Phelps and Dr. Krane are speakers—and has become active in the colorectal cancer patient advocacy community. On Instagram, she shares openly about her story as @BootyCancerMom.
“You can't get screened for every ailment under the sun but considering that colorectal cancer is predicted to become the leading cause of cancer deaths among people between the ages of 20 and 49, we have to talk about this,” she says.
That means overcoming the taboo around talking about bowel function, which starts at an early age. Adults often teach kids that mentioning bowel movements is inappropriate “potty talk.” Just saying the word “poop” can cause a room full of kids to fall on the floor laughing. Dr. Krane says it’s important to normalize these discussions, which she does with her own young children.
“There’s nothing wrong with talking about these things,” she says. “We have to raise awareness because this is a cancer that is difficult for people to talk about.”
Each Mother’s Day, Dr. Krane receives an email from Phelps that includes a picture of her kids, now ages 2 and 5, and thanks the colorectal surgeon for enabling her to celebrate the day. “Natalie is the reason why a lot of doctors went into medicine,” says Dr. Krane. “She's been a strong advocate to push people to get the health care that they need, to push the medical community to do tests and figure out what’s going on.”