In 2023, Bret Hulick was in his second year of medical school at LECOM in Erie, analyzing the case of a 24-year-old colon cancer patient. The patient had to choose between an established therapy with a high likelihood of unwanted side effects or a newer experimental treatment.

For Hulick, though, it wasn't an academic exercise. He was the patient — part of a dramatic rise in young people diagnosed with colon cancer — and his treatment decision was a difficult one.

"It's very challenging when you have a 24-year-old patient, a medical school student, right in the middle of school," said Ibrahim Sahin, a medical oncologist at UPMC Hillman Cancer Center, who treated Hulick. "You need to continue school, you have dreams to be a doctor, and there's a lot of emotions, stress and anxiety."

Hulick began experiencing symptoms in the summer of 2023, eventually visiting the emergency room for what he thought might be a stomach bug. He got a basic CT scan, a diagnosis of unspecified Crohn's disease or colitis, and a recommendation to see a specialist.

When he saw the specialist about three months later, they agreed with that diagnosis but recommended a colonoscopy. That colonoscopy showed a tumor, and Hulick was diagnosed with stage 3 colon cancer that had spread to his lymph nodes.

He decided to proceed quickly with surgery performed by Jennifer Holder-Murray, a colorectal surgeon at the UPMC Hillman Cancer Center, squeezing the procedure in during the two weeks that he got off from medical school around Christmas.

On Dec. 8, he went into surgery, which became more involved than expected when Holder-Murray discovered that the tumor had started to invade his stomach.

As Hulick recovered from surgery, he began discussing next steps with Sahin. The standard treatment was chemotherapy, which he needed even after surgery because the cancer had spread beyond the colon. But the recommended type of chemotherapy has a common side effect of peripheral neuropathy — weakness, numbness and pain in his hands and feet.

For Hulick, who hopes to work with his hands as an emergency room physician, that side effect could be life-changing.

Sahin thought there might be another option.

Hulick's tumor markers indicated the presence of mismatch repair deficiency (MMR), a genetic abnormality which makes it more difficult for cells to repair damage to DNA.

In 2022, researchers at Memorial Sloan Kettering Cancer Center in New York City published the results of a small study that achieved a 100% cure rate in 12 patients using the immunotherapy drug dostarlimab to treat rectal cancer that also had MMR status. The study, published in the New England Journal of Medicine, immediately changed the practice of treatment for rectal cancer.

Hulick didn't have rectal cancer, though, and there wasn't an equivalent study for colon cancer. But Sahin thought that the study was dramatic enough — and Hulick's cancer was similar enough — to try immunotherapy instead of chemotherapy, thus avoiding the risk of damage to his hands.

A doctor in Erie also consulting with Hulick disagreed, urging him to stick with the proven treatment of chemotherapy.

"I was really kind of up in the air," said Hulick. "I knew what the potential downsides of the chemotherapy were, but there was a lot more chance to take with the immunotherapy."

In the end, Hulick, an adventure junkie who snowboards and rides motorcycles and dirt bikes, decided to go with the less proven, higher potential immunotherapy option. "If there's a chance of something that's a little risky but with a better outcome, I'm likely to do it," he said. "It was worth taking the shot."

Thus far, his treatment has gone as well as possible. He was able to do about six months of immunotherapy with no interruption to medical school. And his scans are now completely clear, with no evidence of cancer.

"Luckily, it played out the way we were hoping," said Sahin, on the decision to use immunotherapy. "It wasn't the standard of care, it wasn't tested, but sometimes science proceeds itself — the studies were not perfect so we had to make the decision, what is more in the interest of the patient."

Just as Hulick was completing his treatment in the summer of 2024, Memorial Sloan Kettering released more data, with 42 patients now treated with immunotherapy for rectal cancer and every one of them cured. The first 24 patients all showed no evidence of cancer two years after their initial treatment. In December, the U.S. Food and Drug Administration granted dostarlimab "breakthrough therapy designation" to treat mismatch repair deficient rectal cancer.

Studies are now recruiting to test the immunotherapy treatment on colon cancer similar to Hulick's.

While Sahin and Hulick didn't have the luxury of waiting for official studies, they are grateful the science that did exist came along just in time, along with other advances in cancer treatment.

"What was available to him now wouldn't have been even five years back," said Sahin.

Hulick also received genetic testing and counseling that resulted in a diagnosis of Lynch syndrome, common among those with MMR tumors. Lynch syndrome, which was previously called hereditary nonpolyposis colorectal cancer, is a condition passed from parents to children associated with a higher risk of colon cancers and other cancers, especially at a young age.

Once Hulick received the diagnosis, his younger brother, younger sister and father were screened for cancer as well. And while his siblings were clear, his father found out in May 2024 that he had an active tumor that was thus far asymptomatic.

The tumor was removed surgically, which was considered curative because it was caught so early.

"That was the best thing to come of it was finding all this out and getting my siblings ahead of the ball," said Hulick. "We were able to figure that out for my dad before it became a much bigger problem."

Hulick's doctors are also hoping that his story can raise awareness of the rise in colon cancer in younger patients. The percentage of colorectal cancer cases in adults younger than 55 increased from 11% in 1995 to 20% in 2019, according to the American Cancer Society.

Symptoms of colon cancer are easy to dismiss as being from other causes, such as hemorrhoids or irritable bowel syndrome, said Holder-Murray, so getting them checked out is essential.

And while Hulick did have a hereditary component to his colon cancer, the vast majority of cases are sporadic, without a known history. "We're seeing it happen for younger and younger patients," said Holder-Murray. "It's one of the most heart-wrenching conversations you can have when you are talking to someone so young, with their whole future ahead of them."

_____

© 2025 the Pittsburgh Post-Gazette. Visit www.post-gazette.com. Distributed by Tribune Content Agency, LLC.