Colorectal Cancer- What You Need To Know30-Jul-2020
Colorectal Cancer Prevention and Treatment
Dr. Steen Jensen has 25 years of experience as a surgeon at Plumas District Hospital. This includes over 10,000 endoscopies as well as advanced endoscopy course work. You might not think colonoscopies would be something he’d be passionate about. But, when he explains that colorectal cancer is the second highest cause of death (behind heart disease) in the United States, or that it ranks fourth in the number of new cases per year (147,950) and that timely screening and treatment can reduce your risk of getting cancer by 68% and death by 80%, his drive to get this message across makes sense.
Dr. Jensen is a big proponent of colonoscopy as the test of choice for detecting colorectal cancer. It finds and removes precancerous polyps (adenomas), and also all other tests, when positive, are followed by a colonoscopy. According to Dr. Jensen, the other tests are around primarily because the colonoscopy is so expensive. In most places, he said, it would be impossible to screen everyone. Therefore, the low risk group (no family history, no Irritable Bowel Syndrome, etc.) can utilize one of the other tests. Plumas County has such a small population, however, “you can offer full colonoscopies to everyone,” said Dr. Jensen. “So we don’t do a lot of these other screening tests. We skip straight to the colonoscopy.
70% of Californians who should have colorectal screenings do so (counting all screening methods), and two-thirds of these patients get colonoscopies. Because Plumas County ranks significantly higher than the state average for smoking and drinking, and because of decreased access to care as a whole, Dr. Jensen said “you’d think colon cancer deaths” would be very high, “but they’re not.”
He attributes this to the “fairly aggressive screening program recommended by primaries (primary care providers)” in Plumas County. When he first came here in 1995, Jensen said, he saw a patient with colorectal cancer “every month or two.” Now, the number has seen a huge drop thanks to colonoscopies. “Every time we take out a polyp we are, potentially, preventing cancer,” he added.
Colorectal cancer screenings are recommended for all people 50 - 75 years of age. For patients age 76 - 85, the decision to screen should be individualized - it depends on overall health and prior screening history. Also, the patient should have a likely ten-year life expectancy. Plumas District Hospital, and Plumas County as a whole, have been lucky in that most primary care physicians are committed to educating their patients and recommending the appropriate screenings, said Jensen.
As mentioned, there are a number of screening tests available to patients. Dr. Jensen described all of them but, he said, “all roads lead to the colonoscopy,” which is considered the “gold standard” of screening tests for colorectal cancer. Besides needing to get a colonoscopy as follow up to a positive alternate screening in order to remove adenomas (pre-cancerous polyps) or cancer itself, all other tests have lower rates of detection/prevention.
That said, patients can be hesitant to get a colonoscopy, either because of the prep or the test itself. The list below will help you learn about the various tests out there and what’s good and bad about each one. You should talk with your primary care provider to determine which test is right for you.
Colorectal Cancer Screening Tests
Fecal occult blood test (FOBT) [how often?]: offers a 15% lower cancer rate and a 45% lower risk of death. A stool sample is put on a card, and chemicals are used to determine the presence of hemoglobin. If the sample changes color, that shows blood in the stool, a sign of cancer. In this case, you’ll need to get a colonoscopy.
FIT test (annually): an immunology test. It’s a different, more sensitive, way to detect blood, in which antibodies attach to the hemoglobin. This shows a 20% cancer reduction and 50% lower death rate. If the test is positive, you’ll need to get a
Barium enema: an older test that is typically used in third world countries, for example, where newer, better tests aren’t available.
Sigmoidoscopy (every 5 years): covers the first third of the area covered by a colonoscopy (the most common area to develop cancer). It’s usually done without medication and is quicker, cheaper, and safer than a colonoscopy. It results in a 37.5% reduction in cancer and death. Paired with a FIT or FOBT test, is offers a 50% reduction in cancer and 65% lower risk of death. You would do a FIT or FOBT tests first. If that’s positive, you’d get a colonoscopy. If it’s negative, you’d get a sigmoidoscopy. And, if that’s negative, your testing is complete. If the sigmoidoscopy reveals precancerous changes, you’d still need a colonoscopy.
Virtual colonoscopy (every 5 years): a CAT scan of the abdomen. It’s good at identifying larger polyps and cancers, which makes it fairly good. It uses a lot of radiation, however, and most insurances will not cover this expensive test. Again, if something is found, you’ll need a colonoscopy. Dr. Jensen noted that this test has real value if, for some reason, he isn’t able to “get all the way in” during a colonoscopy.
DNA test - e.g. Cologuard stool test (every 3 years): detects pieces of genetic code associated with cancer. It can
find code and come up with a positive result on occasion even if you don’t have cancer (false positives range from 8 - 13%). It catches about 42% of advanced adenomas (pre-cancerous polyps). It does, however, detect 92% of cancers.
This is a new test, and it’s likely to get better over time.
Colonoscopy (every 10 years): finds adenomas (pre-cancerous polyps), thereby preventing cancer before it starts. “We find it before you have it, and stop it,” explained Jensen. Colonoscopy screenings reduce your chance of getting cancer by 68% and the death rate drops by a stunning 80%. It’s considered the best of the tests. The downside is, it’s the most expensive (though most insurance covers it when done at the recommended time), it’s invasive, and it has a slight risk of danger: there’s a 1 in 1,000 chance of a serious complication, which includs perforation, hemorrhaging, reaction to medications used before or during the procedure, and a very small chance that other organs inside the abdomen could be damaged. For example, the spleen could get a tear. In general, insurance will pay for colonoscopies for patients 50 and over, but Dr. Jensen recommends that patients call their insurance companies to confirm coverage.
Colorectal Cancer Treatment
Cancer staging is determined by how much cancer is in the bowel and how much is outside of the bowel.
Stage 1: in general, it’s curable “endoscopically, or with surgery,” said Dr. Jensen. Stage 2: surgery may not get everything, so chemo is added to “clean up.” Stage 3: surgery won’t get everything, so a lot of chemo is added.
Stage 2 and 3: life will be extended, and some patients will be cured.
Stage 4: the disease has grown in other locations, advancing in the bowel and out of the bowel. Cancer at this stage is “thought to be non-curable,” according to Dr. Jensen. These patients will receive chemo and/or radiation in addition to surgery. Sometimes patients at this stage will receive a colostomy bag. There are a few new treatments on the horizon, said Jensen, but the above are the current protocols.
“At the advanced stage (of the disease), you question everything you do,” Dr. Jensen said. In effect, he asks himself, “Will this make a difference?” If, for example, the disease has spread to the lungs, that cancer will likely kill before the colon cancer does, “so there’s no point,” in any aggressive treatment. Life expectancy is highly variable at this stage, Dr. Jensen explained. “It depends on how responsive the patient is to treatment, where the cancer is, and how much there is. There’s a huge range. Some people will be dead in a week; some will last ten years.”
Rectal cancer and its treatment is different from colon cancer. Typically, patients will get radiation with some chemo upfront, followed by surgery, then more chemo - especially at Stages 2 and 3. The rectum is fairly fixed in place because of the layers of muscle, fat, and lymph tissue surrounding it. Because of this, it holds still and is a good target for radiation. Also, the surrounding tissue is more tolerant of radiation, which is meant to do enough damage to hurt the cancer.
In contrast, the colon is loosely attached to the edge of the abdomen, and there are also nearby organs that can be damaged by radiation. The colon, then, is a moving, and more sensitive, target. The downside of radiation in the rectum is that it can damage anal function, and the patient can end up with a colostomy bag for the rest of his or her life.
Dr. Jensen noted that, while the colorectal cancer rate is decreasing in the older population, it’s on the rise in the 20 - 50 year age group. This is a recent enough phenomenon that researchers aren’t sure why this is occurring. Dr. Jensen speculated that it could have something to do with bacterial flora or an increase in obesity. He said, also, that this recent trend is the reason several cancer societies have suggested screenings should start at age 45.
Certain populations also have an increased risk of colorectal cancer. Native Americans and black Americans have a higher rate of cancer at younger ages. Eskimos should start the screening process even earlier — at age 40. Dr. Jensen looks to the future when genomic health profiling advances to the point where it will indicate at what age an individual should start getting screened. When these genetic markers are identified, younger people who are at risk will be able to get screened.
Patients who have a “person who put them at risk” by having cancer or polyps removed, need to start their screenings “ten years younger than the person who put them at risk,” Dr. Jensen said. He noted that he removes polyps from about ten people per month. That’s ten people who potentially will not go on to get cancer. “That’s why the numbers are so good,” Jensen added. “Removing the place where cancer was going to start before it starts - it’s prevention. All the other tests are screenings.”
Dr. Jensen is so confident in the life-saving potential of the colonoscopy, he said the pap smear is the only other screening test that’s as good. It identifies areas on the cervix that can be cervical cancer, and these are removed. “It no longer kills women like it used to because of screening,” Jensen said. Skin cancer is another reliable life saver. “Identifying and removing tags and little spots makes a big difference.” But, most all other cancers aren’t identified until they’ve grown so large they’re visible or the patient is suffering symptoms.
Breast and lung cancers, for example, often grow for a long time before they are found, said Dr. Jensen. “With colon cancer, we can find it before you have it and stop it. It’s a preventable disease.” Having fought this disease for 25 years, Dr. Jensen wants to convince patients of the life saving difference colorectal screenings make. “Because it (colorectal cancer) is preventable, we certainly should try and prevent it, rather than get it and go on to die from it. In the United States alone, 147,000 people a year get it; 53,000 per year die of it — and it’s preventable. It’s a shame,” said Dr. Jensen. He hopes this article might offer people “on the fence the guidance and education they need to make the right choice.”