Misleading News on Colonoscopy for Colon Cancer Screening

I rarely take issue with research which is peer reviewed and published in prestigious medical journals but a study published in the New England Journal of Medicine regarding screening for colon cancer created more havoc and uncertainty about the worthiness of screening with a colonoscopy than is appropriate.

Michael Bretthaur, MD, PhD of the University of Oslo in Norway invited almost 85,000 adults aged 55-64 in Europe to participate in a screening colonoscopy or serve in a control group with no screening. Only 42% of those invited took the colonoscopy. Based on the large numbers in the study, the conclusion was that the procedure did little to reduce death from colon cancer over a 10-year period. This conclusion was noted by the international media and played up with the idea that maybe screening colonoscopy isn’t such a great tool? NBC and CBS nightly news covered it that way. CNN actually led with a misleading headline about it.

If you actually looked at just the data of those who had the procedure, it appears that colonoscopy reduced the incidence of colon cancer by 31 % and the risk of colon cancer related death by 50%. The message should have been “If you were screened with colonoscopy your chances of dying from colon cancer were reduced by at least 50%.”

There were problems with the study. The health care providers doing the colonoscopy were not as accomplished at finding polyps as the physicians who perform the study in the USA. The 10-year follow-up period of who developed colorectal cancer is considered too short a window for this particular disease which probably requires a 15-year observation window. The research team conducting the study will now be following the participants for another five years to correct this flaw. The numbers and conclusions are expected to change with the additional five years of data.

No sane person wants to prep for a colonoscopy and have the procedure. However. it is one of life’s necessary prevention evaluations. The media’s presentation of this study added great doubt to its efficacy. People will undoubtedly skip colonoscopy screening due to the way newspapers and TV news shows covered this study.

Colonoscopies save lives and by removing precancerous polyps with malignant potential save suffering too. I just had my colonoscopy. I hated every minute of the prep. The bowel cleansing preparation continued to upset my system for twelve hours post procedure. That said, it was worth every second of feeling uncomfortable to prevent a miserable disease.

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Artificial Sweeteners: Good for Weight Loss but Possible Increased Cancer Risk

J. L. Sievenpiper, MD, PhD of St. Michaels Hospital in Toronto, Canada and his associates published a review article in the Journal of the American Medical Association Network Open which looked at 17 controlled studies aimed at showing that using artificial sweeteners led to loss of weight, lower Body Mass Index (BMI) and reduction in cardiovascular risk factors. One week later, Charlotte Debras, a PhD candidate at the Sorbonne, and her colleagues published in PLoS Medicine a study showing that several of these products result in an increased risk of cancer. They noted that aspartame and acesulfame potassium carried the increased risk while sucralose did not.

Consumption of certain artificial sweeteners caused a 13% increased risk for developing obesity-related malignancies including colorectal, stomach, oral, liver, esophageal, breast, ovarian and prostate cancers. A 15% higher risk of obesity-related cancers was seen for aspartame alone and a 22% increased risk for breast cancer. They then looked at those consuming low doses of these sweeteners. They still faced a higher risk of cancers. Sucralose products did not carry a higher cancer risk at any dosage.

The message is clear. If you must consume artificial sweeteners, Sucralose is the best choice. Sucralose is used in Splenda and NutraSweet. The authors, from Paris, made it clear that they hoped a larger study of this issue would be undertaken to confirm their findings.

Multivitamins Do Not Reduce Invasive Cancer in Older Adults

Several years ago, a research study published in a peer reviewed journal claimed that taking a multivitamin daily (Centrum Silver) had positive benefits on the health of women health care workers taking part in the Women’s Health Initiative. A similar study hinted at positive benefits in reducing certain cancers in men including prostate cancer.

Since every male in the last two generations of my family had prostate cancer, I have been taking a Centrum Silver for men for years. I have blissfully been ingesting it daily with no ill effects I can remember.

It was with personal interest that I saw a synopsis of an article in the American Journal of Clinical Nutrition, March 16^th edition in which Howard D. Sesso, ScD., MPH, from Brigham and Women’s Hospital in Boston, and associates looked at daily multivitamin use and invasive cancers. They randomly assigned 21,442 US adults, free of cancer and cardiovascular disease, to receive a multivitamin. They then followed them for 3.6 years. These study participants were all 65 years of age or older – 1,266 were women and 8,776 were men.

Over the 3.6 years they were observed, there were 518 invasive cancers detected in the daily multivitamin group and 535 invasive cancers in the placebo group. In this group of senior citizens, taking the vitamin for less than 4 years, there was no clear-cut benefit in preventing invasive cancers.

 I am not sure what to make of this publication other than in seniors who start a multivitamin at age 65 or older daily you will not prevent invasive cancers. If they started it at 45 or 55 years old would the results be different?  For now, the recommendation remains the same to eat a healthy balanced diet filled with fresh fruits and vegetables, limited in fats, simple sugars, and sodium chloride and have regular checkups. My multivitamin bottle is still filled to the brim. I think I will continue to take them because no ill effects were reported in this study,

Cancer Detection Blood Test – Pros and Cons

For several years I have been following the development of blood tests drawn in a physician’s office which can be used to detect malignancies in their early stages. Recently, a publication discussed the proper use of four blood tests that already exist paired with a flow sheet or algorithm to identify those individuals most likely to develop pancreatic cancer. I am in the process of researching that study and learning how to introduce it into our office practice for my patients benefit.

Two weeks ago,  a wise, worldly, extremely disciplined, and health-conscious individual asked me if I would draw blood on him and send it to a particular lab for evaluation and detection of early cancers. I had not yet received any literature on this company or test, but it is certainly easy enough to draw blood and send it off. He provided the name of the firm and through the miracle of computers and the internet I found their website and information about the testing. This firm was in the fifth year and version of cancer detection.

They have learned that developing malignancies send out a signal through the bloodstream using genetic tools to announce their presence. Their genetic methylation testing procedures can detect these early signals. The company went on to say that for many cancers such as breast cancer, lung cancer, prostate cancer, colon cancer and skin cancers there are quality driven early detection screening programs available to patients and physicians. About two thirds of cancer deaths yearly occur in cancers with no early detection programs designed to find them. Their blood test was designed to do just that. The website for the company listed their research findings, the endorsement of several major national cancer centers in the United States and contained an educational video for doctors and patients.

It was clear from the video that if my patient were to receive this test, I would be a passive phlebotomist drawing her blood and sending it to the lab. I first was asked to establish an account and agree to receive the results and explain them to the patient. Thus, my role was no longer that of a passive good Samaritan. I was expected to be an interpreter of an innovative technology I knew little about.

The cost of the test was listed as $1250 but my patient assured me, she could get it for less at $955. The turnaround time from drawing the blood, to receiving results, is supposed to be less than two weeks. I called the Center for Medicare Services (CMS) and Florida Blue Cross Blue Shield and asked if this test would be a covered service. They both said it would not. I next asked this question of them and two Medicare expert consultants I have worked with for decades, “If the test reports a positive signal for an unexpected malignancy, will your insurance pay for the diagnostic testing to confirm or refute the labs indication of cancer being present.” They again said, “absolutely not”.

This means that if the blood test suggests the patient has pancreatic cancer, they will now need at least a CT scan of the abdomen with contrast for about $500 and an ERCP procedure including a gastroenterologist, anesthesia, nurse, and a facility fee for about $5000+. These costs will all be out of pocket and non-reimbursable by insurance. If these diagnostic tests fail to detect a malignancy, does it mean there is not one or, does it mean the test is so sensitive that it picked up the tumor prior to it being large enough to be detected? How often will you need to repeat these tests? No one knows yet.

Under the current program design, the findings of the blood test will become part of your permanent health chart and record. What will that due to future attempts to obtain health or life or disability insurance?

I am in no way trying to be negative about a medical breakthrough of extraordinary importance. I am just saying it’s incredibly early, expensive and there are many unanswered questions requiring research prior to being tested.

New Blood Test Aids in Lung Cancer Screening

The US Preventive Screening Task Force updated its recommendations in 2021 for screening patients with  increased risk for lung cancer. Current guidelines call for providing a low radiation dose CT scan of the lungs annually for patients 50- 80 years old who have a smoking history of twenty pack years (calculated number of packages smoked per day x number of years smoking) and are still smoking or have quit within the last 15 years. These expanded criteria reduced the age to 50 from 55 and pack years from 30 to 20 years.  The recommendation is based on research showing that these criteria reduce deaths due to lung cancer by 20% as seen in the National Lung Screening Trial.

Despite this recommendation, many smokers who meet these criteria never get tested. Access to CT scans is one problem along with financial costs. For this reason, a group of researchers at MD Anderson Medical Center, led by Sam Hanash, MD, PhD, professor of clinical cancer prevention, developed a 4-panel blood test to screen for lung cancer. Their four test blood panel results were published in the Journal of Clinical Oncology on January 7, 2022.

The researchers then combined the results of the blood test with low dose CT scans of the chest and found that the accuracy of this method was far more sensitive than performing lung CT scans alone in the groups recommended for the procedure by the USPTF guidelines. Using the blood test and the low dose CT scan of the lungs, they found 9.2% more lung cancer cases for screening and reduced referrals for further evaluation by almost 14%

The blood test is still in the research phase and not available commercially for screening just yet. It will have to go through the full Food and Drug Administration (FDA) approval and evaluation process first.

The panel included tests for surfactant protein B, cancer antigen 125, CEA and cytokeratin-19 fragment. Currently the Ca125 test and CEA are available through commercial labs but there were no comments or recommendations from the authors or reviewers about whether clinicians should be using those two tests now with low dose lung CT scanning for screening.

An Extra Tablespoon of Olive Oil Per Day May Keep Death Away

Dr. Marta Guash-Ferre’ and team at Harvard T. H. Chan School of Public Health evaluated whether substituting a teaspoon of olive oil daily to replace margarine, butter, mayonnaise and dairy fat led to a drop in the likelihood of death from cardiovascular disease, cancer, dementia and respiratory diseases.

Her team looked at 92,00 participants who were free of cancer and cardiovascular disease in 1990. Every four years, for the next 28 years of follow-up, the researchers assessed each person’s diet through a detailed questionnaire. Olive oil consumption was determined from olive oil used on salads, cooking, or used on breads and foods.

Their long-term calculations showed that olive oil consumption increased in the study participants during the test period while consumption of margarine decreased, and other fats stayed the same. Participants with higher olive oil consumption were more likely to be physically active, less likely to smoke, consumed more fruits and vegetables than lower olive oil consumers. When the researchers compared those with little olive oil consumption to those with the highest consumption, the high consumers had a 19% lower risk of death from cardiovascular disease, a 17%lower risk of cancer death, a 29% lower risk of death from dementia and an 18% lower risk of respiratory disease death. The study also concluded that substituting ten grams of olive oil per day (a bit less than one tablespoon) for other fats such as butter, margarine, mayonnaise, and dairy fat their death risk dropped by 8-34% from all causes.

In reviewing the data, its seems that their study group represented an extremely well-educated health-conscious group of individuals. Substituting olive oil for other fats is certainly a worthy goal based on these numbers and I will certainly aim to try it.

Sugary Drinks & Increased Colon Cancer

The Nurses Health Study II followed 95,464 nurses’ health from 1991- 2015. Principal researcher Yin Cao, ScD, MPH, of Washington University in St. Louis and co-researchers found that those women consuming two sugar sweetened beverages a day in adulthood had more than double the early onset colorectal cancer risk as those consuming less than one serving a week. The risk rose by 16% with each additional serving per day.

In adolescents aged 13-18, each serving per day increment was accompanied by a 32 % higher risk of early onset colorectal cancer. As adolescents reach adulthood, replacing these sugar sweetened beverages with artificially sweetened beverages, coffee or milk was associated with a 17-36% lower risk.

The diagnosis of colorectal cancer in those born around 1990, and risk of developing it, is twice as much risk of developing colon cancer and four times the risk of developing rectal cancer as in adults born around 1950. Cao and associates offered several theoretical reasons for the findings including the use of fructose corn syrup as a sweetener instead of real sugar. Fructose corn syrup is known to make changes to the intestinal wall making it more susceptible to carcinogens. And, it has been shown to cause intestinal tumors in mice.

The message is clear. Obstetricians, family practitioners, pediatricians and internists need to start asking about sugar sweetened beverages in our patient histories. Screening for colon and rectal cancer at a younger age with fecal globulin tests, Cologuard fecal genetic testing and fiber optic exams in a younger group is essential. Most importantly, we must educate teenagers and young adults about the dangers of these sugar sweetened beverages so they don’t give them to their friends and eventually their own children.

Aspirin Reduces the Risk of Several Gastrointestinal Cancers

With everyone focused on surviving the Coronavirus epidemic, it’s easy to miss articles dealing with issues other than COVID-9   The Annals of Oncology published a review study performed by Cristina Bosetti, M.D. and colleagues from Milan, Italy.  They performed a literature search examining studies looking at the relationship between aspirin consumption and gastrointestinal cancer.

They found that taking one or two aspirin per week was associated with a reduced risk of pancreatic cancer, colon and rectal cancer, squamous cell esophageal cancer, stomach cancer and hepatobiliary cancer.  When they looked specifically at colon and rectal cancer, they found the risk of developing the disease dropped with increased aspirin dosages. “An aspirin dosage between 75-100 mg a day was associated with a 10% reduction in a person’s risk of developing cancer compared to people not taking aspirin.  A dose of 325 mg a day was associated with a 35% reduction and a dose of 500 mg a day was associated with a 50% reduction in risk.

To obtain this type of risk reduction, patients had to be taking the prophylactic aspirin for a long time, at least 10 years. The ingestion of aspirin may have lowered the risk of intestinal cancer, but it carried with it the increased risk of bleeding.

Much has been written recently about the lack of protection against cardiovascular disease in patients without diabetes or documented heart disease who take daily aspirin. That may be true but there does appear to be a positive effect in preventing intestinal cancer. This is a complicated topic which should be discussed with your physician before embarking on a course of prevention.

PLCO Data Support Protective Effect of Aspirin in Preventing Deaths

In recent months, the US Preventive Task Force has recommended adults without diabetes or documented coronary artery disease avoid taking baby aspirin to prevent heart attacks and strokes. They believe the risk of bleeding outweighs the benefit derived. They still recommend aspirin prevention in men with known cardiovascular, cerebrovascular disease and diabetes.

The Prostate, Lung, Colorectal and Ovarian Cancer Trial (PLCO) just made the decision-making much more complex. In their study, reported in this month’s JAMA Network Open, they found that taking aspirin as infrequently as 1 to 3 times per month reduced the risk of all-cause and cancer related mortality compared to no aspirin in their study with 146,152 patient participants.

Weekly use of aspirin significantly reduced the risk of mortality from both GI and colorectal cancer and all mortality endpoints irrespective of how heavy you were. When the study looked at 12.5 years of aspirin use 1 to 3 times a month, compared to none, the all-cause mortality was reduced by 16%. The results were even more encouraging when aspirin was taken three or more times per week.

The PLCO Cancer Screening Trial involved participants aged 55-74 who were randomized to a cancer screening group or a control group at 10 United States Medical Centers. This review looked at men and women 65 years or older at baseline. While this study showed a beneficial effect of aspirin in the elderly, other recent studies have been less favorable. The ASPREE study, Aspirin in Reducing Events in the Elderly, found that individuals taking 100 mg of aspirin daily were at increased risk for all-cause mortality compared to those taking a placebo.

The decision to take low dose aspirin, or not, is something you should discuss with your physician so that you can tailor the situation and risks to your personalized needs.

Blood Test Detects Gastrointestinal Cancers

David Wolpin, M.D. MPH of the Dana-Farber Cancer Institute discussed with online periodical MedPage Today the results of his research on detecting gastrointestinal cancers with a simple blood test. The test is not yet commercially available and is still in its developmental stages. The blood test did not detect cancer in 2000 cancer free individuals but did find it in the 135 GI cancer patients being evaluated at the Dana-Farber Cancer Institute. In most cases they were able to pinpoint the location of the malignancy in the GI tract based on the testing used. The more advanced the cancer, the more accurate the blood test was.

The report was part of a larger study named the Circulating Cell-Free Genome Study. This is a multi-center trial looking at over 15,000 individual patients from over 142 different medical institutions. The hope is that as the sophistication and accuracy of the test are improved, the ability of physicians to detect cancers early would improve as well.

Dr. Wolpin reminds us that most cancers that occur in the gastrointestinal tract are difficult to find and screen for and are detected at an advanced stage. He hopes that lives can be saved by finding the cancers early with a simple blood test.