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.

March Is Colon Cancer Awareness Month

Colon CancerColon Cancer is still the second leading cause of death from cancer in the United States despite numerous advances in screening and early detection. It is a disease that is found more commonly in black Americans with 46.7 cases per 100,000 individuals as compared to 38.9 cases per 100,000 individuals for Caucasian Americans. Death from colorectal cancer occurs in every 21.1 cases for African Americans and only 14.6 cases for white Americans.

Even with these dismal figures the cancer death rate from this disease has decreased by 22 percent over the last decade. We attribute this to increased awareness and increased screening.

All individuals should report a change in bowel habits to their doctor immediately. Blood stained stool is a cause for an immediate call to your physician. Generally at age 40 all adults should be having a digital rectal examination as part of a checkup. Stool occult blood slides or stool fecal immunoglobulin slides are used to screen for microscopic gastrointestinal tract bleeding. These tests involve placing a small smear of stool on a slide and submitting it to the lab where it is tested for microscopic blood loss. Usually a CBC or complete blood count is performed as well since gastrointestinal blood loss in small constant amounts usually produces a low blood count or anemia of the iron deficient variety.

Screening colonoscopies are recommended for all non-Black Americans at age 50. Due to the increased risk of colon cancer in Black Americans we recommend that they start screening colonoscopies at age 45. If you have a first degree relative who had colon cancer or precancerous polyps we ask that you start your screening at an age that is 10 years earlier than your relatives disease became apparent.

For those individuals unwilling to have a screening colonoscopy we can offer a CT Virtual Colonoscopy. The preparation is simpler than for a colonoscopy but the radiation dosage involved is equivalent to receiving ten years’ worth of chest x-rays all at once. If the virtual colonoscopy shows a polyp or a mass you will then need to undergo a traditional colonoscopy for biopsy and removal preceded by a traditional pre- colonoscopy bowel cleansing prep.

Cologuard is a new and attractive stool test that detects abnormal DNA associated with premalignant polyps and cancerous tumors. It is fairly new but readily available.

Numerous lifestyle choices can influence your development of colon cancer. Tobacco use is associated with an increased risk, as is drinking more than moderate alcohol. Red meat intake is associated with an increased risk of colon cancer with a 20% increase per 100 gram increase in red meat per day. Regular exercise and intake of high fiber food helps to decrease your risk of developing colon cancer.

March is colon cancer awareness month. Speak to your physician about your risk of developing this serious disease and ways to prevent it from developing. You can use the visit to establish your own personalized colon cancer screening surveillance schedule.

New Test for Colon Cancer Screening Approved

Colon Cancer RibbonThe Cologuard test is the first DNA based screening test for colorectal cancer that has received approval for use from the FDA and preliminary approval by Medicare to cover the cost of the test. The test detects hemoglobin ( a component of red blood cells) and abnormal DNA in cells picked up by stool . A positive test indicates a need for colonoscopy to identify or eliminate colon cancer as a possibility. We currently screen patients with the fecal occult blood slide test and the more sophisticated fecal immunochemical test or FIT. The new Cologuard detected 92% of colon cancers and 42% of advanced adenomatous colon polyps as compared with 74% and 24 % for FIT. While the Cologuard test was accurate in picking up more colon cancers than the FIT it had slightly more false positive tests than the traditional Fecal Occult Blood Slide.

The Center for Medicare Services ( CMS) is proposing allowing coverage of the DNA test once every three years for beneficiaries who are 50 – 85 years old, asymptomatic and have average risk of colorectal cancer. The new test adds another non-invasive means of screening for colon cancer. We will need to see the cost of the test to the individual patient and accumulate more data on its accuracy in the near future before it becomes a mainstay of colon cancer screening.

At the same time that Cologuard was approved, researchers at the University of Michigan in Ann Arbor published in the online journal Cancer Prevention Research, information showing that evaluation of the pattern of bacteria in the colon of patients improved performance and detection of colon cancer by more than 50% as compared to the Fecal Occult Blood Test alone. Researchers using DNA sequencing and polymerase chain reaction methods were able to identify distinctly different patterns of bacteria in colon cancer and pre-cancerous polyps than in patients with no colon lesions.

It is clear that as researchers apply DNA technology to cancer screening their ability to detect abnormalities and avoid invasive colorectal screening will improve. At the moment recommendations for screening colonoscopy at age 50 remain but as science moves forward that too may soon change.

Low Dose Aspirin Cuts Colon Cancer Risk in Women

AspirinNancy Cook, SCD of Brigham and Women’s Hospital in Boston and colleagues reported in the July 16, 2013 issue of the Annals of Internal Medicine that data from the Women’s Health Initiative including 39,876 women 45 years or older, who were randomly assigned to take 100 mg of aspirin every other day for ten years, experienced a 20% reduction in the risk of colorectal cancer. The study did not show that there was an all-cause reduction in mortality .

The very conservative US Preventive Services Task Force currently recommends aspirin in Women 55 – 79 only if potential benefits are greater than harms. The aspirin group did have more bleeding from peptic ulcers and gastrointestinal bleeding. The article was accompanied by an editorial comment by Peter Rothwell, MD, PhD of the University of Oxford. He felt that the risk of bleeding and the fact that there was no all-cause mortality reduction, or risk in all cause cancer reduction, should result in a tempering of suggestions for widespread use of aspirin in healthy middle-aged women. MedPage Today, the online Journal of the University Of Pennsylvania School Of Medicine, ran a comment from Dr. Randal Burt, MD, a gastroenterologist at the Huntsman Cancer Institute who felt that this was one more piece of evidence that aspirin can reduce colorectal cancer.

It is clear that there are multiple studies showing that aspirin can reduce the risk of colorectal cancer. There are studies showing it reduces the risk of a stroke in women as well.

Like all decisions to take or prescribe a medication, the risks and benefits must be examined first. It is clear to me that in a woman with a strong family history of colorectal cancer, and little or no history of gastrointestinal or systemic bleeding, an aspirin with close monitoring should seriously be considered.

Traditional Colonoscopy vs. No Laxative CT Colon Exam

Research radiologists at the Massachusetts General Hospital in Boston evaluated the accuracy and detail of imaging the colon (a virtual colonoscopy or colonography) with no laxatives as preparation and comparing it with traditional colonoscopy.  There are clear evidence based guidelines suggesting that all low-risk men and women have a screening for colon cancer with a colonoscopy at age 50.  If that study is normal they are directed to repeat it every 10 years.  Routine screening colonoscopies are discontinued after age 80 years old.  There is no question that screening colonoscopies save lives from colon cancer.  There is no question that the laxative taken the day before to clean you out, plus the actual procedure, are reasons that individuals avoid going for colon cancer screening.

The study directors fed their patients a low fiber diet before the scan. The patients drank an oral contrast material that marked stool feces and allowed the radiologists to distinguish colon abnormalities from retained feces and stool.  This virtual colonography was excellent at detecting larger colon adenomas of 10 mm or larger picking up 91% of the existing lesions as compared to 95% with traditional preparation and colonoscopy. The difference between the 91% on virtual colonography and 95% on traditional prep and colonoscopy was not felt to be statistically significant.   The virtual colonography didn’t do as well at detecting the smaller growths.  Researchers pointed out that “the vast majority of polyps that impact cancer and survival outcomes are 10 mm or larger.”  They went on to say that the “the laxative free method would likely be worthwhile as a way to reach the many adults whose strong aversion to laxative bowel preparations stops them from getting screened.”

Clearly getting screened is always preferable to no screening.   The laxative free virtual colonoscopy was not as good as the traditional colonoscopy at finding smaller lesions.

The data in this research study were based on the skill and experience of three radiologists only. Previous studies have emphasized the need to have an experienced radiologist interpret these studies.  The researchers did not discuss the radiation exposure, which is significant, with the virtual colonoscopy.   They additionally did not mention the cost which many health insurance companies will not pay for at this time.

Despite these issues it is wonderful to have another tool in the fight against colon cancer especially to offer to those patients who have said they will “never” have a colonoscopy.

Screening Colonoscopy

A recent study proved what physicians and scientists suspected for years – early detection of colon cancer by screening colonoscopies saves lives. The current guidelines call for asymptomatic individuals to begin having a digital rectal exam at age 40. If there are no high risk situations for the patient then it is recommended that they start having screening colonoscopies at age 50. If their screening colonoscopy is negative then they can start scheduling follow-up colonoscopies for screening purposes every ten years.

Experts are now suggesting we stop performing screening colonoscopies at age 80.  At that age, the risk of a complication from the preparation for the test, plus the risk of a complication of the test (primarily perforation of the colon) make the risks far higher than the benefits. We certainly would continue to screen with annual digital rectal exams, and fecal occult blood tests, but the decision to perform a colonoscopy would be individualized based on the patients health, quality of life and expected longevity.

For high risk individuals, those with inflammatory bowel disease (Crohn’s Disease or Ulcerative Colitis), a history of polyps or a family history of colon cancer or inflammatory bowel disease the schedule is more stringent and starts earlier. The same would apply to individuals with a family history of premalignant colon polyps.  The interval of time between colonoscopies is shortened as well. For example, if a patient had a first degree relative who developed colon cancer at age 50 we would start screening that patient at age forty.

Recent studies and evaluations of screening colonoscopies have actually shown that primary care physicians are recommending colonoscopies too frequently with too short of a time interval between studies.  If you are low risk and have no symptoms you begin at age 50 and space the colonoscopies every ten years if the studies are negative.

Within the past few years radiologists have developed the CT Colonoscopy. The prep is less arduous than a traditional colonoscopy. The films, when read by an experienced radiologist, are as detailed and accurate as a fiber-optic traditional colonoscopy. The down sides are the amount of radiation you are exposed to and the need to do a traditional colonoscopy to biopsy any suspicious lesions found on the CT Colonoscopy. Cost is a factor as well with many insurance companies refusing to use this technology for screening purposes.