The American Cancer Society and Colorectal Cancer Screening

Colorectal cancer is the fourth most common cancer with 140,000 diagnoses in the nation annually. It causes 50,000 deaths per year and is the number two cause of death due to cancer.

Colorectal cancer screening guidelines have called for digital rectal examinations beginning at age 40 and colonoscopies at age 50 in low risk individuals. An aggressive public awareness campaign has resulted in a marked decrease in deaths from this disease in men and women over age 65.

The same cannot be said for men and women younger than 55 years old where there is an increased incidence of colorectal cancer by 51% with an increased mortality of 11%. Experts believe the increase may be due to lifestyle issues including tobacco and alcohol usage, obesity, ingestion of processed meats and poorer sleep habits.

To combat this increase, the American Cancer Society has changed its recommendations on screening suggesting that at age 45 we give patients the option of:

  • Fecal immunochemical test yearly
  • Fecal Occult Blood High Sensitivity Guaiac Based Yearly
  • Stool DNA Test (e.g., Cologuard) every 3 years
  • CT Scan Virtual Colonoscopy every 5 years
  • Flexible Sigmoidoscopy every 5 years
  • Colonoscopy every 10 years.

Their position paper points out that people of color, American Indians and Alaskan natives have a higher incidence of colon cancer and mortality than other populations.  Therefore, these groups should be screened more diligently. They additionally note that they discourage screening in adults over the age of 85 years old. This decision should be individualized based on the patient’s health and expected independent longevity.

As a practicing physician these are sensible guidelines. The CT Virtual Colonoscopy involves a large X irradiation exposure and necessitates a pre- procedure prep. Cologuard and DNA testing misses few malignancies but has shown many false positives necessitating a colonoscopy. Both CT Virtual Colonoscopy and Cologuard may not be covered by your insurer, and they are expensive, so consider the cost in your choice of screening.

I still believe Flexible Sigmoidoscopy must be combined with the Fecal Occult Blood High Sensitivity Testing and prepping.  Looking at only part of the colon makes little sense to me in screening.

Colonoscopy is still the gold standard for detecting colorectal cancer.

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.

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.

“Colonoscopies Are Overdone In The Entire Population.”

Current recommendations by the American College of Gastroenterology call for colonoscopy as a screening test for colon cancer beginning at age 50 for Caucasians and 45 years old for African Americans. If the initial test is negative, and you have no symptoms, the recommended interval for follow-up colonoscopy is 10 years.  Despite this, a recent study published in the Archives of Internal Medicine revealed that nearly half of the the Medicare patients with negative findings on colonoscopy underwent repeat exams much sooner than the guideline recommended interval of 10 years.

The study looked at 24,000 Medicare enrollees who had a negative colonoscopy from 2001 through 2003.  Forty six percent of these individuals had a repeat exam in less than seven years.  According to lead author James S. Goodwin, M.D. of the University of Texas Medical Branch in Galveston, there was “no clear indication for the early repeated examination “in just under half of the recipients.   He said that even in patients 80 years of age and older repeat exams were done within 7 years in 32.9 % of the study group even though these patients were much more likely to die of something other than colorectal cancer in the near future.

Goodwin and his associates were surprised by the frequency of the repeat colonoscopies since Medicare regulations preclude reimbursement for screening colonoscopy within 10 years of a negative examination result. Despite this, only 2% of the repeat exams were denied by Medicare and not paid.

Brooks Cash, M.D., chief of medicine at the National Naval Medical Center in Bethesda, MD said, “I think colonoscopies are overdone in the entire population. “  He believes some of the frequent studies are provider driven and many are patient driven.

Colonoscopy is an invasive test with risks. The preparation can lead to fluid and electrolyte and volume problems in some individuals and the chance of a bowel perforation is rare but always present.  Patients need to talk to their personal physician about the need for a follow-up colonoscopy and the appropriateness of the timing suggested by the gastroenterologist before scheduling one.

Smoking Increases the Risk of Breast Cancer, Lung Cancer and Colon Cancer in Women

The Surgeon General of the United States issued another report on the dangers of smoking and its addictive potential last year.  At the time of release I was quite skeptical about the cost of the report and the need to remind Americans again that smoking is dangerous for you.  Then along comes a detailed review of the National Surgical Adjuvant Breast and Bowel Project. According to Stephanie Land, PhD, of the University of Pittsburgh, long-time smokers had a 59% increase in the risk of invasive breast cancer compared with nonsmokers.  The study looked at the links between four types of malignancy: breast, lung, colon, and endometrial cancer with smoking, alcohol use and leisure time activity.  The findings suggested that:

1.       Women who had smoked between 15 and 35 years had a 35% increase in the risk of breast cancer compared to non smokers. In that same group, if a woman smoked more than a pack a day she had a five – fold higher risk than non smokers.

2.       Women who had smoked 35 years or more had a 59% increase in the risk of breast cancer. These long-term smokers had a 30 times higher risk of lung cancer than non smokers.

3.       The risk of colon cancer among long–term smokers was five times higher than among non smokers.  A drink of alcohol a day reduced the risk of colon cancer by 65% compared to non drinkers.

4.       Inactive women had a 72% increased risk of uterine endometrial cancer compared to active participants in the study.

The study of almost 14,000 women highlighted the benefits of improving life style choices.  While researchers search for drugs and medication to prevent these life threatening illnesses, the study pointed out the benefits of altering the life style choices of women to prevent the development of cancer.

It is clear that smoking prevention and smoking cessation programs can do far more to prevent these cancers than pharmaceuticals. With cutbacks on funding for public health and the elimination of most health and hygiene classes in middle schools and high schools due to financial constraints, I wonder if we are being penny wise and pound foolish.