Ep. 28 – LiveWell Talk On…Colon Cancer Trends & Screening (Dr. Dean Abramson & Joan O’Connor, RN)
Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health – St. Luke’s Hospital
Dr. Arnold: This is LiveWell Talk On…Colon Cancer trends and screening. I’m Dr. Dustin Arnold, chief medical officer at UnityPoint Health – St. Luke’s Hospital. Colon cancer is the fourth most commonly diagnosed cancer in the United States and is the fifth most commonly diagnosed cancer at St. Luke’s. Colonoscopy is the most common form of screening for colorectal cancer. However, alternative screening options have surfaced over the years leading to some confusion about what exactly is the best modality to screen for colon cancer. Here to tell us more about colon cancer and screening recommendations is Dr. Dean Abramson with St. Luke’s Gastroenterology and Joan O’Connor, nurse manager of endoscopy services at St. Luke’s. Thanks for coming by.
Joan O’Connor: Thanks for having us.
Dr. Abramson: Thank you.
Dr. Arnold: March is colon cancer month and so it brings attention to go blue, I believe is the color, correct Joan?
Joan O’Connor: Yup, go blue day!
Dr. Arnold: So I think there’s a lot of confusion, particularly if you watch TV, about Cologuard, FIT testing whether or not to get a colonoscopy. I think those TV ads are misleading on some level. But what are some recent trends? Have you seen how this is impacting people’s willingness, Dr. Abramson, to get a colonoscopy?
Dr. Abramson: Well, there’s certainly more reticence to get a colonoscopy when people perceive that there are alternatives to it. Such as the Cologuard, which is on television advertisements so frequently. Particularly during the daytime and evening hours when people at the age for screening are watching. So I think it has had a bit of an adverse impact on the number of people willing to undergo colonoscopy. And moreover, I think that there’s some misrepresentation for the Cologuard. Although if you see the fine print there are some warnings there. But I think the larger question is, yes we’d like to, detect colon cancer. But our primary goal is to prevent colon cancer. And colonoscopy was demonstrated to do that more than 20 years ago. And it’s kind of evolved. But the national polyp study, that was released in 1993 showed that it had the ability to prevent colon cancer when used as a population screening tool. So we’d really like to detect precancerous polyps before they become colon cancers.
Dr. Arnold: And at what age would a patient need to consider a colonoscopy for screening?
Dr. Abramson: Well, typically a screening of average risk individuals begins at age 50. Earlier if there’s a family history of colon cancer in a parent or a sibling. But that may be shifting to a younger age now because probably the thing that we’re seeing now in the last few years. Has been quite striking, is that the young onset colon cancers. So meaning in the fourth and fifth decades, starting at age 30 and age 40. And over the past 10 years, the incidents of early onset colon cancer has been increasing 2-3% a year, particularly for rectal cancer. So cancer of the colon that’s low down. So unfortunately, insurance coverage doesn’t necessarily catch up with what we’re seeing. So a lot of people may desire to start screening at age 45. But most insurance companies still don’t allow for that. Even though the American Cancer Society has issued an edict that it’s appropriate. And we knew even before that, that African Americans were at increased risk, that they’d get earlier onset colon cancer. That’s more advanced. And insurance companies, we’re never willing to allow for screening there before age 50 either.
Dr. Arnold: So that’s a trend that you’ve observed this younger age presenters with colon cancer?
Dr. Abramson: Absolutely, absolutely. And it’s documented. It’s a true trend. The reasons for it are unknown, speculated that it has to do with diet and lifestyle. But again, that’s just speculation.
Dr. Arnold: What are the common lifestyle measures somebody could take, diet and lifestyle to help reduce their risk of colon cancer?
Dr. Abramson: Well, the good news is that they’re good recommendations to reduce many diseases. So definitely, no smoking because colon cancer is a tobacco related disease. Exercising, weight loss, avoiding red meats, highly processed meats, diets that is high in fiber and vegetables are all reasonable measures that will not only reduce the risk for colon cancer, but also for other diseases like cardiovascular problems.
Dr. Arnold: And what is the most common presenting symptom with someone that is having colon cancer? If they have a concern, how would it present?
Dr. Abramson: So unfortunately, the most common presentation is to be asymptomatic. So most people with colon cancer, have absolutely no symptoms or signs of disease. But were they to have considerations they include rectal bleeding, change in bowel habit, abdominal pain, unexplained weight loss.
Dr. Arnold: Joan, we’re going to come to the preps here real quick, but as far as the Cologuard, how does that fit into your practice? How do you use something, this noninvasive sort of testing?
Dr. Abramson: So again, Cologuard is a test. You see the man in the box, you collect your stool specimen, send it off in the mail and get the result back. What it’s looking for is DNA markers that are common to colon tumors and also a test for blood in the stool as well. So it’s going to detect 92% of colon cancers present. So right there, that’s a bit of a red flag. Is that really good enough? You’re going to miss 8% of colon cancers present at the time of the test. Moreover, it’s going to miss 40% of advanced polyps of the colon that have the potential to become colon cancers within the next one to two years. Although Cologuard is approved for insurance coverage every three years. So again, it comes back to yes, we’d like to detect colon cancer, but we’d really like to prevent it. So we’d like to remove these precancerous polyps before they ever become cancer. So as far as I’m concerned, it doesn’t have a great place in our diagnostic strategies when we come back to the idea of removing polyps before they become cancers.
Dr. Arnold: That’s a good point. I think often we wait until we have problems, not just with colon issues, but just in general in life. And that’s good advice. I guess the analogy I use with patients is the Cologuard will detect smoke, but it doesn’t tell you whether or not there’s fire. And the colonoscopy will put the fire out. So, you know, go with the test that’s going to give you the most benefit.
Dr. Abramson: Yeah. I mean we have to come back to the fact that colon cancer is fairly unique in that there is this precancerous lesion that in most cases precedes the actual cancer, that precancerous lesion being the polyp. So you remove that polyp and we know that that markedly reduces the chance to develop colon cancer in the future, particularly if you go through a periodic repeat examination. So it offers us a unique chance to intervene as opposed to breast cancer or prostate cancer where there is no precursor lesion. So we’re kind of blowing that chance if we use Cologuard.
Dr. Arnold: Absolutely. Now Joan, walk us through what it takes to get prepared to take a colonoscopy. Certainly there’s, I think it’s urban myth. I don’t think the prep is as terrible as people think, but walk us through that.
Joan O’Connor: Yeah, I’d say the majority of our patients tolerate the prep very well. But it’s just very important to follow the doctor’s instructions on the prep. And that’s starting three days prior to have a decrease in your fiber intake with your food. That makes it easier to prep. So on the day before when you do prep, things will go through better for you. We also are doing a split prep, which has proven to be a better prep. So you only drink half of the prep the night before. And half the morning before you come. So that the volume is cut in half in two different stages. So it is more tolerable for you.
Dr. Arnold: And the prep is important to get the benefit of the procedure, correct?
Joan O’Connor: Right, right. So we need to flush that colon out, make sure that there’s no fecal matter left in there. And that it’s nice and clear because if there’s anything remaining in there, we could miss the start of a polyp or a precancerous lesion.
Dr. Arnold: That’s good to know. And like most things compliance can add to greater benefit to the patient and the physician performing the procedure. Tell us about the recovery. I’m 50 this year, so that’s something I need to get done. But miss the whole day of work, walk us through that.
Joan O’Connor: Yeah, because you’ll be sedated for the procedure. You will have some restrictions. You won’t be able to drive for 24 hours. You shouldn’t go back to work or make any major decisions. So the recovery is a good 24 hours afterwards. So after the procedure, you’re in our department for about an hour. We just wanted to make sure that you’re waking up, your vitals are stable, you’re able to drink fluids without getting sick to your stomach. So it’s an hour recovery in the hospital, but you are restricted from driving or making any major decisions for 24 hours after the procedure.
Dr. Arnold: Okay and then Dr. Abramson, if during the procedure a pathology is found, whether it’s a polyp, can you take it off at that time?
Dr. Abramson: So if we find polyps, we remove them unless they’re extremely large and not amenable to endoscopic resection. So anything that’s reasonable to remove, we will remove. Not all polyps are pre-cancerous and by and large we can’t tell the difference simply by looking at them. So anything we remove is sent to the pathology department. And the sort of follow up that people would get is based upon the type of polyps they are, the sizes and numbers of them, whether they contain high grade elements or not. So typically if someone had a small precancerous polyp, they’re going to need another colonoscopy in five years. If they have multiple and larger or more high grade polyps, then maybe every two to three years for the next exam. If we find a colon cancer, that’s something that needs to be handled surgically. If we’re highly suspicious that something is cancerous or not amenable to removal, we actually perform, interoperative tattooing. Where we put dye into the wall of the colon. So it’s a lesion that can be easily found by the surgeon from the outside.
Dr. Arnold: Outstanding. I actually was not aware of that. We talked about what age to start to have a colonoscopy. Is there an age where it’s no longer needed? Does it get to be an age where you just say the chances of you dying from colon cancer are low enough that I don’t think we need to repeat this test?
Dr. Abramson: So actually the incidence of both colon polyps and colon cancer goes up with age. So I think there’s a mistaken belief out there that, Oh, I hit page 75. I can’t get colon cancer anymore. And that’s exactly wrong. But it becomes an economic calculation. So say someone has been a good patient and had a screening colonoscopy every 10 years, beginning at age 50, they’ve never had a polyp. We will typically quit after age 75 but that’s not because they’re not at risk. That’s because economically, it doesn’t make as much sense because we like to say that people should have another 5 to 10 years of healthy lifetime ahead of them to warrant going through a colonoscopy for screening purposes. Very different in terms of people who are in a higher risk group. Be it a family history of colon cancer or a personal history of precancerous polyps. Typically we’ll keep going until age 80 or so for those patients. But again, there are some 50 year olds who are simply in too poor health to undergo a colonoscopy. And there are some 76 year olds who are in phenomenal health, never been in the hospital or anything in their lives. And you know, an argument can be made, that they have longevity and that they are a good candidate for screening tests.
Dr. Arnold: Yeah. I placed a lady in the hospital last weekend that was 96 and this is the first winter she hasn’t shoveled her own driveway. And she was disappointed in herself that she couldn’t make that happen. So that’s impressive. Joan, did you have anything to add about perhaps scheduling the colonoscopy?
Joan O’Connor: Yes. So you want to go through your primary care physician. They’ll help you get that scheduled or call that gastroenterology office and it’s typically very easy to get it scheduled and it’s at your convenience. You’ll have to bring in a responsible adult with you to drive you home. So that’s what’s really important. And that they need to be with you once you get home. We just want to be safe for you. Safe for all of our patients when they go home and they’re slightly sedated.
Dr. Arnold: Yeah. And that’s from the medications used during the procedure, right? Not the procedure itself that causes that, correct? Let’s be clear on that.
Joan O’Connor: Correct. Yes. Yes.
Dr. Arnold: What if I’m a 50 year old that doesn’t have a regular family doctor? Can I get hooked up with that through your department?
Joan O’Connor: You can give us a call and they will direct you to where you can schedule the procedure, but you would come to our department for the procedure. But you do need to connect with that UnityPoint gastroenterology office to make that schedule.
Dr. Arnold: What’s the number for your department, Joan?
Joan O’Connor: My number is (319) 369-7301.
Dr. Arnold: Okay, and Dr. Abramson, what’s the number for the gastroenterology office?
Dr. Abramson: So you can call our office at area code (319) 366-8695. And ask for one of the screening nurses.
Dr. Arnold: Okay, outstanding. Well this is great information, but as we wrap up, I wanted to ask both of you a question to close. How did you end up in gastroenterology, Dr. Abramson?
Dr. Abramson: Well, I actually completed my training right before screening colonoscopy took off. So I don’t know that we ever imagined it being something that would be become so routine. So I actually went into it because I liked digestive diseases. I was interested in inflammatory bowel disease and to a somewhat lesser extent, interested in all the procedures that are involved with our specialty. But certainly the scope of what we do, no pun intended, has shifted quite a bit because we now spend the majority of our time doing colonoscopy for screening and surveillance purposes. But it’s a great field and a variety of diseases that we look at and changing tumor biology and new diseases always presents challenges for us.
Dr. Arnold: And you’ve seen the technology advance with the procedure itself.
Dr. Abramson: The technology has certainly advanced some of the procedures that we do have changed. So yeah, it keeps you young.
Dr. Arnold: Well, that’s important. And Joan, as long as I’ve known you, Joan, you’ve worked up in endoscopy, what brought you to endoscopy?
Joan O’Connor: Well or me it was a personal interest. I have a family that has a polyposis. I have three people in my family that develop polyps frequently. And so I thought if I could be in this field, I could see the new technologies and it could really benefit my family.
Dr. Arnold: Well that’s great. Certainly a great team to work with and you’re one of the crown jewels of St. Luke’s Hospital. Thank you so much for taking the time to talk about this. Again, that was Dr. Dean Abramson with St. Luke’s gastroenterology and Joan O’Connor, a nurse manager of endoscopy services at St. Luke’s Hospital. More information or to schedule a colonoscopy, talk with your primary care provider or contact St. Luke’s gastroenterology and Joan, what was that number for you?
Joan O’Connor: For the digestive health center, it’s (319) 369-7301.
Dr. Arnold: And Dr. Abramson your clinic?
Dr. Abramson: For the gastroenterology clinic, (319) 366-8695.
Dr. Arnold: If you have a topic you’d like to suggest for our Talk On podcast, shoot us an email at firstname.lastname@example.org. We encourage you, tell your family, friends, neighbors, strangers about our podcast. Until next time, be well.
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