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Colonoscopy: two points worth mentioning

 

I have been working on this article for several days trying to determine the ideal message to focus on. As you may know, March is designated as Colon Cancer Awareness month. Although our professional societies have been promoting the need for colon cancer screening for more than 20 years, I wonder who is listening to this advice and what more do we need to say. There were two thoughts that came to mind:

My first point is to address the age of a first colon screening. At two recent community dinners, I spoke about colon cancer screenings. The audience was mostly retirees. Where were all the “young” people? Colon cancer is not just your grandparents’ disease. It is occurring more and more in young adults 40 to 50 years old. I have even found it in a 16 year old with no family history of colon cancer! There is a very disturbing trend in the U.S. of finding colon cancer and advanced pre-cancerous polyps in a much younger demographic with no family risk factors. These cancers are frequently well-advanced when diagnosed. Young adults can’t just sit tight and avoid the question of colon cancer screening until they reach the magic age of 50. Earlier screening is undoubtedly worth considering. Many are now advising to begin colon cancer screening by age 45. Certainly, if any concerning symptoms arise before then, the symptoms need to be checked out.

Why colon cancer is developing at a much younger age (and with more aggressive features) is a question still unanswered. Diet and environment probably play an important role, perhaps even more so than a family history of colon or rectal cancer. Warning signs of bleeding, anemia, a change in bowl habits, significant abdominal pain and unexplained weight loss should not be ignored, regardless of the person’s age!

Secondly, I want to address some new technologies in colon cancer detection and ask whether they should even be used for screening, or in place of the “Gold Standard” colonoscopy exam.

Much effort has focused on how to make colorectal cancer screening and detection easier to perform, more readily available, less costly and with higher rates of polyp/cancer detection. Ideally, the test of choice would be simple, reliable and something the patient would willingly perform. Well, despite what you might see and hear in the media, we aren’t there yet. Is new always better? Perhaps not.

One test garnering a lot of attention is a commercial product that tests for abnormal DNA in the stool. The TV ads proclaim “Get, Go, Gone” as the convenient alternative for “low risk patient” colon cancer screening. It is a neat concept, but it misses the point. This is really a test for colon cancers. Their data shows it misses over 30 percent of the serious pre-cancerous polyps. It even misses 9 percent of the cancers! That is not acceptable. This is an example of how new technology can take us three steps back. I don’t want my patients waiting until they develop colon cancer. The idea is to detect the pre-cancerous polyps BEFORE they become cancerous.

Colonoscopy remains the “gold standard” as it is the ONLY test that allows detection AND removal of precancerous lesions (polyps). It has the highest sensitivity for detecting polyps and cancer which means it is more likely to detect a cancer or polyp than any other test. And isn’t that our goal? Colonoscopy is “invasive” — basically a minor surgery. Fortunately, with sedation most patients have little or no recollection of the procedure. The major complaint by patients is usually the required pre-procedure liquid diet and colon purge. Technology has helped in this regard as several “low volume” preps are now available and much-better tolerated.

To be complete, I did want to mention one other “newer” screening option. A recent report has suggested that performing a yearly FIT test (test for “human” blood in the feces) can be comparable to a colonoscopy for finding large polyps and cancers. It is simple to do but lacks the ability to detect “flat” polyps and its sensitivity for polyps and cancers depends on these lesions bleeding. It also requires patients to perform yearly exams. As it is, less than 50 percent of patients return these stool cards to their physicians. Not a very useful test if it doesn’t get performed.

Hopefully, the importance of colon cancer screening is clear in your mind even if you are under the age of 50. Talk to your healthcare provider to determine the most appropriate screening exam/regimen for your situation. And please don’t ignore any concerning symptoms. You just never know.

Thomas Ruffolo, MD, is a gastroenterologist with Vidant Gastroenterology in Washington. If you have any questions or concerns about your risk for certain cancers, contact your local provider.