UPDATED GUIDELINES LOWER COLORECTAL CANCER SCREENING AGE TO 45 YEARS
Updated guidelines from the American Cancer Society recommend that all adults at average risk for colorectal cancer BEGIN screening for the disease at the age of 45 years.
New data is showing a rising trend of colorectal cancer incidence among younger patients.
The researchers recommended that average-risk adults begin screening for colorectal cancer at age 45 years, either by colonoscopy or stool-based test. This was a qualified recommendation, meaning that although the guideline development group had identified a clear benefit from screening at a younger age, there was “less certainty about the balance of benefits and harms.
Researchers maintained a STRONG recommendation for regular screening for adults aged 50 years and older.
The group also made qualified recommendations that all patients aged 75 years or younger with a life expectancy of at least 10 years should undergo regular screening; that patients aged 76 through 85 years should base their screening choices on personal preference, health status, life expectancy and screening history; and that patients aged older than 85 years should discontinue screening.
The American Cancer Society recommended a variety of possible screening methods. These methods were all given equal weight, and can be used depending on patient preferences or a patient’s access to a specific method.
The recommended methods were:
- fecal immunochemical testing every year;
- high-sensitivity, guaiac-based fecal occult blood testing every year;
- multitarget stool DNA testing (Cologuard) every 3 years;
- colonoscopy every 10 years;
- CT colonography every 5 years; or
- flexible sigmoidoscopy every 5 years.
Updated guidelines from the American Cancer Society recommend that all adults at average risk for colorectal cancer BEGIN screening for the disease at the age of 45 years.
New data is showing a rising trend of colorectal cancer incidence among younger patients.
The researchers recommended that average-risk adults begin screening for colorectal cancer at age 45 years, either by colonoscopy or stool-based test. This was a qualified recommendation, meaning that although the guideline development group had identified a clear benefit from screening at a younger age, there was “less certainty about the balance of benefits and harms.
Researchers maintained a STRONG recommendation for regular screening for adults aged 50 years and older.
The group also made qualified recommendations that all patients aged 75 years or younger with a life expectancy of at least 10 years should undergo regular screening; that patients aged 76 through 85 years should base their screening choices on personal preference, health status, life expectancy and screening history; and that patients aged older than 85 years should discontinue screening.
The American Cancer Society recommended a variety of possible screening methods. These methods were all given equal weight, and can be used depending on patient preferences or a patient’s access to a specific method.
The recommended methods were:
- fecal immunochemical testing every year;
- high-sensitivity, guaiac-based fecal occult blood testing every year;
- multitarget stool DNA testing (Cologuard) every 3 years;
- colonoscopy every 10 years;
- CT colonography every 5 years; or
- flexible sigmoidoscopy every 5 years.
COLONOSCOPY
A TEST THAT CAN SAVE YOUR LIFE
Hated your last colonoscopy prep?
Putting off having a colonoscopy because the horror stories you have heard about drinking the liquid prep?
Well here is the good news. There is a tolerable prep available.
Not all gastroenterologists will allow you to switch from the prep they like using, but no harm in asking them if this is appropriate for you.
MIRALAX - GATORADE COLONOSCOPY PREPARATION
Purchase these over the counter laxatives:
1. GATORADE 02 (64 ounces) of lime-lemonade or other clear Gatorade (two 32 oz. bottles)
2. DULCOLAX 5mg tablets (four tablets)
3. MIRALAX BOTTLE 238 grams (over the counter only)
4. MAGNESIUM CITRATE 10 oz bottle (lemon-lime flavor) 2 bottles need
The DAY BEFORE your colonoscopy:
Drink only clear liquids. Absolutely no solid food.
Examples of clear liquids: Water, clear fruit juices such as apple or white grape, chicken or beef bouillion, jello (no RED or PURPLE), clear Gatorade 02, popsicles (no RED or PURPLE), clear soft drinks, coffee without cream or sugar.
NO MILK OR MILK PRODUCTS. NO ORANGE JUICE. NO RED OR PURPLE JELLO OR JUICES.
1PM: Drink a 10 oz bottle of magnesium citrate (lemon-lime flavor) chilled.
3 PM: Take 2 DULCOLAX tablets
4 PM: Mix the entire bottle of MIRALAX into the 32 oz of GATORADE 02. (Put half the bottle in each 32 ounce bottle). Shake the solution until fully dissolved. Drink an 8 ounce glass every 30 minutes until the solution is gone. 32 oz total.
7 PM: Drink second bottle of Magnesium citrate (chilled)
The DAY OF your colonoscopy:
Take the second 32 oz bottle of the MIRALAX/GATORADE combination plus 2 DULCOLAX tablets 3 hours before the procedure.
No medication on day of procedure.
Bring along someone to take you home.
No aspirin, aspirin by-products or Plavix for 1 week prior to your colonoscopy. No Coumadin for 4 days or check with your physician who orders the Coumadin. Please contact the physician that prescribed the aspirin, Plavix, and Coumadin to see if this is acceptable.
REMEMBER:
The preparation is very important. An adequate clean out allows for the best evaluation of your entire colon. During the prep, using baby wipes may ease some of your discomfort.
You should NOT plan on working or driving the rest of the day due to sedation given at the procedure.
Putting off having a colonoscopy because the horror stories you have heard about drinking the liquid prep?
Well here is the good news. There is a tolerable prep available.
Not all gastroenterologists will allow you to switch from the prep they like using, but no harm in asking them if this is appropriate for you.
MIRALAX - GATORADE COLONOSCOPY PREPARATION
Purchase these over the counter laxatives:
1. GATORADE 02 (64 ounces) of lime-lemonade or other clear Gatorade (two 32 oz. bottles)
2. DULCOLAX 5mg tablets (four tablets)
3. MIRALAX BOTTLE 238 grams (over the counter only)
4. MAGNESIUM CITRATE 10 oz bottle (lemon-lime flavor) 2 bottles need
The DAY BEFORE your colonoscopy:
Drink only clear liquids. Absolutely no solid food.
Examples of clear liquids: Water, clear fruit juices such as apple or white grape, chicken or beef bouillion, jello (no RED or PURPLE), clear Gatorade 02, popsicles (no RED or PURPLE), clear soft drinks, coffee without cream or sugar.
NO MILK OR MILK PRODUCTS. NO ORANGE JUICE. NO RED OR PURPLE JELLO OR JUICES.
1PM: Drink a 10 oz bottle of magnesium citrate (lemon-lime flavor) chilled.
3 PM: Take 2 DULCOLAX tablets
4 PM: Mix the entire bottle of MIRALAX into the 32 oz of GATORADE 02. (Put half the bottle in each 32 ounce bottle). Shake the solution until fully dissolved. Drink an 8 ounce glass every 30 minutes until the solution is gone. 32 oz total.
7 PM: Drink second bottle of Magnesium citrate (chilled)
The DAY OF your colonoscopy:
Take the second 32 oz bottle of the MIRALAX/GATORADE combination plus 2 DULCOLAX tablets 3 hours before the procedure.
No medication on day of procedure.
Bring along someone to take you home.
No aspirin, aspirin by-products or Plavix for 1 week prior to your colonoscopy. No Coumadin for 4 days or check with your physician who orders the Coumadin. Please contact the physician that prescribed the aspirin, Plavix, and Coumadin to see if this is acceptable.
REMEMBER:
The preparation is very important. An adequate clean out allows for the best evaluation of your entire colon. During the prep, using baby wipes may ease some of your discomfort.
You should NOT plan on working or driving the rest of the day due to sedation given at the procedure.
VIDEO OF A COLONOSCOPIC EXAMINATION
Expert Q & A
10 Questions You Need to Ask About Colonoscopy
By Douglas K. Rex, MD : NY Times : February 24, 2009.
Colorectal cancer is the second leading cause of cancer death in the United States, it affects both men and women and it almost always starts in a benign growth called a polyp. Polyps originate in the inner lining of the colon, where they may be visible during the popular screening test known as colonoscopy.
Whether you’re going for your first colonoscopy or are a veteran of the process, the following questions and answers contain important information about maximizing the procedure’s effectiveness and safety. Did you think that colonoscopy was completely effective at preventing colorectal cancer? Think again. The level of protection in various studies has ranged from a high of 80 percent to a low of no protection at all.
Here’s what you need to know to get the maximum benefit from colonoscopy at the lowest risk.
Q. Why is effective bowel preparation important?
A. Bowel preparation for colonoscopy refers to the laxatives taken before the procedure to clean the colon of fecal debris. A colonoscope is a long, flexible tube with a television camera on the tip. The camera can’t see through fecal debris. So any fecal debris left in the colon could obscure identification of a polyp or even a small cancer.
Several studies have shown that fewer small and large polyps are detected in patients with less-than-optimal bowel preparation. And poor preparation has several potential consequences during the procedure itself.
First, your colonoscopy may last longer because the doctor will need to take time to clear out debris.
Second, your doctor may lack confidence that the colon lining was seen adequately and may ask you to return for a subsequent screening earlier than would be otherwise recommended — say 1 year, rather than 5 or 10 years. This will subject you to increased costs and risk.
Finally, if the preparation is very poor, the doctor may have to stop the procedure entirely, and you will need to reschedule.
Q. How can I maximize my chance of an effective bowel preparation?
A. First, ask if the doctor recommends what is called split-dosing. Split-dosing refers to taking half the laxative prescription the night before colonoscopy, and the other half on the day of the procedure, usually about four to five hours before the procedure is scheduled. Several studies have shown that split-dosing significantly improves the quality of the preparation for colonoscopy.
In the past, it was common for doctors to have patients take all the prescription the night before colonoscopy. This effectively cleaned out the fecal debris, but left the potential for a different problem that can develop when the time between the end of the preparation process and the start of the colonoscopy is prolonged. Thick mucus and intestinal secretions empty out of the small intestine during that interval and stick to the first parts of the colon. [See Figures]
This area, called the cecum and ascending colon, is an important area to see with the colonoscope because cancers commonly develop there. It’s also the most likely area for cancers to develop after a normal colonoscopy. Flat polyps are common in this area and can be hard to see even when bowel preparation is perfect.
The solution to this problem is split-dosing, though there are still doctors who don’t recommend it. One reason given for sticking with a single dose is that a patient scheduled to have a colonoscopy early in the morning would have to get up at 2 or 3 a.m. to take the second half of the laxatives. That doesn’t sound great, does it?
Look at it this way, though. You may undergo colonoscopy as infrequently as every 10 years. Therefore, you want the doctor to have the best possible shot at making sure your colon is normal. If you get up during the night for things like crying babies or sick family members, you can do it to avoid dying from colorectal cancer. So if you want that early morning appointment, let the doctor know you’re willing to get up and take the second half of the preparation.
Another reason that split-dosing is not used is that some anesthesiologists won’t let patients drink fluids after midnight, or for six to eight hours before they are sedated. They are worried that the patient may vomit and inhale fluids during the procedure. But this concern is misplaced. The evidence shows that when people are drinking only clear liquids, the same amount of liquid is left in the stomach whether you stop fluid intake two hours before the procedure or many hours before. Guidelines from the American Society of Anesthesiologists say that patients may take clear liquids by mouth until two hours prior to the time of sedation.
In addition to split-dosing, the next step is to get written preparation instructions from the endoscopy unit and to read through them at least a few days before the procedure is scheduled. This will allow you time to get all the materials you need and adjust your schedule if necessary for the day or evening before the procedure. Most bowel preparation regimens can cause some dehydration, so make plans to stay well hydrated. Sport drinks are better than water for this purpose. It’s good to start the hydration process before you start the laxatives and to continue to hydrate during the period of laxative ingestion and even after you complete the procedure. You’ll feel better and stronger if you stay hydrated.
Q. Are there certain medications I should stop taking before colonoscopy?
A. Some doctors tell patients to stop taking aspirin, which has blood-thinning properties, 7 to 10 days before the procedure, reasoning that if a polyp is removed you’ll be less likely to bleed from that site. The evidence that aspirin causes bleeding from polypectomy sites is weak, and the American Society for Gastrointestinal Endoscopy says you don’t need to stop taking it before a colonoscopy, regardless of whether a polyp is removed. If you’re on aspirin for a good reason like a prior heart attack or stroke, it’s better to continue taking it.
Whether to temporarily discontinue more potent blood thinners like Coumadin (warfarin) and Plavix (clopidogrel) is more complicated. You should not decide to stop these medicines on your own, and the management of these drugs should be handled either by the doctor who prescribed them or the doctor doing the colonoscopy — or by both in consultation.
The exact management depends on why you need the medication, how long you’ve been taking it and what the colonoscopist plans to do during the procedure. Although the possibility of bleeding from the colonoscopy procedure is scary, the risk of bleeding when taking these medicines is related primarily to removal of large polyps, which most patients don’t have. In some cases it’s better to risk some bleeding from the procedure by continuing the medications than to risk a heart attack or stroke by stopping them. Let your doctors decide what to do.
Few patients need antibiotics before colonoscopy. Although you might expect colonoscopy to carry a high risk of bacteria entering the bloodstream, the risk is actually much lower than for other procedures, like dental work. Patients with heart problems like mitral valve prolapse and even artificial heart valves do not need antibiotics before colonoscopy.
Some colonoscopists give antibiotics to patients who have liver disease with fluid in the abdominal cavity, a condition called ascites.. Antibiotics are also sometimes prescribed for patients who have had vascular grafts, like those used to repair an abdominal aortic aneurysm, in the previous year, or for those who have had artificial joints put in place in the last six months. But the evidence to support these policies is weak, the risk of infection in these conditions is low, and the wisdom of using antibiotics in these situations is uncertain.
Q. Are all colonoscopists equally effective at finding polyps and cancers during colonoscopy?
A. Colonoscopy is what we in medicine call a highly “operator dependent” procedure. That is, some doctors are not only better than others at doing colonoscopy, they are a lot better.
Stated in reverse, some doctors are really bad at doing colonoscopy. Virtually every study that has looked for evidence that some people are better than others has found it, and the differences between doctors in how many precancerous polyps they find varies by 4- to 10-fold.
Q. How can I be sure that my colonoscopist will do a careful examination?
A. Current guidelines for measuring the quality of performance of colonoscopy recommend that doctors measure their “adenoma detection rate.” That is, they should determine whether they are being careful by counting the percent of patients in whom they identify one or more precancerous polyps, or adenomas, during screening.
Minimum thresholds for the adenoma detection rate have been determined. Doctors doing colonoscopy should find one or more adenomas in at least 25 percent of men and 15 percent of women who are age 50 or older and undergoing screening colonoscopy. Most doctors who do colonoscopy still haven’t measured their adenoma detection rate and therefore can’t tell you whether they are careful or not. The only way you can find out is to ask whether the rate has been measured and what it was.
It has also been recommended that doctors doing colonoscopy should take at least six minutes to examine the colon as they withdraw the colonoscope. Doctors who take six minutes or longer find more precancerous polyps, though the correlation between withdrawal time and polyp detection is not perfect.
Other factors also come in to play, including the quality of the preparation, how well the doctor sees flat lesions and how hard the doctor works to see the hidden portions of the colon on the opposite side of folds and bends. The doctor’s skill and care will be reflected in the adenoma detection rate.
You can help by making sure your colon is thoroughly cleansed. Find a doctor who has measured his or her adenoma detection rate and can show you that it exceeds the recommended thresholds. And ask the doctor to be careful and take enough time.
Also ask for a copy of the report and the pictures taken. The report should document that the doctor reached the beginning of the colon (the cecum) and took photographs of the anatomic landmarks that prove it. Somewhere in the record the withdrawal time should be recorded. If you really want to push the issue (It’s your colon right?), ask for a video recording of the entire procedure. Many doctors don’t have the equipment to provide such a recording, and if they do you might have to pay for it. Knowing that a permanent record of the procedure is being made might be just what’s needed to help ensure a careful examination.
Q. How can I reduce the risk of a complication during colonoscopy?
A. The most dreaded complication of colonoscopy is perforation, or making a hole in the colon. Perforation usually requires surgical repair, often on an emergency basis. Perforation can occur either during insertion of the colonoscope, from the side of the instrument’s rupturing the lower colon, or it can occur during polyp removal.
The risk of rupture during insertion of the colonoscope is higher in the elderly. Risk is also higher in people with severe diverticulosis; in those with weakened colons because of prior radiation, chronic use of steroids and previous or a serious colonic disease; and perhaps in those with adhesions around the colon in the pelvic area from surgeries like hysterectomy.
With a skilled operator, rupture of the colon is distinctly uncommon, particularly in the screening setting where the colon is usually anatomically and structurally normal. Although rupture occasionally occurs despite precautions and a skilled endoscopist, people at increased risk could ask the doctor to use a pediatric colonoscope. These colonoscopes are the same length as a standard instrument but are thinner and more flexible and exert less force on the colon wall. They have some disadvantages, and in certain circumstances the doctor could legitimately object to using one.
Perforations that occur during or after polyp removal are almost invariably caused by the application of electrocautery during the removal process. Electrocautery means electrical current is applied during removal to heat the tissue and seal off blood vessels to stop them from bleeding.
Polyps can be removed using a wire loop called a snare, or by forceps, which open and shut like a pair of jaws. Forceps should be used only for polyps that are five millimeters or smaller in maximum dimension. In my opinion, there is no reason to use electrocautery with forceps tools, and even snares can be used to cut off small polyps without electrocautery.
In fact, there is no need to use electrocautery for small polyps at all, since there are no large blood vessels to seal off. Still, many doctors use electrocautery to remove even small polyps.
Large polyps, on the other hand, are typically removed with a snare and require electrocautery to effectively cut through the tissue and seal the larger blood vessels sometimes found in those polyps.
Although a small polyp removed using electrocautery is much less likely to be associated with bleeding or perforation than a large polyp removed by electrocautery, small polyps are much more common than large polyps. Therefore, removal of small polyps results in most of the complications of colonoscopy over all. It is reasonable to ask the doctor to avoid using electrocautery to remove small polyps if possible.
Q. Should I try colonoscopy without sedation?
A. You should do this only if you’re highly motivated. The advantages of having colonoscopy unsedated are that you can watch the procedure on the television screen and you can get up and walk out after the procedure with no restrictions on your activity. But only 1 percent of colonoscopies in the United States are done without sedation.
People who are most interested in this option are typically highly educated and have low levels of anxiety, they more often are men, and they usually have no abdominal pain before the procedure. Because of anatomic factors, colonoscopy is usually easier in men, so men are better candidates for trying colonoscopy unsedated.
Colonoscopy is sometimes quite easy, causing very little discomfort, but a lot of people have significant discomfort if they try it without sedation. High levels of discomfort might make you less willing to have a colonoscopy in the future and might cause you to say negative things about the procedure to your friends and relatives, which would in turn make them less willing to undergo colonoscopy.
Most of us who do colonoscopy want our patients to be comfortable and to have an experience that is so easy they are surprised by it. We don’t want to push anyone to try it unsedated. But if you really want to skip sedation, you can probably get through it with a skilled doctor.
It has been shown recently that some unsedated patients tolerate colonoscopy better when the doctor uses “water immersion” to insert the instrument. In this technique the doctor fills the colon with water, rather than the air that is typically used, on the way in. Water stretches and elongates the colon less than air and is very safe, though air is still needed during the withdrawal to see the lining well. If you’re really interested in trying colonoscopy unsedated, you might ask whether the doctor can do water immersion.
Q. If I undergo sedation, should it be given by an anesthesiologist?
A. This will depend a lot on where you live in the United States and what your doctor does routinely.
Traditionally, doctors who do colonoscopy have given the sedation for the procedure themselves or have supervised a registered nurse who administers the medicine. The professional fee for performance of a colonoscopy includes payment for the delivery of sedation.
But in the last 10 years, many endoscopy groups have begun working with anesthesiologists or nurse anesthetists to deliver sedation for the procedure. This practice tends to be concentrated in certain parts of the country, including the New York City and Philadelphia corridor as well as Florida.
Anesthesia specialists use a drug called propofol for sedation, which keeps patients quite comfortable and allows them to awaken very quickly after the procedure. Several gastroenterologists in the United States use propofol without an anesthesiologist, but anesthesia specialists and their professional society have resisted this trend as they would like to control the use of the drug.
The only downside of having an anesthesiologist or nurse anesthetist involved is that it increases the cost of the procedure substantially. Aetna pays an average of $700 extra when an anesthesiologist is involved, and in some settings having an anesthesiologist doubles the cost of the procedure. Many insurers restrict the circumstances under which they will pay for an anesthesiologist to help with endoscopy.
There is virtually no evidence that the procedure is any safer when an anesthesiologist is involved, and using an anesthesiologist for a routine procedure like colonoscopy, if you are healthy, is not a cost-effective medical practice. Gastroenterologists and other endoscopists typically have enormous experience with sedating patients for colonoscopy using medicines that are safe and that provide excellent patient satisfaction.
Given that our country is in dire financial straits and that health care costs are contributing to the struggles of many businesses, it would be better if people elected to have colonoscopy with sedation provided by the doctor doing the procedure. But depending where you live in the country, you may not have a choice.
Q. Do all colonoscopists follow the same rules to determine when my colonoscopy should be repeated?
A. Doctors have guidelines that recommend how often colonoscopy should be done depending on whether the colonoscopy is normal; the number, size and type of polyps found during the colonoscopy; the results of previous colonoscopies; and family history of colorectal cancer. These guidelines, issued by groups like the American Cancer Society and the U.S. Multi-Society Task Force (a collaboration of the gastroenterology professional societies and the American College of Physicians), recommend colonoscopy at sufficient intervals to prevent most colorectal cancers, provided that your colonoscopy was done carefully.
Several studies have shown that some doctors recommend repeat colonoscopies at intervals that are shorter than those recommended by professional guidelines. General surgeons and primary care physicians who perform colonoscopy are more likely than gastroenterologists to make recommendations for more frequent procedures. Recommending colonoscopy at intervals that are too short may reflect a lack of knowledge of the guidelines, or a lack of confidence in the quality of the doctor’s own inspection of the colon, neither of which is a good reason to shorten the interval. A more appropriate rationale for shortening the interval is if the bowel preparation was less than optimal.
Q. Why aren’t the problems with the delivery of colonoscopy already solved?
A. The American health care system is not nationalized, and the delivery of high quality health care is often up to the integrity of individual providers. Many providers deliver outstanding care, but quality problems in colonoscopy have only been fully appreciated in the last few years.
Recommendations for monitoring the quality of colonoscopy were made by gastroenterology specialty groups in 2002 and 2006, but there is no mandate for practitioners to follow the guidelines and no penalty for not following them. Insurance companies could step in with a monitoring system that rewards good-quality colonoscopy and penalizes poor-quality colonoscopy, but they have not done so. That means that finding a competent and careful colonoscopist is the responsibility of the patient.
Dr. Douglas K. Rex, a distinguished professor of medicine at Indiana University School of Medicine and clinical gastroenterologist at Indiana University Hospital, is past president of the American College of Gastroenterology.
YOU CAN BOOK YOUR OWN COLONOSCOPY
BY CALLING
THE G I UNIT AT MOUNT AUBURN HOSPITAL
617-499-5019
Colon Cancer Overview
Colon, or colorectal, cancer is cancer that starts in the large intestine (colon) or the rectum (end of the colon).
Other types of cancer can affect the colon, such as lymphoma, carcinoid tumors, melanoma, and sarcomas. These are rare. In this article, use of the term "colon cancer" refers to colon carcinoma only.
ALTERNATIVE NAMES
Colorectal cancer; Cancer - colon; Rectal cancer; Cancer - rectum; Adenocarcinoma - colon; Colon - adenocarcinoma
CAUSES »
According to the American Cancer Society, colorectal cancer is one of the leading causes of cancer-related deaths in the United States. However, early diagnosis often leads to a complete cure.
Almost all colon cancer starts in glands in the lining of the colon and rectum. When doctors talk about colorectal cancer, this is usually what they are talking about.
There is no single cause of colon cancer. Nearly all colon cancers begin as noncancerous (benign) polyps, which slowly develop into cancer.
You have a higher risk for colon cancer if you:
Smoking cigarettes and drinking alcohol are other risk factors for colorectal cancer.
SYMPTOMS »
Many cases of colon cancer have no symptoms. The following symptoms, however, may indicate colon cancer:
EXAMS AND TESTS
With proper screening, colon cancer can be detected before symptoms develop, when it is most curable.
Your doctor will perform a physical exam and press on your belly area. The physical exam rarely shows any problems, although the doctor may feel a lump (mass) in the abdomen. A rectal exam may reveal a mass in patients with rectal cancer, but not colon cancer.
A fecal occult blood test (FOBT) may detect small amounts of blood in the stool, which could suggest colon cancer. However, this test is often negative in patients with colon cancer. For this reason, a FOBT must be done along with colonoscopy or sigmoidoscopy. It is also important to note that a positive FOBT doesn't necessarily mean you have cancer.
Imaging tests to screen for and potentially diagnose colorectal cancer include:
Note: Only colonoscopy can see the entire colon, and this is the best screening test for colon cancer.
Blood tests that may be done include:
Stages of colon cancer are:
TREATMENT »
Treatment depends partly on the stage of the cancer. In general, treatments may include:
Stage 0 colon cancer may be treated by removing the cancer cells, often during a colonoscopy. For stages I, II, and III cancer, more extensive surgery is needed to remove the part of the colon that is cancerous. (See: Colon resection)
There is some debate as to whether patients with stage II colon cancer should receive chemotherapy after surgery. You should discuss this with your oncologist.
CHEMOTHERAPY
Almost all patients with stage III colon cancer should receive chemotherapy after surgery for approximately 6 - 8 months. The chemotherapy drug 5-fluorouracil has been shown to increase the chance of a cure in certain patients.
Chemotherapy is also used to improve symptoms and prolong survival in patients with stage IV colon cancer.
RADIATION
Although radiation therapy is occasionally used in patients with colon cancer, it is usually used in combination with chemotherapy for patients with stage III rectal cancer.
For patients with stage IV disease that has spread to the liver, various treatments directed specifically at the liver can be used. This may include:
OUTLOOK (PROGNOSIS)
Colon cancer is, in many cases, a treatable disease if it is caught early.
How well you do depends on many things, including the stage of the cancer. In general, when they are treated at an early stage, many patients survive at least 5 years after their diagnosis. (This is called the 5-year survival rate.)
If the colon cancer does not come back (recur) within 5 years, it is considered cured. Stage I, II, and III cancers are considered potentially curable. In most cases, stage IV cancer is not considered curable, although there are exceptions.
POSSIBLE COMPLICATIONS
WHEN TO CONTACT A MEDICAL PROFESSIONAL
Call your health care provider if you have:
PREVENTION
The death rate for colon cancer has dropped in the last 15 years. This may be due to increased awareness and screening by colonoscopy.
Colon cancer can almost always be caught by colonoscopy in its earliest and most curable stages. Almost all men and women age 50 and older should have a colon cancer screening. Patients at risk may need earlier screening.
Colon cancer screening can often find polyps before they become cancerous. Removing these polyps may prevent colon cancer.
A daily dose of aspirin has also been shown to reduce the development of
colon cancer by >20%.
Colon, or colorectal, cancer is cancer that starts in the large intestine (colon) or the rectum (end of the colon).
Other types of cancer can affect the colon, such as lymphoma, carcinoid tumors, melanoma, and sarcomas. These are rare. In this article, use of the term "colon cancer" refers to colon carcinoma only.
ALTERNATIVE NAMES
Colorectal cancer; Cancer - colon; Rectal cancer; Cancer - rectum; Adenocarcinoma - colon; Colon - adenocarcinoma
CAUSES »
According to the American Cancer Society, colorectal cancer is one of the leading causes of cancer-related deaths in the United States. However, early diagnosis often leads to a complete cure.
Almost all colon cancer starts in glands in the lining of the colon and rectum. When doctors talk about colorectal cancer, this is usually what they are talking about.
There is no single cause of colon cancer. Nearly all colon cancers begin as noncancerous (benign) polyps, which slowly develop into cancer.
You have a higher risk for colon cancer if you:
- Are older than 60
- Are African American of eastern European descent
- Eat a diet high in red or processed meats
- Have cancer elsewhere in the body
- Have colorectal polyps
- Have inflammatory bowel disease (Crohn's disease or ulcerative colitis)
- Have a family history of colon cancer
- Have a personal history of breast cancer
- Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome
Smoking cigarettes and drinking alcohol are other risk factors for colorectal cancer.
SYMPTOMS »
Many cases of colon cancer have no symptoms. The following symptoms, however, may indicate colon cancer:
- Abdominal pain and tenderness in the lower abdomen
- Blood in the stool
- Diarrhea, constipation, or other change in bowel habits
- Narrow stools
- Weight loss with no known reason
EXAMS AND TESTS
With proper screening, colon cancer can be detected before symptoms develop, when it is most curable.
Your doctor will perform a physical exam and press on your belly area. The physical exam rarely shows any problems, although the doctor may feel a lump (mass) in the abdomen. A rectal exam may reveal a mass in patients with rectal cancer, but not colon cancer.
A fecal occult blood test (FOBT) may detect small amounts of blood in the stool, which could suggest colon cancer. However, this test is often negative in patients with colon cancer. For this reason, a FOBT must be done along with colonoscopy or sigmoidoscopy. It is also important to note that a positive FOBT doesn't necessarily mean you have cancer.
Imaging tests to screen for and potentially diagnose colorectal cancer include:
Note: Only colonoscopy can see the entire colon, and this is the best screening test for colon cancer.
Blood tests that may be done include:
- Complete blood count (CBC) to check for anemia
- Liver function tests
Stages of colon cancer are:
- Stage 0: Very early cancer on the innermost layer of the intestine
- Stage I: Cancer is in the inner layers of the colon
- Stage II: Cancer has spread through the muscle wall of the colon
- Stage III: Cancer has spread to the lymph nodes
- Stage IV: Cancer has spread to other organs
TREATMENT »
Treatment depends partly on the stage of the cancer. In general, treatments may include:
- Surgery (most often a colectomy) to remove cancer cells
- Chemotherapy to kill cancer cells
- Radiation therapy to destroy cancerous tissue
Stage 0 colon cancer may be treated by removing the cancer cells, often during a colonoscopy. For stages I, II, and III cancer, more extensive surgery is needed to remove the part of the colon that is cancerous. (See: Colon resection)
There is some debate as to whether patients with stage II colon cancer should receive chemotherapy after surgery. You should discuss this with your oncologist.
CHEMOTHERAPY
Almost all patients with stage III colon cancer should receive chemotherapy after surgery for approximately 6 - 8 months. The chemotherapy drug 5-fluorouracil has been shown to increase the chance of a cure in certain patients.
Chemotherapy is also used to improve symptoms and prolong survival in patients with stage IV colon cancer.
- Irinotecan, oxaliplatin, capecitabine, and 5-fluorouracil are the three most commonly used drugs.
- Monoclonal antibodies, including cetuximab (Erbitux), panitumumab (Vectibix), bevacizumab (Avastin), and other drugs have been used alone or in combination with chemotherapy.
RADIATION
Although radiation therapy is occasionally used in patients with colon cancer, it is usually used in combination with chemotherapy for patients with stage III rectal cancer.
For patients with stage IV disease that has spread to the liver, various treatments directed specifically at the liver can be used. This may include:
- Burning the cancer (ablation)
- Delivering chemotherapy or radiation directly into the liver
- Freezing the cancer (cryotherapy)
- Surgery
OUTLOOK (PROGNOSIS)
Colon cancer is, in many cases, a treatable disease if it is caught early.
How well you do depends on many things, including the stage of the cancer. In general, when they are treated at an early stage, many patients survive at least 5 years after their diagnosis. (This is called the 5-year survival rate.)
If the colon cancer does not come back (recur) within 5 years, it is considered cured. Stage I, II, and III cancers are considered potentially curable. In most cases, stage IV cancer is not considered curable, although there are exceptions.
POSSIBLE COMPLICATIONS
- Blockage of the colon
- Cancer returning in the colon
- Cancer spreading to other organs or tissues (metastasis)
- Development of a second primary colorectal cancer
WHEN TO CONTACT A MEDICAL PROFESSIONAL
Call your health care provider if you have:
- Black, tar-like stools
- Blood during a bowel movement
- Change in bowel habits
PREVENTION
The death rate for colon cancer has dropped in the last 15 years. This may be due to increased awareness and screening by colonoscopy.
Colon cancer can almost always be caught by colonoscopy in its earliest and most curable stages. Almost all men and women age 50 and older should have a colon cancer screening. Patients at risk may need earlier screening.
Colon cancer screening can often find polyps before they become cancerous. Removing these polyps may prevent colon cancer.
A daily dose of aspirin has also been shown to reduce the development of
colon cancer by >20%.
Unnecessary Colon Screenings for Elderly Patients
By Paula Span : NY Times May 25, 2011
Forgive me for sounding like a broken record, to use a highly retro phrase, but the evidence on overtesting and overtreatment of older adults keeps piling higher.
We’ve already learned that nearly 20 percent of elderly women with advanced dementia are subjected to pointless, disturbing mammograms. We’ve also learned that nursing home patients frequently take antibiotics (and the wrong kinds, and for too long) for suspected urinary tract infections, in direct contradiction of medical guidelines. Frail, older diabetics are pushed to maintain very low blood sugar levels even though they’re unlikely to live long enough to benefit. All these treatments pose risks and can cause more harm than good when they’re used on the wrong people.
Maybe we should institute an Older Americans Overtreatment of the Month award. Picking a winner might be a tough task, though.
The latest candidate: everyone’s favorite screening test, the colonoscopy, which allows doctors to spot and then remove growths called polyps that can evolve into colon cancer. Routine screening has probably contributed to the declining death rate from that disease, considered highly curable in its early stages, and it’s still underused, particularly among members of racial and ethnic minorities and the uninsured.
But colonoscopies are considerably overused among elderly patients, a new study suggests.
“This is truly mindless application of guidelines that were developed for 50-year-olds,” said Dr. James Goodwin, a geriatrician at the University of Texas Medical Branch and lead author of the study, published this month in The Archives of Internal Medicine.
For years, the recommendations for screening colonoscopies (as opposed to those performed because of a specific symptom) have been virtually unanimous. Medical authorities agree that people over age 50 should have one. Patients with negative results and no subsequent symptoms or indications don’t need another one for 10 years. “It takes a long time for polyps to evolve into cancer,” Dr. Goodwin said.
But in the Texas researchers’ sample — more than 24,000 Medicare enrollees who had a negative colonoscopy from 2001 to 2003 — more than 46 percent underwent a repeat colonoscopy in less than seven years. In fact, many of these tests took place after just three years or five. Yet in almost a quarter of all these repeat colonoscopies — 23.5 percent — the researchers, scrutinizing the medical records, could find no reason for performing them so soon.
Dr. Goodwin was especially troubled by the fact that a third of patients who were older than 80 when they had initial colonoscopies received another within seven years. The United States Preventive Services Task Force recommends no routine colon cancer screening for those older than 75, and no screening at all for those over age 85.
Preparation for a colonoscopy, merely unpleasant for most of us, can take a steep physical toll on the very old. They can become incontinent, setting off a cycle of prescriptions for drugs to stop diarrhea and then constipation. The preparations can disrupt eating and sleep. “It can throw people off for a long time,” Dr. Goodwin said.
“It would be a very bad idea for people with moderate dementia,” he added, and that’s a significant proportion of the 85-plus population. They may not understand the test’s purpose or be able to comply with the prep directions. Even more to the point, people with dementia, a terminal disease, are unlikely to live long enough to benefit from colon cancer screening.
The researchers also found that older patients with three or more health problems — like heart failure, high blood pressure, chronic bronchitis and asthma — had even higher rates of repeat colonoscopies without medical indications. “That’s bizarre,” Dr. Goodwin said. With multiple diseases, “you’re less likely to live long enough to develop colon cancer. You should be less likely to be screened.”
Fortunately, the rate of complications from colonoscopy is low: one Medicare patient in 1,000 requires hospitalization, and one in 10,000 dies. “It’s a small number, which is dwarfed by the cancers you can prevent,” Dr. Goodwin said. “But if you double the rate of screening, you double the complications and deaths, without any benefit to patients.”
So why does this happen? At about $1,000 per procedure, there’s clearly an economic incentive, Dr. Goodwin said. But patients and their families bear some responsibility as well.
“We’ve done too good a job with some of these messages” urging tests for various diseases, he said. “Some of the demand comes from patients who don’t understand that there’s a cost to these things, and I don’t mean the economic cost.” But the expense is an outrage, too. Medicare supposedly reimburses for screening colonoscopies only every 10 years, but it denied only 2 percent of the claims in this study.
Overtesting and overtreating aren’t merely expensive and unnecessary. “They’re harmful,” Dr. Goodwin said. “They hurt people. When that message gets out, I think we’ll have more pushback from patients.”
Noted. A key question for seniors and their caregivers to lob at doctors: What’s the reason for this colonoscopy when routine screening isn’t recommended for someone this age? (That is, a patient older than 75.)
Sometimes, of course, there’s a valid explanation. When there’s not, said Dr. Goodwin, “even if you had a rabid doctor who just loved to do colonoscopies, that question would give him pause.”
Report Affirms Lifesaving Role of Colonoscopy
By Denise Grady : NY Times : February 22, 2012
A new study provides what independent researchers call the best evidence yet that colonoscopy — perhaps the most unloved cancer screening test — prevents deaths. Although many people have assumed that colonoscopy must save lives because it is so often recommended, strong evidence has been lacking until now.
In patients tracked for as long as 20 years, the death rate from colorectal cancer was cut by 53 percent in those who had the test and whose doctors removed precancerous growths, known as adenomatous polyps, researchers reported on Wednesday in The New England Journal of Medicine. The test examines the inside of the intestine with a camera-tipped tube.
“For any cancer screening test, reduction of cancer-related mortality is the holy grail,” said Dr. Gina Vaccaro, a gastrointestinal oncologist at the Knight Cancer Institute at Oregon Health and Science University who was not involved in the research. “This study does show that mortality is reduced if polyps are removed, and 53 percent is a very robust reduction.”
Colorectal tumors are a major cause of cancer death in the United States and one of the few cancers that can be prevented with screening. This year, more than 143,000 new cases and 51,000 deaths are expected. Incidence and death rates have been declining for about 20 years, probably because of increased use of screening tests and better treatments. But only about 6 in 10 adults are up to date on getting screened for colorectal cancer, according to federal estimates.
Cancer screening tests have come in for greater scrutiny recently. A government panel recommended in October that men no longer get the P.S.A. blood screening test for prostate cancer after concluding it did not save lives. The new study on colonoscopy has limitations — it is not a randomized clinical trial — but some experts say it nonetheless was well done and helps answer questions about the effectiveness of the procedure.
Earlier research had proved that removing precancerous polyps could greatly reduce the incidence of colorectal cancer. But a major question remained: Did removing the polyps really save lives? In theory, it was possible that doctors were finding growths that would not have killed the patient, or missing ones that could be fatal.
“This study puts that argument to rest,” said Dr. David A. Rothenberger, a professor and deputy chairman of surgery at the University of Minnesota Masonic Cancer Center. He was not part of the study.
Robert A. Smith, the senior director for cancer control at the American Cancer Society, said, “This is a very big deal.”
A team of researchers led by Dr. Sidney J. Winawer, a gastroenterologist at Memorial Sloan-Kettering Cancer Center in New York City, followed 2,602 patients who had adenomatous polyps removed during colonoscopies from 1980 to 1990. Doctors compared their death rate from colorectal cancer with that of the general population, where 25.4 deaths from the disease would have been expected in a group the same size. But among the polyp group, there were only 12 deaths from colorectal cancer, which translates into a 53 percent reduction in the death rate.
The new study did not compare colonoscopy with other ways of screening for colorectal cancer and so does not fully resolve a longstanding medical debate about which method is best. Tests other than colonoscopy look for blood in the stool or use different techniques to examine the intestine. All the tests are unpleasant, and people are often reluctant to have them.
Although doctors have differed about which method is best, they agree that it is important to get over the squeamishness and have some type of test, usually starting at age 50. Screening is worthwhile because colorectal cancer is one of the few types of cancer (cervical and skin cancer are others) in which premalignant growths have been identified and the disease can be prevented if those growths are detected and cut out. Research indicates that not every polyp turns into cancer, but that nearly every colorectal tumor starts out as an adenomatous polyp.
Even if intestinal cancer has already developed, it can still be cured if it is found early and treated.
“Not all adenomas become cancers, and not all cancers cause death,” said Ann Zauber, the lead author of the study and a statistician at Sloan-Kettering. But in many cases, she said, “we have gotten those that would have had the potential to go on and cause a cancer death.”
Dr. Smith, at the American Cancer Society, said the new study on colonoscopy was well done, and noted that changes in death rates can be difficult to measure because they require long-term studies like this one.
But Dr. Harold C. Sox, an emeritus professor of medicine at Dartmouth Medical School and former editor of a leading medical journal, Annals of Internal Medicine, cautioned that the new study was not the last word. He said it was not clear that the same reduction in the death rate found in the study would occur in the general population.
Nonetheless, he said, “I suspect that removing polyps does reduce colorectal cancer mortality.”
The type of evidence in this study, based on looking back at patient records, is not considered as reliable as that from a randomized controlled study, in which groups of patients are picked at random to have one treatment or another and then compared over time.
Dr. Sox also said that because all of the patients in the study had adenomatous polyps, it is not certain that the findings would apply exactly to the general population, in which this type of polyp is found in about 15 percent of women and 25 percent of men.
In addition, Dr. Sox said, the people with polyps were part of a study that provided high-quality colonoscopy, so they may not have been comparable to the general population.
Other studies have found that doctors vary in their ability to find polyps, that certain types of polyps are hard to detect and that colonoscopy is better at finding polyps in the lower part of the intestine than in its upper reaches.
Other screening tests look for blood in the stool, and if it is found, the patient is advised to have a colonoscopy. Another test, sigmoidoscopy, examines only the lower part of the colon. Barium enemas with X-rays can also show some abnormal growths. But sigmoidoscopy and barium enemas are not used much anymore in the United States.
Stool tests need to be done once a year; many people do not comply. In fact, a study from Spain in the same issue of the journal as Dr. Winawer’s article found that when people were offered a stool test, only 34.2 percent took it. The figure for colonoscopy was even worse: 24.6 percent.
Colonoscopy does not have to be done every year: If there are no polyps, it is recommended just once every 10 years. People with polyps are usually told to have the test every three years.
But colonoscopy is expensive, costing hundreds or thousands of dollars, depending on whether polyps are removed and on the part of the country where it is done. It also carries small risks of bleeding or perforation of the intestine. And it requires sedation as well as strong, foul-tasting laxatives to clean out the intestines so that the doctor can look for polyps.
“Any screening is better than none,” Dr. Winawer said. “The best test is the one that gets done, and that gets done well.”
His study was paid for by the National Cancer Institute, Memorial Sloan-Kettering Cancer Center and private foundations dedicated to colon cancer.
Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.
A screening colonoscopy every 10 years is the recommended interval for adults without increased risk for colorectal cancer, beginning at age 50 years.
Published studies indicate the risk of cancer is low for 10 years after a high-quality colonoscopy fails to detect neoplasia in this population.
Therefore, following a high-quality colonoscopy with normal results the next interval for any colorectal screening should be 10 years following that
normal colonoscopy.
Do not repeat colonoscopy for at least five years for patients who
have one or two small (< 1 cm) adenomatous polyps, without highgrade dysplasia, completely removed via a high-quality colonoscopy.
The timing of a follow-up surveillance colonoscopy should be determined based on the results of a previous high-quality colonoscopy. Evidencebased (published) guidelines provide recommendations that patients with one or two small tubular adenomas with low grade dysplasia have surveillance colonoscopy five to 10 years after initial polypectomy. “The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the physician).”
