COLON CANCER FOR DUMMIES
I do not intend to be condescending, but I do believe that most people are ignorant of the dangers of this killer. I have spent a half-century grappling with most of the variations of this disease and have some idea how underhanded, furtive, and devastating it can be.
Unfortunately, even fellow physicians have ignored patients presenting with symptoms that demand investigation, such as blood in the stool. But because the patient was too young, too old, just worked up a year ago and not found to have a problem, etc. it was ignored. As astonishing as it sounds, there are 26-year-old people that get colon cancer too. Familial adenomatous polyposis, a hereditary condition, patients can develop cancer quite early and need to start screening as young as age 10. Almost 100% of patients that have presented with colon cancer to me self-diagnose as bleeding from hemorrhoids. The patients, or sometimes their primary physician, has treated the hemorrhoids for months for this benign disease while ignoring the tell-tale signs of the monster waiting to be discovered just beyond the finger. Furthermore having hemorrhoids does not preclude also having cancer.
The colon is one organ that does not inspire glamour. Politically the colon does not garner the publicity, the fundraising capability, or the interest as, for example, breast cancer. It is after all the transporter of the end of digestion back to nature. Its contents are often used as a four-letter word to curse or denounce a person, thing, or event, a word that is recognized in all languages as one of extreme displeasure. Even our closest cousins, the chimpanzee, share in this. When they want to show their extreme unhappiness, they throw “it” at you.
There is a story of how the actual word originated. I don’t know if it is true or not. It is said that during our Civil War, wood and coal became a commodity that was increasingly difficult to obtain because the war consumed all possible sources of energy. Cattle feedlots produced large amounts of cow dung that, when dry, burned quite well. It was packed and shipped to parts of the country that needed it most. Some lethal accidents occurred when the cow dung got wet in a closed area, such as the hold of a ship. Methane gas was released. When someone with a lit lantern went down below deck an explosion ensued. From that experience, cow dung had to be shipped above deck. The shipping containers were inscribed with warning signs, “SHIP HIGH IN TRANSIT” abbreviating it into its acronym created SHIT.
1 in 20 Americans will be afflicted with colon cancer during their lifetime. This year 53,200 people will die from it, the second leading cause of cancer deaths of both men and women combined. The lung is still number one. Happily, we are making an impact as the death rate (deaths per 100,000) in colon cancer is dropping, except in the population under 55, where it has increased 2% per year since 2007. This has prompted the American Cancer Society to revise its screening guidelines to age 45 for people at average risk, that includes those people that do not have a family or personal history of colon cancer or polyps, hereditary colon cancer syndromes, or a personal history of inflammatory bowel disease.
Most colon cancer starts as a polyp. There is a condition called Hereditary Non-Polyposis Colorectal Cancer (HNPCC) that skips the polyp phase and goes straight to cancer but is not very common (1 in 400 people have it). But nevertheless, nearly all cancers start as a polyp. There are different types of polyps, some more dangerous than others. In order of increasing risk inflammatory polyps are the lowest risk, then hyperplastic polyps, of which the serrated kind are more dangerous, and then the adenomatous polyp, and finally the highest risk are the villous polyps. Size also plays a role, the larger the more serious. The question often comes up, “When should I have my next colonoscopy?” It is a statistical answer that depends on age, family history, how many, what kind, and how big the polyps found were (about a third of the people I have examined I have found have had one or more polyps) I would often enlist the patient’s input before I would give a semi-definitive answer. Even the low-risk hyperplastic polyps, that are supposedly benign and offer no increased risk, but if there are lots of them, especially on the left side of the colon or have elements of being a serrated polyp on microscopic exam worry me, and I would see these people back in 1 to 3 years.
Additionally, many pathologists are not yet attuned to the serrated polyp designation that makes them a notch more dangerous. I always reviewed the pathology slides myself with the pathologist and recall seeing a polyp that was half hyperplastic and half villous which is just a step away from cancer, and raised my threshold of concern for the supposedly harmless hyperplastic polyp. Recently the ACS guidelines state you do not need a colonoscopy after age 85. But if you are healthy and likely will live another 10 years, why not? Death from untreated colon cancer is quite unpleasant with colostomies and painful swollen bellies at the end.
There are several screening exams that have their own risks, accuracy, costs, difficulty, and inconvenience. The simple test for blood in the stool has no risk, although a little unpleasant. It is hower not all that accurate. Only one-third of cancers will show a positive test, not a very good track record. A more accurate test is the Cologuard stool test, although it is not a certainty that if positive you have cancer and if negative that you don’t. 13% of the time it is positive and the patient does not have cancer (false positive) and 8% of the time the test is negative when indeed the patient has cancer (false negative). It has no real risks and is easy to do. Just collect a stool sample in the privacy of your home and send it off to the lab in the provided container. It screens for DNA that is related to cancer or pre-cancer, such as a polyp. Many insurances pay part or all of the cost of $649.
Colonoscopy is the gold standard, but also the most expensive, unpleasant, and risky. The radiologists have expanded on the old fashioned barium enema, or more sophisticated double contrast study, both of which are screening exams for colon cancer, but they too can miss cancer. The newer version is the CT colonography. By offering this exam the patient avoids the unpleasantness of a colonoscopy, but not the prep for it. The patient must still have a pristine colon. Otherwise small bits of stool will be interpreted as a polyp, which will then prompt a colonoscopic exam. The CT colonography often raises more questions than it answers and has not been the answer to how to avoid the formal colonoscopy.
Colonoscopy is a direct visual inspection of the entire colon and therefore is the most accurate. But it too is not 100%. The colon has many twists, turns, and folds where small cancers or polyps can hide, but if done correctly it is extremely unlikely that anything will be missed. It will surprise you that doing a colonoscopy too fast is actually a measure of poor quality. At some centers, nurses actually time your withdrawal time and if you come out in less than 6 minutes you are “timed out” so to speak.
The big risk is a perforation, followed by bleeding, a partial burn injury from polyp removal, infection, adverse anesthetic problems, complications from the prep especially in older individuals getting fluid overload, or sometimes dehydration, and cardiovascular problems. Still, perforation remains the most feared of the complications. The literature quotes a rate of 0.016% to 0.2% risk. But therapeutic colonoscopies and large polypectomies have a perforation rate as high as 5%. My own perforation rate in 40 years was 2 in about 15,000 colonoscopies (.013%), but I do remember both vividly, and both survived.
A word about the prep. Having had several colonoscopies myself in my now 77 years of life, I must say that for science to have landed us on the moon, being able to transplant hearts, livers, lungs, we are woefully lacking sophistication in cleaning out the colon. To say it was unpleasant is an understatement, and the most often prescribed prep, Go-LYTELY, is a misnomer in my book. Newer preps are available that make it a bit easier but at rather exorbitant prices. The old 1.5 oz. of Fleets Phosphosoda taken two times was still the easiest, quickest, and least unpleasant. Unfortunately, it killed a few people and was removed from the market.