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March: Time to be Tested for Colon Cancer

By: Jeffrey Goldstein, MD


It's time to schedule a routine test for colon cancer. Just as October is the reminder for women to schedule a mammogram, March is the reminder for men and women 50 or older to be tested for colon cancer.

The latest statewide data from the Center for Disease Control and Prevention Behavioral Risk Factor Surveillance Survey shows that in 2007, 64 percent of New Yorkers over 50 reported having had Fecal Occult Blood Tests or Sigmoidoscopy or Colonoscopy tests as per the American Cancer Society Guidelines. Slowly, colon cancer testing being accepted as a rite of passage, just like mammography, but there is still more work to be done to increase the number of colon cancers prevented or caught early, and reduce the number of deaths due to this type of cancer.

What Causes Colon Cancer?

Risk factors you cannot change:

• Age - Your chance of having colon cancer goes up after age 50. More than 9 out of 10 people with colon cancer are older than 50.

• Having had colon cancer or colorectal polyps before

• Having a history of bowel disease

• Family history - a family history of colon cancer or if your doctor tells you that you have a condition that puts you or your family members at increased risk for colon cancer. In these instances, you will want to talk with your doctor about being tested for colon cancer even earlier.

• Race or ethnic background - Some racial and ethnic groups such as African Americans and Jews of Eastern European descent (Ashkenazi Jews) have a higher rate of colon cancer.

Risk factors linked to things you can control:

• Certain types of diets

• Lack of exercise

• Overweight/obesity

• Smoking • Alcohol consumption

• Type 2 diabetes

For further detail on the above risk factors and other risk factors that are less certain, visit the American Cancer Society.

Types of Colon Cancer Testing

There are two types of tests to detect colon cancer in individuals without symptoms of colon cancer.

1. Tests that can find both colorectal polyps and colon cancer:

Colonoscopy - every 10 years, starting at age 50
This test that may actually prevent colon cancer if polyps are removed during the procedure. A thin, flexible, lighted tube about the thickness of a finger is placed into the lower part of the colon through the rectum. This allows the doctor to look at the inside of the rectum and the entire colon for cancer or polyps. Be sure your doctor is aware of any medicines you are taking, as you may need to change how you take them before the test.

During the test, if a small polyp is found, your doctor may immediately remove it. This can be done with tools used through the scope. If a small polyp is found during the procedure, the doctor will remove it. If a larger polyp or colon cancer is discovered, a biopsy may be done.

Before the test, you will need to clean out your colon and rectum so the doctor can clearly see the lining. Often, you will hear from people who have had a colonoscopy that “the prep is the worst part.” You will need to use the bathroom a lot, but advances have been made so that preps used today are more tolerable than those used even a couple of years ago.

Flexible Sigmoidoscopy (Flex-Sig)* - every 5 years, starting at age 50
Similar to colonoscopy, a thin, flexible, lighted tube about the thickness of a finger is placed into the lower part of the colon through the rectum. However, the scope is much shorter, allowing the doctor to view the lower half of the colon, and does not require sedation. The test can be uncomfortable, but it should not be painful.

Before the test, you will need to clean out your colon and rectum. If a small polyp is found your doctor may remove it during this test. This can be done with tools used through the scope. If an adenoma polyp or colorectal cancer is found during the flex-sig, you will need to have a colonoscopy to look for polyps or cancer in the rest of the colon.

Double-Contrast Barium Enema (DCBE) - every 5 years, starting at age 50
To do this test a chalky substance is used to partly fill and open up the colon. Air is then pumped in to cause the colon to expand. This allows good x-ray pictures to be taken. If an area does not look normal you will need to have a colonoscopy.

The preparation for this test is much like that for the colonoscopy, but for the DCBE you will not be given drugs to make you sleepy.

CT Colonography/Virtual Colonoscopy - every 5 years, starting at age 50
This test is an advanced type of computed tomography (CT or CAT) scan of the colon and rectum. A CT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied. For CT colonography, special computer programs create both two-dimensional x-ray pictures and a three-dimensional "fly-through" view of the inside of the colon and rectum, which allows the doctor to look for polyps or cancer.

This test may be especially useful for some people who cannot have or do not want to have more invasive tests such as colonoscopy. It can be done fairly quickly and does not require sedation. But even though this test is not invasive like colonoscopy, it still requires the same type of bowel preparation and uses a tube placed in the rectum (similar to the tube used for barium enema) to fill the colon with air. Another possible drawback is that if polyps or other suspicious areas are seen on this test, a colonoscopy will still probably be needed to remove them or to explore them fully. \

2. Tests that can mainly find colon cancer:

Fecal Occult Blood Test (FOBT)/Fecal Immunochemical Test (FIT) - annual, starting at age 50
The fecal occult blood test (FOBT) is a take-home screening kit used to find occult (hidden) blood in feces. The idea behind this test is that blood vessels at the surface of larger colorectal polyps or cancers are often fragile and easily damaged by the passage of feces. The damaged vessels usually release a small amount of blood into the feces, but only rarely is there enough bleeding to be noticeable in the stool.

The FOBT detects blood in the stool through a chemical reaction. If this test is positive, a colonoscopy is needed to see if there is a cancer, polyp, or other cause of bleeding such as ulcers, hemorrhoids, diverticulosis (tiny pouches that form at weak spots in the colon wall), or inflammatory bowel disease (colitis).

Fecal Immunochemical Test (FIT) - annual, starting at age 50 The fecal immunochemical test (FIT), also called an immunochemical fecal occult blood test (iFOBT), is a newer kind of test that also detects occult (hidden) blood in the stool. This test reacts to part of the human hemoglobin protein, which is found on red blood cells.

The FIT is done essentially the same way as the FOBT, but some people may find it easier to use because there are no drug or dietary restrictions (vitamins or foods do not affect the FIT) and sample collection may take less effort.

As with the FOBT, if the results are positive for hidden blood, a colonoscopy is required to investigate further. In order to be beneficial the test must be repeated every year.

Stool DNA Test: - interval uncertain, starting at age 50
Instead of looking for blood in the stool, these tests look for certain abnormal sections of DNA (genetic material) from cancer or polyp cells. Colorectal cancer cells often contain DNA mutations (changes) in certain genes. Cells from colorectal cancers or polyps with these mutations are often shed into the stool, where tests may be able to detect them.

This is a newer type of test, and the best length of time to go between tests is not yet clear. This test is also much more expensive than other forms of stool testing.

This test is not invasive and doesn't require any special preparation. But as with other stool tests, if the results are positive, a colonoscopy is required to investigate further.

American Cancer Society: Pros and Cons of Colon Cancer Screening Tests:

Test
Pros
Cons
Flexible Sigmoidoscopy
Fairly quick and safe
Usually doesn't require full bowel preparation
Sedation usually not used
Does not require a specialist
Done every 5 years
Views only about a third of the colon
Can miss small polyps
Can't remove all polyps
May be some discomfort
Done in a doctor’s office, clinic, or hospital
Very small risk of bleeding, infection, or bowel tear
Colonoscopy will be needed if abnormal
Colonoscopy
Can usually view entire colon
Can biopsy and remove polyps
Done every 10 years
Can diagnose other diseases
Can miss small polyps
Full bowel preparation needed
More expensive on a one-time basis than other forms of testing
Sedation of some kind is usually needed
Will need someone to drive you home
You may miss a day of work
Small risk of bleeding, bowel tears, or infection
Double Contrast Barium Enema (DCBE)
Can usually view entire colon
Relatively safe
Done every 5 years
No sedation needed
Can miss small polyps
Full bowel preparation needed
Some false positive test results
Cannot remove polyps during testing
Colonoscopy will be needed if abnormal
CT Colonography (Virtual Colonoscopy)
Fairly quick and safe
Can usually view entire colon
Done every 5 years
No sedation needed
Can miss small polyps
Full bowel preparation needed
Some false positive test results
Cannot remove polyps during testing
Colonoscopy will be needed if abnormal
Still fairly new - may be insurance issues
Fecal Occult Blood Test (FOBT)

No direct risk to the colon
No bowel preparation
Sampling done at home
Inexpensive

May miss many polyps and some cancers
May produce false-positive test results
May have pre-test dietary limitations
Should be done annually
Colonoscopy will be needed if abnormal
Fecal Immunochemical Test (FIT)
No direct risk to the colon
No bowel preparation
No pre-test dietary restrictions
Sampling done at home
Fairly inexpensive
May miss many polyps and some cancers
May produce false-positive test results
Should be done annually
Colonoscopy will be needed if abnormal
Stool DNA Test
No direct risk to the colon
No bowel preparation
No pre-test dietary restrictions
Sampling done at home

May miss many polyps and some cancers
May produce false-positive test results
More expensive than other stool tests
Still a fairly new test
Not clear how often it should be done
Colonoscopy will be needed if abnormal

Source: American Cancer Society

Free Colon Cancer Testing for the Uninsured and Underinsured
In New York State, screening rates have improved; but a recent report from the American Cancer Society shows that the uninsured are less likely to receive recommended cancer screening tests, including colon cancer screening.

In Monroe and surrounding counties, free colon cancer testing is available to adults age 50 or older with little or no health insurance through the NYS Cancer Services Program. Call 1-877-293-0822 to learn more.

American Cancer Society guidelines for the early detection of colon cancer:

Risk Category Age to Begin Recommended Test(s) Comment
INCREASED RISK -- Patients With a History of Polyps on Prior Colonoscopy
People with small rectal hyperplastic polyps Same as those with average risk
Colonoscopy, or other screening options at regular intervals as for those at average risk Those with hyperplastic polyposis syndrome are at increased risk for adenomatous polyps and cancer and should have more intensive follow-up.
People with 1 or 2 small (less than 1 cm) tubular adenomas with low-grade dysplasia 5 to 10 years after the polyps are removed Colonoscopy Time between tests should be based on other factors such as prior colonoscopy findings, family history, and patient and doctor preferences.
People with 3 to 10 adenomas, or a large (1 cm +) adenoma, or any adenomas with high-grade dysplasia or villous features 3 years after the polyps are removed Colonoscopy Adenomas must have been completely removed. If colonoscopy is normal or shows only 1 or 2 small tubular adenomas with low-grade dysplasia, future colonoscopies can be done every 5 years.
People with more than 10 adenomas on a single exam Within 3 years after the polyps are removed Colonoscopy Doctor should consider possibility of genetic syndrome (such as FAP or HNPCC).
People with sessile adenomas that are removed in pieces 2 to 6 months after adenoma removal Colonoscopy If entire adenoma has been removed, further testing should be based on doctor’s judgment
INCREASED RISK – Patients With Colorectal Cancer
People diagnosed with colon or rectal cancer At time of colorectal surgery, or can be 3 to 6 months later if person doesn't have cancer spread that can't be removed Colonoscopy to view entire colon and remove all polyps If the tumor presses on the colon/rectum and prevents colonoscopy, CT colonoscopy (with IV contrast) or DCBE may be done to look at the rest of the colon.
People who have had colon or rectal cancer removed by surgery Within 1 year after cancer resection (or 1 year after colonoscopy to make sure the rest of the colon/rectum was clear) Colonoscopy If normal, repeat exam in 3 years. If normal then, repeat exam every 5 years. Time between tests may be shorter if polyps are found or there is reason to suspect HNPCC. After low anterior resection for rectal cancer, exams of the rectum may be done every 3 to 6 months for the first 2 to 3 years to look for signs of recurrence.
INCREASED RISK – Patients With a Family History
Colorectal cancer or adenomatous polyps in any first-degree relative before age 60, or in 2 or more first-degree relatives at any age (if not a hereditary syndrome). Age 40, or 10 years before the youngest case in the immediate family, whichever is earlier Colonoscopy Every 5 years.
Colorectal cancer or adenomatous polyps in any first-degree relative aged 60 or older, or in at least 2 second-degree relatives at any age Age 40 Same options as for those at average risk. Same intervals as for those at average risk.
HIGH RISK
Familial adenomatous polyposis (FAP) diagnosed by genetic testing, or suspected FAP without genetic testing Age 10 to 12 Yearly flexible sigmoidoscopy to look for signs of FAP; counseling to consider genetic testing if it hasn't been done If genetic test is positive, removal of colon (colectomy) should be considered.
Hereditary non-polyposis colon cancer (HNPCC), or an increased risk of HNPCC based on family history without genetic testing Age 20 to 25 years, or 10 years before the youngest case in the immediate family Colonoscopy every 1 to 2 years; counseling to consider genetic testing if it hasn't been done Genetic testing should be offered to first-degree relatives of people found to have HNPCC mutations by genetic tests. It should also be offered if 1 of the first 3 of the modified Bethesda criteria is met.1
Inflammatory bowel disease
-Chronic ulcerative colitis
-Crohn's disease
Cancer risk begins to be significant 8 years after the onset of pancolitis (involvement of entire large intestine), or 12 to 15 years after the onset of left-sided colitis Colonoscopy every 1 to 2 years with biopsies for dysplasia These people are best referred to a center with experience in the surveillance and management of inflammatory bowel disease.

Source: American Cancer Society

Resources
American Cancer Society 1-800-227-2345 cancer.org
New York State Cancer Services Program 1-877-293-0822

 

About the Author 

Jeffrey Goldstein, MD Jeffrey Goldstein, MD

Jeffrey A. Goldstein is a private gastroenterologist who owns the Digestive Center of Western NY, located at the medical office building of Rochester General Hospital. A graduate of the University of Rochester Medical School, Dr. Goldstein completed his residency at Strong Memorial Hospital and his fellowship at Jackson Memorial Hospital/University of Miami School of Medicine. He is currently on the faculty and serves as an attending physician at Rochester General Hospital's Gastroenterology Unit. He is a member of the American College of Gastroenterology and a member of the Monroe County Board of Advisors for the American Cancer Society (Lakes Region). Dr. Goldstein has published extensively in his area of clinical expertise.

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