By Dr. Aleksandr Sokolovsky
According to the CDC, colorectal cancer is the second leading cancer killer in the U.S. What makes it so dangerous is that it is very difficult to detect without actually visualizing it firsthand. In other words, very few symptoms warn a person they may be developing this type of cancer, since it lives inside the body. This makes prevention and screening extremely important starting at the age of 45.
What is a Colorectal Screening or a Colonoscopy?
Colorectal screening is one of the most important parts of what I do, because I get to prevent something that could be potentially fatal to a patient in a fairly short period if it is missed. The symptoms of the disease don’t occur until it is well developed and they frequently t a later stage when the condition is much more difficult to cure.
What is Colorectal Cancer?
Colorectal cancer develops from a benign polyp inside the colon. It’s like having a small mole on your skin. It could be there be benign for many years. Then, all of a sudden, it starts changing after sunlight exposure and becomes a skin cancer. It’s a very similar process inside the colon. Unfortunately, we can’t see the inside of the colon readily. So a benign polyp that was present for a few years could become malignant and grow larger. It is very difficult to detect unless you go looking for it. If you have a colonoscopy starting at the recommended age of 45 and we remove one, two, three or more benign non-cancerous polyps, then we have prevented them from slowly growing potentially into cancer over time.
Once the cancer grows large enough, it can cause bleeding, obstruction, and perforation of the colon. It can spread to other organs and can eventually become fatal if it isn’t treated. Some of the symptoms are bloody or black stools, changes in bowel habits, constipation, difficulty passing stool, bloating, indigestion and nausea. If the tumor causes bowel perforation, it becomes an acute issue causing patients to go to the hospital urgently or the emergency department.
The CDC states that nine out of every ten people whose colorectal cancers are found early and treated appropriately are still alive five years later.
Are Colonoscopies Effective?
Colonoscopies are extremely effective. Unfortunately, in our society, the colonoscopy is stigmatized and we need to fight against that, because the good it does far outweighs the inconvenience or discomfort associated with the procedure. The discomfort of a colonoscopy is minimal nowadays because, you are under sedation through the entire process.
Yes, there’s a little bit of discomfort the day before when you have to drink the laxative and go to the bathroom. This is not pleasant, but that’s the extent of it. The procedure itself causes no pain. It takes about 30 minutes and the patient wakes up in the recovery room frequently surprised and saying, “Is it over yet?”
Why did the American Cancer Society Change its Age Recommendations for an Initial Colonoscopy?
The American Cancer Society changed the recommended age of getting your first colonoscopy from 50 to 45. That’s because we have been seeing more precancerous polyps and malignant tumors developing in the younger population.
Family history is the number one risk factor for colorectal cancer. This disease is very much related to genetic changes, which is often why folks who lead a healthy lifestyle develop polyps and cancer. So much of this condition is genetic that you can do everything right and you can still develop precancerous polyps. If you don’t remove them in time, they could still turn into cancers and tumors and cause more advanced diseases.
Who is at Risk for Colorectal Cancer?
Having said that, there are risk factors that make the disease more likely to occur. Smoking, for example, has been shown to increase all kinds of cancer risks including colon cancer. Smoking is probably the greatest non-genetic risk factor. Other well-studied and proven aspects of increased cancer risk are inflammatory bowel diseases, Crohn’s and ulcerative colitis.
There have been studies to determine if there are ways to reduce risk factors, such as being active, avoiding red meat, eating more fiber-oriented foods and taking certain vitamins. However, the evidence to support those claims is somewhat weak and as physicians, we make recommendations based on strong and reliable evidence
Yes, a healthy lifestyle is always a good thing, but from my personal experience, I can tell you that there are plenty of folks out there who lead a very healthy lifestyle, but for some reason choose not to have the screening done. Unfortunately, I’ve seen way too many of those folks come to me in their sixties or sometimes even seventies, for their first colonoscopy, because now they have symptoms and they end up with terrible colorectal cancer disease.
What is the Process for Getting a Colonoscopy?
Gifford General Surgeon, Dr. Aleksandr Sokolovsky performing a procedure
These days, colonoscopies are very noninvasive procedures and they’re pretty straightforward. After the appropriate bowel preparation the night before (taking the laxative and cleaning out the colon), the patient comes into the hospital on the morning of the procedure. We’ll put in the I.V. and get the patient comfortable before bringing them into the endoscopy suite for sedation. The procedure takes about half an hour. Usually, we use a flexible endoscope, which is a tube approximately 1½ to 2 centimeters thick. It’s six feet long and flexible so we can advance it to the very high part of the colon where it joins with the small intestine. That way we can examine the entire colon from top to bottom. We inflate the colon with CO2 gas (Carbon Dioxide is resorbed by the colon much faster than regular air, causing a lot less cramping after the procedure). We do this so we can directly visualize the entire colon wall. Frequently, we will also get into the small intestine just to make sure there are no polyps or abnormalities. If we see any kind of growths or polyps, we remove them. We have small tools to do that. Then we cauterize the area so there’s no bleeding afterward. If we see a larger tumor or mass, we mark the area with dye and take biopsies for appropriate diagnosis. Then we wake up the patient and give them something to eat and drink, after which the patient is ready to go home.
Once we remove the polyp, we will send it off to the pathology department where it will be sectioned into small pieces and put it under a microscope for examination. That will tell us what type of polyp it is and how much of a malignant potential it carries. We get that result within a week. I usually see my patient for a follow-up seven to ten days after the procedure, give them the results and tell them the next steps.
Is a Colonoscopy safe?
It’s a very safe procedure, but like any procedure there are risks. One of the potential risks is bleeding. If we’re removing polyps or taking biopsies, those little areas can bleed a little bit. That’s why we frequently cauterize. But usually, it’s self-contained bleeding and stops on its own pretty quickly. Every once in a while there is delayed bleeding from an area where we take a polyp out. Very rarely is it clinically significant. In other words, we very rarely have to give a patient a blood transfusion or have them admitted to the hospital for bleeding.
Even a rarer, but obviously more serious complication is a perforation of the bowel. Any time we put an instrument inside any part of the intestine, there is always a risk that that bowel can get perforated or ruptured by that instrument. Again, this is an extremely rare occurrence. In my 20-year career over thousands of these procedures, I’ve had two bowel perforations.
How Often Do I Need A Screening?
If a patient doesn’t have any family history of colorectal cancer or colorectal polyps and has their first colonoscopy at 45 years old, they don’t have to have another one for 10 years if no polyps are found. If a patient does have a family history of colorectal cancer, especially in first-degree relatives (mother, father, sister, brother, children), then they should have their screening colonoscopy done every 5 years starting at age 45. If the patient has polyps found on their first colonoscopy and they are considered precancerous or adenomatous, then the gastroenterologist or the surgeon may recommend that they have their next colonoscopy done sooner than five years. It depends on what type of polyp it is and how worried that particular practitioner is about it.
Are At-Home Tests Reliable?
Several at-home tests we used for a long time rely on just detecting blood in the stool. They are good tests to try to detect microscopic blood in the stool. Unfortunately, it does not detect any precancerous polyps. It detects either cancer already so large that it’s already bleeding or it can catch bleeding hemorrhoids that have nothing to do with cancer. It’s a test that doesn’t have very good sensitivity or specificity for colorectal cancer. In the past few years, we’ve had a couple of different additional tests, including Cologuard.
Cologuard is a good test. It does detect certain DNA patterns from the colorectal cancer, so it’s more than just a test for blood cells. It is fairly good in detecting developed colorectal cancer with 92% effectiveness. That means it has an 8% chance of missing colorectal cancer and as a physician who does this for a living, I always look at that side of it.
Unfortunately, the literature that was used to approve this test also states that it detects between 42% and 50% of pre-cancerous polyps that are larger than one centimeter. Most of the polyps we remove during a colonoscopy are in a range of 2 to 5 millimeters or only half a centimeter. Cologuard would have an even harder time detecting such small polyps.
In my mind, Cologuard is useful, but I don’t think it’s as useful for preventing cancer as it is for detecting it. It’s good to be able to detect the cancer early, but it’s better in my mind to prevent the cancer from happening in the first place. I don’t think that Cologuard does that and I think the Cologuard folks understand that. They published this research openly so it’s in their literature.
Cologuard has excellent potential for folks who either absolutely will not do a colonoscopy or who cannot have a colonoscopy, because they’re not medically cleared for it. But, for a person who is healthy enough to have it, the colonoscopy is still the gold standard by a long stretch.
Gifford General Surgeon, Dr. Aleksandr Sokolovsky
Can I Wait Until After the Recommended Age To Get My Initial Screening?
Even if you don’t want to get a screening every ten years, I encourage folks to get that initial screening at least for your peace of mind and your doctor’s peace of mind. Then, you make decisions about future procedures down the road, but it’s very important to have that first one done. If you get it done and nothing is found, you’ve got nothing to worry about for a long time.
Again, with this particular type of cancer, when you start to get symptoms, it might be too late. Fortunately, with colorectal cancer, we have ways of detecting it early. Other cancers like pancreatic or lung cancer don’t have that option.
For more information on Colorectal Cancer Screening recommendations made by the U.S. Preventative Services Task Force, click here.
To learn more about the general surgery department at Gifford call 802-728-2430 or go to giffordhealthcare.org and click on services for General Surgery.
