Dr. Ian Cohen, a Mount Sinai gastroenterologist, says age is a key risk factor for colon cancer. Photo: Courtesy of Mount Sinai
Here's the good news: since the Citywide Colon Cancer Control Coalition was formed in 2003 to advise the New York City Department of Health, colon cancer screenings among New Yorkers aged 50 and older has increased from 42 percent to 69 percent in 2017. So the word is getting out that colon cancer screening saves lives. However, many people are still procrastinating, and while some things can be put off in life, colorectal cancer screening is not one of them.
March is Colorectal Cancer Awareness Month, a great reminder to get screened. Colorectal cancer is second only to lung cancer as the leading cause of death in the United States. In New York State, about 9,000 men and women are diagnosed with colon cancer every year, with about 3,200 dying from it annually. And more than 51,000 are expected to die from colorectal cancer nationwide this year. It is estimated that about one in every 20 people will be diagnosed with colon cancer at some point in their life.
If all that isn't motivation enough, consider this — according to the American Cancer Society, the colon cancer death rate could be nearly cut in half if people followed recommend screening guidelines.
You may think you're not at risk, since you may eat well and exercise, but when it comes to risk factors, age is key. According to the Centers for Disease Control and Prevention (CDC), nearly 90 percent of colon cancer cases occur in people who are 50 or older. The lifetime risk of developing colorectal cancer is similar in men and women, with the median age of colon cancer diagnosis for men at 68 and women at 72; while the median age for rectal cancer is 63 for both. And younger adults can get colon cancer too — with this proportion of cases nearly doubling from 6 percent in 1990 to 11 percent in 2013. (Colon cancer in people under 50 may be more likely associated with heredity or other conditions, such as inflammatory bowel disease, known as Crohn's disease, or ulcerative colitis.)
A colonoscopy is the most thorough way for a physician (usually a gastroenterologist) to directly examine and evaluate the colon for disease and then, if necessary, to therapeutically act on it during the same procedure. This is particularly advantageous for colon cancer screening and the removal of precancerous polyps. There is up to a 90 percent reduction in colorectal cancer risk following a colonoscopy and polypectomy. The colonoscope is a thin, steering instrument with a high definition camera and light source on one end that allows the physician to traverse the entire large intestine, which is about three to four feet long.
The most common concerns people have about a colonoscopy are the preparation for it and if it will be painful. It's true that before a colonoscopy you will be required to drink a solution (with or without some pills) that will clean your colon of all residual stool. Today, there are a multitude of different preparations (large and small quantities, by prescription and over-the-counter) for this. As for the second worry, a colonoscopy is usually not painful. Almost all colonoscopies are now performed using sedation where you will feel drowsy and comfortable, while also breathing on your own. The most common type of sedation used also has an amnesic component, so patients do not remember the procedure. A thorough discussion with your health care provider can help determine the most appropriate preparation and sedation regimen for you.
If you still resist the colonoscopy, there are other screening methods. The fecal immunochemical test (FIT) is a stool test that may detect small amounts of bleeding that some colon cancers and polyps may create. The stool DNA test, commercially known as Cologuard, also checks your stool for certain gene changes that can be found in colon cancer cells. A flexible sigmoidoscopy is similar to a colonoscopy, except that it only evaluates the distal one-third of your large intestine. A virtual (or CAT scan) colonography is an imaging test designed to look for colon polyps and cancer. The take home point is to at least choose one method in consultation with your health care provider. And please note that when an alternative screening modality has an abnormal finding, the recommendation is to proceed with a colonoscopy.
Finally, keep in mind that the guidelines listed below are for people at normal (or average) risk of developing colon cancer at 50, the currently recommended age to begin screening. (Last year, the American Cancer Society made a recommendation to begin screening of all average-risk individuals starting at age 45. This proposal remains under review by other societies and task forces, and has not been approved yet by insurance carriers.)
• Colonoscopy every 10 years
• Annual FIT test
• Flexible sigmoidoscopy every 5 to 10 years
• Virtual colonography every 5 years
• Stool DNA test (Cologuard) every 3 years
You may be at a higher risk of getting colon cancer if you have:
• A family history of inherited colorectal cancer syndromes, such as familial adenomatous polyposis (FAP) or hereditary nonpolyposis colorectal cancer (HNPCC)
• A family history of colorectal cancer or polyps. This usually means close relatives (parent, sibling, or child) who developed these conditions prior to the age 60.
• A personal history of colorectal cancer or polyps
• A personal history of inflammatory bowel disease (ulcerative colitis or Crohn's disease)
• Are African American. The American College of Gastroenterology has recommended initiating screening for this patient population at the age of 45 due to a higher rate of colorectal cancer at younger ages.
If you are in a higher risk category, you should speak to your health care provider as screening may commence at the age of 40, or even earlier.
Most early colorectal cancers produce NO symptoms, which is why getting screened for colorectal cancer is so important. Some possible symptoms of colorectal cancer, which do not always indicate the presence of cancer, warrant an evaluation by your health care provider. These include:
• New onset abdominal pain
• Rectal bleeding in or on your stool, even if you think it may be from hemorrhoids
• Persistent changes in stool caliber and shape
• A significant change in your bowel habits including constipation and diarrhea
• Unexplained weight loss
As with most cancers, there are ways to reduce your risk of colorectal cancer, in addition to appropriate screening. Adhere to a healthy diet that maintains an appropriate weight. The diet should maximize consumption of vegetables, fruits and whole grains while limiting red meat and processed meats ssuch as, bacon, sausage and hot dogs. Also, exercise regularly, avoid tobacco products and limit alcohol intake.
But above all, get screened, by whichever screening method you will actually follow through on. And never hesitate to speak with your health care provider. That's what we're here for.
Ian Cohen, MD is an Assistant Professor of Medicine (Gastroenterology) in the Division of Digestive and Liver Disorders at Mount Sinai Beth Israel