Colorectal cancer is the second leading cause of death among cancers. For decades, Kentucky had some of the the highest colon cancer incidence rates and mortality rates in the nation. But, in recent years the commonwealth has made remarkable progress in reducing both incidence and mortality from colon cancer due to a rigorous, comprehensive screening outreach initiative started by the Colon Cancer Prevention Project, which was formed in 2004.
On this episode of Kentucky Health, host Dr. Wayne Tuckson speaks with the founder of the Colon Cancer Prevention Project about the best protocols for colon cancer screening and risk factors for getting the disease.
Dr. Whitney Jones, MD, is a gastroenterologist with Gastroenterology Health Partners in Louisville. Since starting the Colon Cancer Prevention Project (CCPP), Jones has been recognized nationally for his advocacy, including winning the 2011 Laurel Award for Advocacy from the Prevent Cancer Foundation. Kentucky’s rank for colon cancer screening has risen from 49th prior to the organization’s founding to 20th currently.
Reflecting on the formation of the CCPP, Jones says “it was really a catalytic and facilitative organization to try to engage other people involved in cancer prevention and really redirect and reapportion resources, because we were the number one state in the nation for colon cancer deaths. And half of our mortality for screenable cancers was from colon cancers.
“I think everyone has gotten on board, everyone is doing a great job, statewide we have a few challenges left, but we’re certainly making a difference,” he says.
Encouraging and Troubling Trends
Jones says that colorectal cancer ranks behind lung cancer in overall annual deaths, both nationally and in Kentucky. He points out that for persons over age 55, the incidence and mortality rates for colorectal cancer are decreasing. “That is a testament to the fact that people are getting screened at higher and higher percentages,” he says.
On the other hand, for people under age 55, incidence rates for colorectal cancer are increasing. This upsurge in diagnoses is driven by higher rates of rectal cancer in particular. “Rectal cancer, which is the last part of the colon, is becoming more important as we move into this new era where colon cancer is changing,” Jones says.
The rising rates of colorectal cancer among middle-aged people are due to a variety of factors, Jones says. Genetics play a role, and lifestyle habits as well, but so far the main cause has not been determined.
“We believe it’s something in our exosome, something we’re ingesting, something we’re eating, perhaps something that we were exposed to,” he says. “There’s a condition called the birth cohort. This is not a United States issue – this is around the world. Something affected people right around the late 1980s to 1990 that has dramatically increased their risks of both rectal cancer and colon cancer, particularly rectal cancer. ”
Incidence rates for this group of people are projected to rise even more in the next several years, which makes early screening even more important as a preventive tool. Jones notes that four out of the last five patients he has diagnosed with colorectal cancer have been under age 50. “This is dramatic,” he says.
An important aspect of rectal cancer and colon cancer located close to the rectum – called left-sided colon cancer based on the position of the colon inside the body – is that they tend to have symptoms, since stool is harder as it nears the exit of the colon and obstruction can occur.
“The biggest things to think about are any kind of rectal bleeding, change in bowel habits, weight loss, and unexplained abdominal pain,” Jones says. “People with a family history of colorectal cancer, or what we call advanced adenomas or large polyps, those folks need to have a special heads-up and be thinking about what their risks are, in their early thirties or even their twenties.”
Genetic Testing and When to Start Screening
Jones says that thanks to the efforts of CCPP and other advocates, health care providers are becoming more collaborative in coordinating their screening protocols to identify and consult persons who have a genetic predisposition to getting colorectal cancer.
Genetic testing done by a medical professional gives a detailed and accurate blueprint of a person’s DNA makeup, and it is far less expensive than it was 15 years ago, Jones says. He acknowledges that the public is becoming more aware of the benefits of genetic research through the popularity of ancestral history products such as 23 and Me, but declares that persons who want to gain a full understanding of their risks for colorectal cancer and other cancers with a genetic component must get comprehensive, “medical-grade” testing.
The most common genetic trait for colorectal cancer is Lynch syndrome, Jones says. A person with Lynch syndrome also has an increased risk of getting ovarian cancer, endometrial cancer, pancreatic cancer, and several other related cancers. Jones states that only 1 in 10 persons are diagnosed with Lynch syndrome prior to receiving a cancer diagnosis – a number that must be improved upon in order to save lives. He explains that polyps in the colon develop into cancer faster for persons with Lynch syndrome or other genetic predispositions, often in less than three years.
In addition to genetics, there are several lifestyle habits that increase one’s risk for getting colorectal cancer, Jones says. They are:
- Obesity
- Tobacco use, especially smoking
- Lack of exercise
- Alcohol intake
- Eating too much red meat
These habits are also linked to a myriad of other diseases, Jones says, making his overall advice for patients to adopt a healthy lifestyle simple and consistent.
Age recommendations for colorectal cancer have recently been lowered, Jones says. These guidelines have shifted because, as noted above, more and more people in their forties, thirties, and even twenties are being diagnosed with colorectal cancer – roughly 10-15 percent of all diagnoses.
Jones says that about 20 percent of people are at increased risk for colon cancer because of family history. “If you have a first-degree relative (parent or sibling) with colon cancer or an advanced adenoma – which is, in layman’s terms, a ‘big ol’ polyp’ – then you need to start at age 40 or ten years prior to when your family member had that problem,” he explains.
For persons who are asymptomatic and have no family history, in Kentucky the recommended age to begin colorectal cancer screening is 45, Jones says. As for when to stop preventive screening, Jones says that the guideline is age 75 for persons who have had clean tests and no family history. But for people who have had polyps discovered and removed over the years, or who have been diagnosed with colorectal cancer, surveillance screening continues into the seventies and eighties.
More Screening Options Than Ever Before
Getting a colonoscopy may be something that most people shy away from initially, due to its invasive nature and its expected cost. But cost is no longer an issue for screening colonoscopies, Jones says.
“The Affordable Care Act made certain screening and preventive services no cost-sharing procedures,” Jones says. “Colorectal cancer screening fits that list. So if you’re asymptomatic and at normal risk – or even if you are at high risk, because of family history or issues – screening colonoscopies are covered in the state of Kentucky.”
Jones says that getting a screening colonoscopy is absolutely essential for persons at elevated risk for colorectal cancer, since it gives the most thorough and detailed visualization of the entire colon, which is roughly six feet long. To prepare for a colonoscopy, the patient must restrict their diet for a day or two and then drink a medication to cleanse the bowel on the evening and morning prior to the procedure. The gastroenterologist will insert a 5 ½-foot long tube roughly the diameter of a pinkie finger into the anus and guide it through the colon’s twists and turns to where it meets the small intestine.
The tube, affixed with a camera, is then slowly removed while the gastroenterologist scans the inner surface of the colon and searches for polyps. If any are found, they are removed during the procedure with a lasso or snipping tool, Jones explains.
“Removal of polyps, not just identification of them, but removal of them, actually prevents colon cancer from happening,” Jones says.
Most people in Kentucky get screened with colonoscopies, Jones says, but relatively new products are now on the market that provide other options for persons who have no family history and are asymptomatic.
“Those mainly include stool testing options called the fecal immunohistochemical test, also known as the FIT, or a FIT with stool DNA, and there’s a prominent one advertised on television all the time with a little box talking to us,” Jones says. “Essentially they are not only looking for blood in your school, but also for DNA changes there.”
Jones says that either of those stool-based options have an equal chance of lowering one’s chance of dying from cancer. “If you don’t want to get a colonoscopy – and there are a lot of folks that don’t want to get a colonoscopy, and I get it – then there’s an option for you still, and you can still get screened, and you can still prevent colon cancer death,” he says. “So that’s a take-home message.”
If results from a FIT test come back positive, Jones says it is imperative that the person schedule a colonoscopy as soon as possible. As for those persons who are found to have polyps during a colonoscopy, they must adhere to their physician’s schedule for follow-up or surveillance screenings.
“Too often, someone gets a couple of polyps, they wake up, they’re a little woozy from the test, they don’t really get the significance of it, and they don’t really think that follow-up is important,” Jones says. “These strategies only work when we follow the guidelines.”
There are two main types of polyps that exist in the colon, and the ones of concern are adenomatous polyps. These polyps are usually benign but have the potential to grow and mutate into cancerous tumors. Jones says that if these polyps are found – and are large in size or if there are several of them – then a follow-up colonoscopy is scheduled in three years. For persons who have small, benign polyps, or scope clean and have no family history, the follow-up may be scheduled for five, or even ten, years.
“Know your options and get screened on time. Because you get no benefit from putting it off,” Jones advises. “The real magic of colon cancer screening occurs when you do the screening test: you get protection after that. There’s no protection just because you need it, you haven’t done it, and you’re feeling okay. Because the most common symptom of colon cancer is no symptom at all.”
For more information on the CCPP and on colorectal cancer in Kentucky, view the documentary “Catching a Killer: Colon Cancer in the Bluegrass” on KET’s website.
