Colonoscopy: The ‘Minor Inconvenience’ That Saves Lives

**By Vlad V. Simianu, MD, MPH**

Helen Nind

Helen Nind

Learning she had colorectal cancer last year surprised Helen Nind. The 55-year-old mother of two had no family history of the disease, no symptoms and generally felt healthy. But the suspicious polyp that was found and removed during her first colonoscopy proved malignant.

According to the American Cancer Society (ACS), colorectal cancer is the third most common cancer diagnosed in both men and women in the U.S. In 2019, the ACS estimates there will be more than 101,000 new cases of colon cancer and more than 44,000 new cases of rectal cancer.

Risk factors
Research has shown that links between colorectal cancer risk and a person’s diet, weight and activity level are some of the strongest for any type of cancer. Lifestyle-related risk factors include:

  • Being overweight or obese. Carrying excess weight raises the risk of colorectal cancer in both men and women, but the link seems to be stronger in men.

  • Physical inactivity. A sedentary lifestyle is associated with a greater chance of developing colorectal cancer. Being more active can help lower your risk.
  • Dietary choices. A diet high in red and processed meats may increase your colorectal cancer risk.
  • Smoking. People who have smoked tobacco for a long time are more likely than non-smokers to develop colorectal cancer and die from it.
  • Drinking alcohol. Colorectal cancer has been linked with moderate to heavy alcohol use.

“The minor inconvenience . . . is nothing compared to what the alternative might be. If they can catch a problem early, the treatment is going to be much easier.” — Helen Nind

There are also risk factors for colorectal cancer that aren’t related to lifestyle, including:

  • Age. Risk goes up with age, which is why screening colonoscopies have been recommended starting at age 50. However, due to an increase in the disease among younger adults, some national medical organizations are considering lowering the recommended age for screening.
  • Family history. Nearly one in three people who develop colorectal cancer have other family members who have had it. People with a history of colorectal cancer in a parent, sibling or child are at increased risk. The risk is even higher if that relative was diagnosed with cancer when they were younger than 45, or if more than one first-degree relative is affected.
  • Inflammatory bowel disease (IBD). Colorectal cancer risk increases if you have IBD, ulcerative colitis or Crohn’s disease.
  • Inherited syndromes. About 5% of people who develop colorectal cancer have inherited gene changes (mutations) that contribute to the disease. The most common inherited syndromes linked with colorectal cancers are Lynch syndrome (hereditary nonpolyposis colorectal cancer, or HNPCC) and familial adenomatous polyposis (FAP).
  • Racial and ethnic background. African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the U.S. Jews of Eastern European descent (Ashkenazi Jews) have one of the highest colorectal cancer risks of any ethnic group in the world.
  • Type 2 diabetes. People with type 2 diabetes are at increased risk for colorectal cancer. They also tend to have a less favorable prognosis after diagnosis.

Treatment
Helen Nind underwent robotic-assisted surgery to remove the cancerous polyp and surrounding tissue. As part of the surgery, a number of her lymph nodes were removed and examined. Unfortunately several were cancerous, requiring a regimen of chemotherapy.

When I asked Helen what she would tell someone facing colon cancer, she recommended having a family member or friend attend appointments as another set of ears. This person can also help take notes and remember information shared at the visit and ask questions the patient may not think about.

“Someone I know who had been through cancer treatment advised me to keep a diary to note any changes or health concerns,” says Helen. “I found this very helpful for recalling things when meeting with my care team.”

Screening guidelines
The current ACS recommendation is that people at average risk of colorectal cancer start regular screening at age 45. This can be done either with a sensitive test that looks for signs of cancer in a person’s stool (a stool-based test), or with an exam that looks at the colon and rectum, such as colonoscopy. As part of the screening process, all positive results from stool-based screening tests should be followed up with a colonoscopy.

Although Helen put off her colonoscopy after turning 50, she now regularly encourages people to follow screening guidelines. “The minor inconvenience of the prep was not as bad as I had thought,” she says. “It is nothing compared to what the alternative might be. If they can catch a problem early, the treatment is going to be much easier.”


Simianu_2018Vlad V. Simianu, MD, MPH, is a general surgeon who practices at Virginia Mason Hospital and Seattle Medical Center. He specializes in colon, rectal and anal cancer with an emphasis on minimally invasive techniques. Other areas of expertise include Crohn’s disease, ulcerative colitis, diverticulitis, polyposis syndromes, rectal prolapse and pelvic floor disorders. Dr. Simianu is actively conducting research on colorectal cancer and diverticulitis.

When Colon Cancer Spreads: Advanced Treatments Help People Live Longer, Better

**By Flavio G. Rocha, MD**

Cancer that starts in the colon can sometimes spread to other parts of your body, including the liver. Another name for it is metastatic, or stage IV, colon cancer.

Colorectal cancer is the third most common cancer diagnosed in both men and women in the United States. The American Cancer Society estimated that in 2016 more than 95,000 new cases would be diagnosed, and it was expected to cause more than 49,000 deaths last year.

Symptoms

As with many malignancies, symptoms vary depending on tumor size and where it has spread in your body. Some people with colon cancer that has spread to the liver don’t 3D human male x-ray digestive system.have symptoms. In other cases, they can include:

  • Bloody stool
  • Abdominal pain
  • Belly swelling
  • Feeling sick and tired
  • Weight loss

Diagnosis

Your doctor might find that the disease has spread to your liver when he or she first diagnoses you. Or, after you’ve been treated, the colon cancer can come back and spread to your liver.

It is normal to worry when you have cancer that has spread. But treatment can make a real difference with symptoms, quality of life and longevity.

Your physician will help determine if you need surgery, chemotherapy, radiation or other liver-focused therapy. Doctors may be able to remove or shrink the tumor. Afterward, you’ll need to keep up with your doctor visits to stay symptom-free.

To determine location and size of the cancer, your doctor may order one or more imaging tests, including:

  • CT (computed tomography) – Powerful X-ray that makes detailed pictures of the inside of your body
  • MRI (magnetic resonance imaging) – Powerful magnets and radio waves that create pictures of organs and internal structures
  • PET (positron emission tomography) – Uses radioactive particles, or tracers, to find disease inside the body
  • Liver biopsy – Removing a tiny sample of the liver to test it
  • Colonoscopy – Visual inspection inside the colon using a camera-enabled scope

Being your own best health advocate

In today’s health care environment, most people understand that patients – along with their opinions and decisions – play an important role in the delivery of care. By advocating for themselves and getting involved in decision making, they can reap numerous benefits.

That is why I tell patients who are diagnosed with cancer that they should ask a lot of questions of their physician, such as:

  • What treatment or treatments will work best for me? What is involved with each?
  • How long will I need treatment?
  • What is my outlook?
  • What problems or side effects could I have? How will they be managed?
  • Should I consider participating in a clinical trial? If so, can you recommend one?
  • Could I benefit from a second opinion? If so, will you recommend another physician to get one from?
  • How often should I see you for follow-up appointments?

Treatment options

Even if the malignancy has spread to a person’s liver, the tumor is still made up of colon cancer cells. For that reason, your doctor will treat it like colon cancer, not liver cancer.

You may get one or more types of treatment. While the mainstay of treatment is chemotherapy, the only potential curative option for colon cancer that has spread to the liver is surgery, when possible.

Thanks to medical advances, there are numerous options for treating liver metastases either alone or in combination.

The innovative techniques described below allow surgeons to remove or “resect” multiple tumors in both lobes of the liver based on the liver’s ability to regenerate. The liver is a unique organ in that it can regrow after surgery, a property called “hypertrophy.” Surgeons can safely remove up to 80 percent of the liver and expect full regeneration in six to eight weeks as long as a patient doesn’t have substantial underlying liver disease, such as cirrhosis or chemotherapy-related liver injury. This is why it’s important to see both a surgical – and medical – oncologist prior to starting any therapy.

  • Parenchymal-sparing surgery – This surgical approach includes resection of individual liver segments (there are eight) performed alone or in combination with ablative therapies, where heat is used to destroy a tumor. Advantages of this strategy include removing less normal liver, which results in a quicker recovery and better chances for future resections, if necessary.
  • Portal vein embolization – This procedure induces regrowth on one side of the liver in advance of a planned resection on the other side. To be suitable, a patient must have enough functional liver remaining after the operation. However, the body requires that a minimum amount of liver remain (liver reserve) to support regrowth. If the liver reserve can’t support regrowth, surgeons may use portal vein embolization to jump start growth before surgery.
  • Two-stage hepatectomy – In this approach, tumors on one side of the liver are removed followed by tumors on the other side after a period of liver regeneration, which is usually on the heels of a portal vein embolization.
  • Microwave or radiofrequency ablation – In this approach, microwaves or an electric current are transmitted into the tumor through a thin needle or probe to heat and destroy liver tumors without removing them. It is used in patients with a few small tumors when surgery isn’t a good option.
  • Laparoscopic hepatectomy – This approach, which is a viable alternative to traditional resection, uses a laparoscope – a viewing tube with a small camera – to perform minimally invasive surgery through small incisions. Advantages can include less surgical stress, early discharge from the hospital, and rapid return to a normal diet and activity.

Other non-surgical treatments include:

  • Chemotherapy
  • Radiation (e.g., external beam radiation, radioembolization and brachytherapy)
  • Targeted therapies, also called “biologics”
  • Immunotherapy (prevention or treatment of disease with substances that stimulate immune response)

Perspective and promise

It is important to remember that every patient’s case is unique. Although these treatments may not cure your cancer, the goal is to help you live a longer, better life.

Researchers around the world are also involved in clinical trials looking for new, innovative ways to treat colon cancer that has spread. These trials test new drugs to see if they’re safe and effective. Clinical trials are often a good way for people to try new medicine that isn’t available to everyone. Your doctor can tell you if one of these research opportunities might be a good fit.

Taking care of yourself

Cancer patients go through a lot when battling a malignancy. During treatment, it’s especially important to rest, exercise, manage stress and eat well. During this trying time, it’s also important to get emotional support. Family, friends, social workers and therapists can be invaluable.

Hope

Treatments for colon cancer that has spread to the liver have greatly improved over the last quarter century. I encourage all my patients to take solace in the fact that people with this cancer are surviving longer than ever.


Dr. Flavio RochaA version of this article originally appeared in Seattle’s LocalHealthGuide. Flavio G. Rocha, MD, has advanced training in surgical oncology and specializes in liver, biliary tract and pancreatic cancer. He is director of research in the Digestive Disease Institute at Virginia Mason and an affiliate investigator at Benaroya Research Institute. Dr. Rocha practices at Virginia Mason Hospital and Seattle Medical Center (206-341-1904).

Getting a Good Colonoscopy

It is easy to talk about preventing colorectal cancer through healthy lifestyle choices and screening. But discussing how to get a good colonoscopy is a more awkward subject. Most of us will start getting routine colonoscopies beginning at age 50 — an important tool in the fight against colorectal cancer. Yet, no one really wanted to discuss their personal colonoscopy experiences with me. Though, one co-worker did offer up that her encounter with a colonoscopy “really wasn’t that bad” and suggested drinking the bowel prep laxative cold versus room temperature.

Step 1
This leads me to the first step in getting a good colonoscopy: good colon prep. And with so many things in life, the first step may be the hardest. Prepping your colon usually involves dining on a special low-fiber diet and drinking what I’ll call a laxative punch (best served cold, according to the anonymous co-worker). A process that causes some “mild to moderate abdominal cramping” after partaking in the preparation and, more honestly, probably an unpleasant day spent in the bathroom.

“We know the prep required is a challenge, but a clean colon is essential for a good exam” says gastroenterologist Johannes Koch, MD, with VM’s Digestive Disease Institute. “If the colon isn’t properly prepped, the procedure can take longer, polyps and lesions may be missed, and the whole thing may need to be repeated sooner or even rescheduled.”

Step 2
Dr. Koch also told me that good preparation is just one part of the quality colonoscopy equation. After the patient completes a good bowel prep, the endoscopist must do their part. “The most important part of an optimal colonoscopy is a careful examination of the entire colon by the endoscopist. Patients should ask the provider about their performance on key quality metrics/outcomes,” he explained.

There are several measures of quality outcomes beyond low complication rates, but the adenoma detection rate is one that is commonly used and easy to understand. During a colonoscopy, the doctor pushes the endoscope to the top of the colon and slowly withdraws it, looking for adenomas (aka benign tumors or polyps). When an adenoma is found (detected), it is removed during the procedure. According to the American Cancer Society, removing polyps can help prevent colorectal cancer from ever starting. Adenoma detection rate refers to the percentage of time at least one polyp is found during all the colonoscopies performed by an individual doctor. When this rate falls below 20 percent, the risk of colorectal cancer diagnoses in their patients goes up. Therefore, you want to get a colonoscopy from a doctor whose adenoma detection rate is at least 20 percent.

Step 3
Of course your doctor’s adenoma detection rate loses much of its luster if you don’t receive timely pathology results from tissue samples taken during the procedure. Ask your physician how and when your results will be reported to you. You can also ask about the qualifications of the pathology team where your samples go for review and interpretation.

As with all preventive health screenings, the bottom line is that early detection saves lives, so be sure to do your part to help boost the process. Besides, no one should have to drink laxative punch without feeling assured that all significant polyps were removed.