Every year when March rolls around I remember when one of my friends found out he had colon cancer at the age of 42. It hit me hard because he was a friend, and I was about to celebrate another birthday. This apparently random cancer chose him instead of me and it didn’t seem fair. In the years since we’ve learned that we can influence the outcome of colorectal cancer. Colorectal cancer (CRC) is the third most common cancer diagnosed in both men and women and the second leading cause of cancer-related deaths in the United States. This month-long observance educates the public about risk factors, symptoms, and the critical need for early detection through screening. My friend’s case is not so unusual after 25 years of survival we have watched the number of cases in younger age groups rise. From 2004 to 2018 the incidence of CRC increased by 1 percent per year under the age of 50 prompting our standard bearers to recommend moving the first year of “routine screening” to 45 from 50 years old.
What is the standard for CRC screening? One simple technique is the yearly “FIT test." FIT is performed on a small sample of stool that the patient provides in a special container. FIT requires only one stool sample and does not require restrictions on medications or diet prior to providing the sample; foods with peroxidase activity (horse radish) do not produce a false-positive FIT. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) generally do not need to be temporarily discontinued to do a FIT test. The FOBT or fecal occult blood test is not as sensitive and does require dietary and medication changes inconveniently tested over 3 different days vs the one day FIT. Cologuard is a composite of tests that include molecular assays to test for DNA (KRAS) mutations and the features of the FIT test too. The stool collection kit is available by prescription and is sent to the patient through the mail with no dietary or medication restriction. If negative, it is generally accepted to have effectively screened out CRC for 3 years. It costs about $600 and is less than the Shield test which recently announced it accepted the $920 reimbursement every 3 years from CMS down from the previous ask of $5000! It’s advantage is the convenience of a blood sample, but it is not as sensitive as Cologuard in the early stages of disease. If you would like to learn more about the Guardant Shield test, you can register for a March 24thwebinar at: https://apgorg.zoom.us/webinar/register/WN_PC50JgV1T42lUooBqlyrcQ#/registration
Colonoscopy is the definitive test for detection of precancerous adenomas and CRC with high sensitivity and acceptable specificity. If any of the above tests are positive, colonoscopy is the next step with its ability to biopsy, remove dangerous polyps and reduce deaths due to CRC. It is time consuming with extensive prep, anesthesia and risks of bleeding. It is still our gold standard.
Can we reduce the risk of CRC proactively? Some risks are just genetic and if there’s a family history of CRC, Breast Cancer (Lynch Syndrome), FAP (Familial Adenomatous Polyposis) or a personal history of Ulcerative Colitis then heightened awareness and meticulous monitoring is required. For most of us, avoiding unhealthy diets high in red meat and low in fiber will help. Diabetes and Obesity contribute statistically to CRC. Cigarette smoking has been associated with CRC. Moderate or diminished alcohol and adequate amounts of Vitamins D, B6, and calcium may help prevent CRC. Fish, garlic, magnesium and even coffee have been associated with reduced CRC incidence. The use of statins, aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) may protect against the development of colonic adenomas. Hormone Replacement Therapy(HRT) in post- menopausal females is linked to a reduced risk of CRC. Even ACE inhibitors, antioxidants and bisphosphonates have been associated with reduced incidence of CRC!
Takeaways:
- The proportion of new CRC cases among adults under the age of 55 years increased from 11 to 20 percent between 1995 and 2019. Heed the new age of routine screening at 45
- You have choices about how to screen, but Colonoscopy is still the gold standard
- There are many ways to minimize your risk of developing CRC, but anyone can still get the disease
Written by: Dr. Jeff Stone, MD
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