According to The American Cancer Society, excluding skin cancers, colorectal cancer is the third most common cancer diagnosed in both men and women in the United States. People may fear a screening colonoscopy for many reasons, however, this is simple, painless test could save your life.
The team at Boston Medical Center is widely known for their expertise in colorectal cancer screening, diagnosis, and treatment.
Joining the show to clear up some of the confusion surrounding colonoscopies, and the importance of a screening colonoscopy to prevent colon cancer, is David Lichtenstein, MD. He is BMC's Director of Endoscopy Services.
David Lichtenstein, MD
David Lichtenstein, MD is BMC’s Director of Endoscopy Services. He has expertise in endoscopic diagnosis and management of gastrointestinal disorders.
Learn more about David Lichtenstein, MD
Melanie Cole: Colorectal cancer is the second leading cause of cancer-related deaths among men and women combined. However, there are tests that can actually prevent or detect colon cancer and its earliest stages. My guest today is Dr. Lichtenstein. He's the director of endoscopy services at Boston Medical Center. Welcome to the show. What are some of the risk factors for colon cancer?
Dr. David Lichtenstein, MD: Probably the strongest risk factor would be a family history of the first degree relative, in particular, had either a precancerous polyp or a prior colon cancer particular if it occurred at a younger age, then there's an increased risk that first degree family members would also have potential development of colon cancer. That would be first-degree relative, meaning parents, brothers, sisters or children. Other risk factors are things like obesity, cigarette smoking, diabetes, some of which are uncontrollable and some of which can be prevented. There are some dietary factors as well – a high-fat diet and potentially red meats appear to be a risk factor as well.
Melanie: What tests can be done to detect and diagnose colon cancer? Speak about colonoscopy and who should have them.
Dr. Lichtenstein: Probably the most widely utilized and best-known test for colon cancer detection and prevention is a colonoscopy. What the colonoscopy entails, essentially, it’s an examination of the colon, which is the same thing as the large intestine, it’s a test that’s specifically done as an outpatient procedure. The test itself is usually 20 to 30 minutes in length with the time spent at the endoscopy unit either an in-hospital based test or as an outpatient in an ambulatory surgery center. It's done typically with sedation and the instrument that's used is just a thin flexible device that can be navigated through the colon and allows in high definition imaging the ability to see the lining of the colon with the goals to be either finding cancer which is uncommon or preferably a precancerous growth called a polyp. Polyps, if they are detected during the procedure, can be removed at the time of the colonoscopy and it's a painless process to remove a polyp.
Melanie: When should somebody have their first colonoscopy and then thereafter based on whether or not you find polyps?
Dr. Lichtenstein: Assuming there are no worrisome signs, for instance, bleeding with bowel movements or there aren’t any high-risk situations like an underlying colitis condition or a family history of colon cancer, the average person should start colon cancer screenings at age 50. One of the benefits of colonoscopy is that it’s tested. It needs to be done frequently unlike other cancers that sometimes require an annual screening colonoscopy; it’s recommended only at 10-year intervals for the average risk population that neither has polyps or family history of cancer.
Melanie: You mentioned that one of the things that might send somebody to see a GI doc would be bleeding, but people get scared. They see blood in the toilet and it could be hemorrhoids. When do you say ‘I need a colonoscopy?’
Dr. Lichtenstein: You're right. Most frequently, bleeding is attributed to hemorrhoids because it’s usually the most common condition that’s identified as a cause for bleeding, but regardless of the amount of bleeding, it should always be investigated by a physician, even if it’s just a small amount of blood on the toilet tissue paper, and not necessarily a large amount in the toilet bowl, it should still be confirmed as hemorrhoids. At a young age, it may be adequate to do a limited examination, a shorter version of a colonoscopy, called a sigmoidoscopy, or a flexible sigmoidoscopy, that doesn't require the sedation that a colonoscopy does. For any individual over the age of 40 that has rectal bleeding, even on a single occasion, it’s very important to undergo at least a one-time colonoscopy to confirm the presence of hemorrhoids and to ensure that it’s not some other alternative process like a polyp, cancer, colitis or other conditions that can bleed from the large intestine.
Melanie: Colonoscopies are a pretty easy exam and I would imagine that people go in there and say ‘when are you going to start’ and you’ve already finished. Explain a little bit about how easy this is and how the prep is really what most people are afraid of.
Dr. Lichtenstein: A lot of people have the preconceived notion that colonoscopy is either complicated, painful, they’ve heard a story from a friend who had a bad experience, but the reality is that for the overwhelming majority of people that undergo a colonoscopy, it's a completely painless procedure that's done with sedation at different levels either administered to a moderate level for comfort by the physician or by an anesthetist sometimes for the point of a deep sedation. In almost all instances, the patient is breathing on their own, it's not general anesthesia and the medication wears off rather quickly afterward, but it's a comfortable procedure. It's uncommon to experience pain during or after the procedure and, like you mentioned, the most difficult part of the procedure is the bowel preparation because the preparation is very important to empty out all the food that was eaten in the days prior to the procedure; otherwise, the doctor performing the procedure can't see adequately inside the colon.
The key to an effective colonoscopy is to be able to see all areas of the colon to identify the precancerous polyps which, if present, can be removed at the procedure. The bowel preparation is definitely the most difficult component for the person undergoing the colonoscopy. It does involve drinking anywhere from a half gallon to a gallon of liquid depending on the different bowel preps that are available. Hopefully, that'll improve in the future.
Melanie: As someone who has had them before, I can attest for the listeners that the prep is not that bad and you actually feel very cleansed. It’s actually really not a bad feeling. If you find a polyp, that can be another scary thing. What do you want people to know about those polyps that you removed and whether they should be worried when they hear ‘I removed a few tiny polyps, no big deal?’
Dr. Lichtenstein: If anything, it should be a feeling of relief and not fear for any person that's had polyps removed. The advantage of having the colonoscopy and having the polyps removed is that the risk for you to have colon cancer in the future has been reduced dramatically by having those polyps removed. The only time there should be a real concern would be for an individual that has a cancerous type of polyp, which is uncommon, and something that would be discussed by the gastroenterologist or surgeon that's actually performing the procedure. If it’s a small polyp or a non-cancerous polyp, the removal of the polyp essentially eliminates the risk of that particular polyp sequentially growing into colon cancer, but it does change the interval of follow-up for the following colonoscopy, something that we call surveillance colonoscopy. Instead of coming back, for instance, in 10 years like I mentioned previously where the average person that doesn't have polyps or cancer, the follow-up colonoscopy is done more frequently for those individuals that do have polyps. The intervals depend on the size and type of the polyps that are removed at the colonoscopy.
Melanie: Wrap it up for us because this is really good information to clear up some of the confusion and the fear that surrounds colonoscopy, but as you said, it’s not something to be afraid of; it’s something to be relieved about. Now, this is even covered as a wellness visit or a wellness screening, correct?
Dr. Lichtenstein: Correct. It's extremely important to undergo colon cancer screening. As you mentioned initially, it's the second leading cause of cancer that's in the United States and it's a large preventative cancer. By undergoing colonoscopies at recommended intervals, we can prevent probably 75% of colon cancers, and for the first time in the last 10 to 15 years, it's been demonstrated in the United States that both the occurrence of colon cancer and the deaths from colon cancer are decreasing substantially. It's still very important since we see about 140,000 new colon cancers a year in the United States and roughly 40,000 deaths per year, so almost one in three individuals that develop colon cancer have a fatal outcome. This is a preventative disease and it's something that can be prevented by a test that's performed as an outpatient procedure, both safely and conveniently once every 10 years.
Melanie: It’s certainly is and thank you so much for really such great information. This is Boston Med Talks with Boston Medical Center. For more information, you can go to bmc.org. That’s bmc.org. This is Melanie Cole. Thanks for tuning in.