Thomas Jefferson University Hospital - Better Detection, Increased Awareness Highlight Progress against Colorectal Cancer, Jefferson Experts Say

Better Detection, Increased Awareness Highlight Progress against Colorectal Cancer, Jefferson Experts Say

Physicians and patients both can do more than ever before against colorectal cancer

Colorectal cancer – the third most common cancer in the United States and the second leading cause of cancer death – takes the life of some 56,000 Americans each year.

Yet, colorectal cancer stands apart from other major cancers.

“Colon cancer is different than the other cancers because we are screening for precancerous growths – not the cancer,” says Richard Wender, MD, Professor and Chair of Family Medicine at Thomas Jefferson University Hospital and Jefferson Medical College (JMC) of Thomas Jefferson University.

Since 90 to 95 percent of all colon cancers stem from polyps, tiny abnormal growths in the colon, finding and removing polyps can prevent cancer from developing.

“That’s why there is such an opportunity here,” says Dr. Wender. “Theoretically, we could prevent 90 percent of the deaths, but current screening rates enable us to prevent death for only one third the amount.

“The real challenge is to make sure that both physicians and their patients get the appropriate information so that lives can be saved,” he says.

A,B: Colon polyps, C: Colon cancer

Screening Choices
A host of screening tests exists. For those over the age of 50, or at particularly high risk from either family history or inflammatory bowel disease, most current guidelines from nationally recognized organizations recommend any of several tests, including a fecal occult blood test (FOBT) annually, a flexible sigmoidoscopy either in conjunction with the FOBT or by itself at least every five years, or a double barium contrast enema every five years. The colonoscopy, considered the gold standard of screening, is also recommended at age 50 and once every 10 years after that.

According to Dr. Wender, patients are increasingly mixing screening tests. While most current guidelines recommend a colonoscopy by age 50, he says, many individuals say they are not ready for a colonoscopy and decide on an FOBT, a simple, do-it-yourself test that looks for blood in the stool. “It’s conceivable that you’ll see official guidelines stating that, for example, flexible sigmoidoscopy and FOBT in combination are a good initial test along with a one-time colonoscopy at age 60. If no polyps are seen, then perhaps an annual stool test 10 years later. Guidelines are a rapidly changing area,” he says.

Still, all roads lead to colonoscopy for a nearly complete view of the colon.

Screening Saves Lives
The incidence of colon cancer has leveled out, Dr. Wender says, not surprising given improved awareness and screening methods. The real impact has come in the death rate from the disease, which has been declining in women since the 1950s and in men since the 1980s.

“We are making progress against colon cancer and cancer in general,” Dr. Wender says. “We know as of the year 2000, cancer screening saves lives.”

Anthony Infantolino, MD, Clinical Director of Endoscopic Ultrasound and Photodynamic Therapy at Jefferson Hospital and Clinical Professor of Medicine at JMC, still sees a problem in awareness. Doctors need to stress the benefits of screening because many people don’t realize they are at risk for colorectal cancer.

At the same time, some patients don’t want to go through the preparation for tests such as the colonoscopy, which includes an uncomfortable process to clean the bowls. In addition, many women have the misconception that colon cancer is mainly a male problem, though women are just as likely to develop the disease.

Ronald Myers, PhD, sees another problem: poor follow-up. About half of those individuals with abnormal colorectal cancer screening results fail to have the necessary follow-up examination, says Dr. Myers, who is Professor of Medicine at JMC. He suggests that primary care physicians pay particular attention to such individuals, and even provide “targeted education” to encourage such individuals to take appropriate steps in their care.

Technology Abounds
Improved screening technology has been a key to improving the fight against colorectal cancer, says Jefferson Hospital radiologist Anna Lev-Toaff, MD, Professor Radiology at JMC. As the use of colonoscopy becomes increasingly widespread, a newer technique under study, virtual colonoscopy, is gaining popularity. Virtual colonoscopy entails using X-rays delivered through a CT scanner to take cross-sectional views through the abdomen, then reconstructing those views with special software. The resulting images provide the same view of the colon, more or less, as does an optical colonoscopy. Virtual colonoscopy is less invasive and relatively quick.

Colonoscopy, notes Dr. Lev-Toaff, isn’t perfect. It may be incomplete roughly one-third of the time because the intestines can be convoluted, with crevices, twists and turns, making it difficult to see the entire colon. While virtual colonoscopy does not have that problem, she says, studies comparing the two techniques have given mixed results.

Virtual colonoscopy will eventually develop more of a role in screening, notes Anthony J. DiMarino Jr., MD, William Rorer Professor of Medicine and Director of the Division of Gastroenterology and Hepatology at JMC and Jefferson Hospital. But for now, “It is a technique in evolution.”

Treatment Choices
If found early, colorectal cancer is 90 percent curable, says Scott Goldstein, MD, Director of the Division of Colorectal Surgery at JMC. Dr. Goldstein explains that it’s crucial to detect the cancer when it remains inside the intestine because it is there that surgeons can remove the disease. The odds worsen when the cancer spreads to other areas of the body, such as the lymph nodes and the liver. Depending on where the disease has spread, oncologists often treat the patient with chemotherapy.

As with most cancers, doctors worry about the disease returning. Dr. Goldstein notes that patients are seen every three months after colorectal cancer surgery for the first two years. Approximately 80 to 85 percent of colorectal cancers return in the first two years.

The Genetic Piece
About 65 to 70 percent of colorectal cancers are sporadic with no family history involved. Roughly 10 to 15 percent occur where a family member has the cancer. A much smaller percentage includes those with hereditary cancer, the most common of which are FP and HNPCC.

According to Bruce Boman, MD, PhD, Director of the Division of Genetic and Preventive Medicine at Jefferson Hospital and JMC, 1 in approximately every 400 people has a genetic mutation that predisposes him or her to develop colorectal cancer. The key is to identify these individuals before the develop cancer.

“It often begins with a patient who is diagnosed with colorectal cancer,” says Dr. Boman, who is also Professor of Medicine at JMC. “Genetic counseling is recommended if the patient has either a family history of colorectal cancer or is younger than age 60 when diagnosed with it. Once we identify someone with a genetic mutation for colorectal cancer risk, we can then screen the rest of their family to see if they carry the mutation.

“Once we confirm the mutation,” Dr. Boman concludes, “we can institute measures such as aggressive screening with colonoscopy to remove pre-malignant polyps before they develop into cancer – an approach that will save many lives.”

Internet Broadcast Available
Recently, a panel consisting of several of the aforementioned Jefferson Hospital experts on colorectal cancer presented an Internet broadcast, “Colorectal Cancer - The facts can save lives.” To view a replay of this webcast at your convenience, click here .