Tim: And here we are again direct from Roswell Park Cancer Institute in Buffalo, New York, with Cancer Talk Live.
I'm Tim Wenger, and this time, this session, we're talking about colorectal cancer and colorectal cancer with specificity toward the direction of high-risk patients. At the end of this session, you'll know exactly what we mean. You'll know who those people are, and you'll know what Roswell Park can do for you or for your loved one who, you might be viewing this and thinking about at this time.
Throughout the evening, we'll take questions from you live via Twitter. We have a hashtag all set. It's on the screen beside me, and that hashtag is #CRCTalk. And over the course of the past several weeks we've been collecting questions from you, not from me, questions from you about high-risk patients with colorectal cancer or concerns about colorectal cancer.
Who will answer the questions tonight? Certainly not me. We've got the panel of experts here from Roswell Park Cancer Institute, and we'll start over here to my right and that is Dr. Steven Nurkin. Dr. Nurkin, welcome to our webinar tonight.
Dr. Steven Nurkin: Thanks for having me.
Tim: Thank you very much. You are a surgical oncologist here at Roswell Park, and you specialize in gastrointestinal and precancerous conditions and cancers of the colon and rectum. Thank you for being here again.
Dr. Nurkin: My pleasure.
Tim: And by your side we've got Dr. Nicoleta Voian, Dr. Voian, Director of the Clinical Genetics Service here at Roswell Park. And you help individuals to understand their cancer risk based on their personal and family history. We're going to talk a lot about that tonight, so I really appreciate you being here as well.
Dr. Nicoleta Voian: Thank you for having me.
Tim: And way over here by my side we've got Dr. Andrew Bain. Dr. Bain, welcome. Chief of Endoscopy and Assistant Professor of Oncology here at Roswell Park, and you work specifically in Roswell's new state-of-the-art Endoscopy Center and perhaps we'll find out a little bit about what that state-of-the-art facility is, so thank you.
Dr. Andrew Bain: Thanks, Tim.
Tim: Dr. Nurkin, I'd like to start with you. Just some basics, some 101, about colorectal cancer if you would.
Dr. Nurkin: Sure. Colorectal cancer is the fourth most common cancer in adults in the United States. It's the second leading cause of cancer related deaths. And what probably is the most important, it's one of the most preventable.
We know that people can develop some changes with the lining of the colon that lead to the formation of polyps or overgrowths. These polyps or overgrowths we know if left long enough, can potentially turn into cancer. We know from large studies that having these polyps removed can reduce your rate of not just developing cancer, but from dying from cancer over many, many years.
So there are a subset of patients or people that can have a propensity of growing some of these polyps. These people are considered at an increased risk of not just polyp formation, but of cancers. And specifically, there are groups that have a high-risk or a high propensity for the development of these cancers such as people with some of the hereditary genetic cancer syndromes.
Most of the people that might be viewing tonight and most of the public is really considered average risk. The average risk folks, which makes up about 80% of the new colorectal cancer diagnosis, which we call sporadic cancer, new cancer diagnoses occur in these average risk folks. So these are people that are over the age of 50, no history of polyps, especially adenomas or precancerous polyps. No family history of cancer or advanced polyps, no medical conditions that can increase the risk of developing colorectal cancer such as inflammatory bowel disease like ulcerative colitis or Crohn's disease.
So if you fall in that population, you really are considered average risk. And usually those guidelines are to start screening at least at the age of 50. That will change if you are considered more at an increased or high risk for developing colorectal cancer.
Tim: A lot of us fall into that average bucket, but a lot of us out there tonight are more concerned. And there are high-risk patients and families of patients that really have some questions, and Dr. Voian, that's why you're here with your specialty in genetics. With regard to this specialization that we're talking about tonight, let's talk a little bit deeper and a little bit more about who is at high-risk. What do we need to know there?
Dr. Voian: So definitely the patients who are referred to our clinic fall in the remaining 20-25%, so beside the sporadic which is the majority of colorectal cancer, the rest is familial or inherited predisposition for cancer. And the red flag is for somebody who is at high-risk due to family history or having an inherited predisposition for colorectal cancer are young age of onset for colorectal cancer, or having adenomatous colon polyps more than ten, having family history of colorectal cancer in multiple family members on the same side of the family, having a family history of colon cancer and other cancers that we know that can be associated with a syndrome like uterine cancer, ovarian cancer, thyroid cancer. These are red flags for somebody who needs to be referred to our clinic.
And if appropriate after reviewing their personal history and family history, we will offer genetic testing to identify if that person carries a mutation that would predispose him or her to an increased risk for colorectal cancer and to try to establish their risks. And we collaborate with Dr. Nurkin and Dr. Bain because even if they don't carry a mutation, having family history they need personalized screening starting earlier. And having the colonoscopy, the interval would be reduced compared with general population at risk.
Tim: Once that determination is made and someone is determined to be high-risk, it all comes down to what kind of diagnostic services are available. And here at Roswell Park, those are great and those are many, and that's why Dr. Bain is here, or at least part of the reason that you're here tonight. Talk about what happens and what is available to a patient here once we get to the point where, yes, we need to be screened.
Dr. Bain: So whether you're at high-risk for colon cancer or average risk, the gold standard for screening for colon cancer is truly a colonoscopy, which most of you know about. But there is another long list of options, which is good because it can be tailored for you, but it can also be confusing because there's a long list of different tests that you can get to detect colon cancer.
Besides colonoscopy, there's flexible sigmoidoscopy. There is a CAT scan devoted to the colon, or CT colonography. There's tests that detect microscopic amounts of blood in the school. And there's a few newer tests like a capsule, a pill capsule that you can swallow that images and takes pictures of your colon that are sort of newer and under investigation. So all these things are good and there's a lot of research and studies going on to determine what is the best, but we'll work through some of these different modalities as the questions come up.
Tim: And some of those questions have already come in to RoswellPark.org over the course of the past several weeks or so, and we're taking questions live on Twitter too. I just want to keep reminding you of that, use that hashtag. The hashtag is #CRCTalk. It's on the screen over here beside me as well, #CRCTalk. Some of those questions are already coming in.
I want to start with the question now that was submitted via the website over the course of the past couple of weeks. Dr. Nurkin, I'll start with you on this. A gentleman writes us and says, "As a 54-year old man in good health with colorectal cancer in close family history, how often should that gentleman be screened?"
Dr. Nurkin: That is an extraordinarily important question. So again first of all, at 54 years old, if he hasn't gotten the colonoscopy, if you haven't gotten the colonoscopy yet, you should be getting one. So even if you are considered average risk, the recommendation, some of the national recommendations are to start your screening at age 50.
It really is important to get a detailed family history whenever somebody is getting risk assessed for colorectal cancer. So the close proximity, it's important whether it's a first-degree relative versus a second degree and others. So really learning about that family history is critical. If it's just one family member, depending on when they were diagnosed, if it's a close family member, even a father or a brother that was diagnosed at age 80, then most likely what's common is common and that is a sporadic cancer. So this gentleman may very well be an average risk person, but should still start getting his colonoscopies at age 50. So he should probably get one if he hasn't got one already.
Then to determine how often he needs one really is dependent on what is found at the time of that colonoscopy. Whether there are polyps that are found specifically adenomatous polyps, how many were found at that time, so that will determine what interval needs to be, or how he needs to be followed after that first initial scope.
Tim: All right. And as the questions come in, we'll get to them. And here's another one. Dr. Voian, I'm going to start with you on this one. It is kind of wordy, so get the thinking cap out right now. "I've recently been diagnosed with FAP. I'm having my colon and rectum removed in April. What is the likelihood of the polyps spreading beyond the colon after removal?"
There's more to the question but we'll start there and you’ll haved cut through the lingo of FAP for us too.
Dr. Voian: So FAP is the abbreviation for familial adenomatous polyposis, which is an inherited predisposition for colorectal cancer. It's a serious condition. It's an autosomal dominant inheritance mode. So if the patient was diagnosed with familial adenomatous polyposis, I would like to know if he or she was tested and a mutation in the APC gene was identified, or the diagnosis was just made clinically. Because if you have a colonoscopy and have more than a hundred colon polyps, a clinical diagnosis can be made.
Identifying APC mutation for the FAP families is very important because we can test other family members. As I mentioned previously, having done autosomal dominant inheritance mode means that each of the caller's children will have a 50/50 chance to inherit the condition. We know that people with FAP would have an increased risk for colorectal cancer, and they will start to develop polyps in their teenage years. By age 20, there'll be multiple polyps. And many of them will have to have colectomy because the burden of polyps is really very high.
And we know there are other extracolonic manifestation of this disease. Sometimes they have polyps in the upper tract, and that's why we recommend colonoscopy and upper scope, at least a baseline, to see if there are any polyps in the stomach or duodenum, because the duodenal cancer is the second cancer for people with familial adenomatous polyposis. And the interval of screenings need to be estimated based on the findings of the colonoscopies or upper GI.
Tim: That viewer was also interested in reading material where they can find information. I always direct people directly to RoswellPark.org, and they can certainly call Roswell Park and get information.
Dr. Voian: Correct. Calling ASK-RPCI. That family can be offered a genetic counseling appointment. Because screening for people who have a mutation in the APC gene, so they have familial adenomatous polyposis, should begin with a colonoscopy by age 10 to 15, so very early. And we can provide material appropriate for a young child or a teenager specifically written for them.
Tim: All right. Again RoswellPark.org, a wealth of information on that website. You can always get all you want right from there, and certainly by calling Roswell Park at 877-ASK-RPCI. They certainly can help you and direct you to qualified information, and that's 877-275-7724.
Dr. Bain, we're going to go right to some of the live questions that are coming in, and I think this one is directed rather right at you. "Can you discuss the advantages of advanced diagnostics such as endoscopic ultrasound for colorectal cancers?"
Dr. Bain: Sure. The mainstay of finding polyps in colon cancer is colonoscopy. There's been a lot of advances with the technology for endoscopes that we use to do colonoscopy, and most scopes that are used nowadays are high definition, and these are very useful for detecting small polyps. And a type of polyp that has been getting a lot of press lately is a flat polyp, and the newer scopes are very good at detecting these flat polyps.
Endoscopic ultrasound is another version of an endoscopy where there's an ultrasound probe at the end of the scope. This doesn't have a huge role in colon cancer. It is used for rectal cancer, mainly after rectal cancer has been diagnosed. Endoscopic ultrasound is a good way to stage rectal cancer to determine how early or how late it is. But for looking at polyps which are benign growths in the colon and for staging colon cancer outside of the rectum, it's actually not very useful. But definitely has a use in rectal cancer, but not so much for colon.
Tim: All right. This is Cancer Talk Live. We are live from Roswell Park Cancer Institute in Buffalo, New York. We are talking about high-risk colorectal cancer. And the next question, Dr. Nurkin, somewhat vague, but I think an opportunity really for yourself and for anyone else here, Dr. Voian or Dr. Bain, to talk about screening again. And this comes from a female viewer. "Should I have additional screenings other than colonoscopy, mammograms, and annual gynecological exams?"
Dr. Nurkin: Well, that is also going to depend on if they do fall into some of the increased risk, high-risk, or some of these hereditary conditions. So there are some what we call extracolonic sites, other areas or associated cancers that are related to some of these cancer syndromes that we discussed. So familial adenomatous polyposis (FAP) Lynch syndrome, some of the other known polyposis syndromes, have their own associated cancers. So I think one of the benefits of coming to a place like Roswell, or some place similar to Roswell, is the focus on a multidisciplinary approach for handling some of these difficult diagnoses and some of these inherited syndromes.
Having a team of experts that are involved in those different cancer sites and are familiar with what cancers you are at risk for by having some of these genetic syndromes, is critical. I think staying on top of the literature, being familiar with some of the new genetic mutations that are coming out.
What’s been fascinating to me is some of the pre-submitted questions of people coming in, really educated on not just their Lynch syndrome, for example, but what specific mutation that they have, which is important because in the past everything was just grouped together as, say, a Lynch syndrome. But now we're learning more and more about what specific mutations are coming in, what specific mutations these individuals have, and their associated risks of developing, not just colorectal cancer, but other cancers. And we can really tailor their screening and their surveillance depending on their exact mutation. And being on top of this and having world experts like Dr. Voian, for example, to kind of oversee some of that and stay on top of the literature is critical. And again, I think that's one of the benefits of coming to a place like Roswell for your high-risk screening needs.
Tim: And I've seen those questions as they've been coming in over the past couple of weeks, and like you, I'm very impressed with the level of knowledge that people have which tells me that we've really struck an area of interest out there with regard to high-risk colorectal cancer.
Dr. Bain, we're going to jump over to you for this next pre-submitted question off the website prior to the webinar tonight. "What kind of screening is required to find out if you're more likely to get colorectal cancer? My mom, my grandmother both had cancers in this area of the body. My mom just recently passed away from the disease. What else can I do to prevent the disease?"
Dr. Bain: I think the important thing that makes a distinction between average risk and high-risk is family history and your personal history. So the more you know about what medical conditions your family has, whether it's colon cancer or whether it's other types of cancers, breast, ovarian, endometrial, that can all play into what risk you are for developing colon cancer, and also your own history. Have you had a colonoscopy in the past? If so, how many polyps were found and what type of polyps were they? That all goes into the formulas that we use to figure out whether you're average risk and you can have your next colonoscopy in five or ten years, or whether you're at high-risk, where you might need additional genetic testing or have more closer surveillance.
Tim: If you're out there on Twitter, the hashtag again is #CRCTalk. And Dr. Nurkin, you want to jump in on that.
Dr. Nurkin: Yeah. It's something else to add because I think the follow-up question was prevention, and there've been a number of questions that have been coming in over the week or so on how can you maybe reduce your risk.
For the high-risk groups, some of the inherited syndromes, getting screening and surveillance in some of these groups is of course critical, and we can't stress the importance of getting your colonoscopy, getting those polyps removed. Good screening is not just identifying. It's both preventing cancer and catching it early on. So again the focus of getting your screening, increasing awareness for screening, and getting your appropriate screening tests like colonoscopy.
With regards to prevention, a lot of the data that's out there with regards to reducing your risk of developing colorectal cancer is stuff that we try to do every day, these modifiable risk factors. So things that have been known to reduce the risk of developing polyps and also cancers are good heart healthy and good living. So stop smoking. Introducing more, get more of those fruits and vegetables, about five servings a day of fruits and vegetables everyday. Alcohol in moderation, don't overdo it. Reducing your red meat intake, processed meats, physical activity, getting your daily allowance of good physical activity, getting up, getting around, reducing the risk of a sedentary lifestyle and all the complications that come with that. So it's good heart healthy, good common sense, good living, treating your body well. And life also is for enjoyment, so everything in moderation. But those are some of the things that have been associated with maybe colorectal cancer prevention.
Some of the new and exciting research that has been out there that I'm starting to mention more and more to patients is maybe getting on aspirin. We know that polyp development and cancer development has some inflammatory component to it. So there's been some emerging data over the past few years on trying to reduce some of that inflammation with some of those medications such as NSAIDs, non-steroidal anti-inflammatory medications, and aspirin showing reduction in polyp development, and also even after being treated for colorectal cancer, showing some good outcomes. So that's some of the newer stuff.
There's some other stuff that was just recently presented at ASCAL looking at vitamin D and taking that. So with regards to maybe adding aspirin to your daily regimen, maybe vitamin D and other things. I would definitely talk to your primary care physician on seeing if whether or not that would be beneficial for you, not just for cardiovascular health, but also for cancer prevention strategies.
Tim: Every two months or so I stand here at Roswell Park, and we talk about a different area of expertise. But every time we do it, somehow, some way, the details of diet, exercise, tobacco, and alcohol come up which really is an important thing to think about. Because I mean like you said, everything in moderation. It seems to cross all cancers as far as prevention is concerned.
Dr. Nurkin: Yeah, many, many.
Tim: All right. Dr. Nurkin, thanks so much for that. The next question that came in via Twitter, I think Dr. Voian, I'll start with you, and I think Dr. Bain might have something to add to it. "I have a family history of colon cancer in my mother and sister. Can I be screened at Roswell Park?"
I think there's probably an easy answer and a longer answer.
Dr. Voian: So definitely the caller is very appropriate for the high-risk colorectal clinic and it would be very important to learn how old were the family members when they were diagnosed with colorectal cancer because it is very important to know your family history, especially the ages when the cancer diagnosis was made. And also were there any polyps during the time when the diagnosis was made. If that caller will definitely start seeing the high-risk colorectal clinic, she or he may be appropriate for genetics, again based on the ages of diagnosis and maybe the type of colorectal cancer they had.
Tim: I'd like to pause for just a moment and ask you this about screening someone for the high-risk. We've gone through the parameters and what you look for, but if someone out there is concerned, what do they do? Call?
Dr. Voian: So they will call ASK-RPCI, and there is a very good, I would say great team that will triage them based on different questions regarding family history and personal history. They will be screened to see if they are appropriate for high-risk colorectal clinic only for the GI component, or if they are appropriate for genetics also, or if they are appropriate for other high-risk clinics, because we have high-risk breast clinic and we have high-risk GYN clinic. And many times cancer can run in a family in multiple ways, so we have people who are appropriate for high-risk breast clinic and also high-risk colorectal clinic. So it will be very important to call ASK-RPCI to identify the exact risks and where that person needs to be seen, whether just by the high-risk clinic and/or the genetics.
Tim: Dr. Bain, I think it's an opportunity for you to jump in and talk about the screening at Roswell Park and the multidisciplinary aspect of colorectal cancer screening that's available here to that person, and obviously, so many others.
Dr. Bain: Sure. I think if the patient is identified as being someone who qualifies for high-risk, they would get an office visit with Dr. Nurkin or myself, and we would talk about the risks and go over the various options for screening. And average risk there are a lot of different options, but with colonoscopy being the gold standard.
But for high-risk, really it is important to stress the need for a colonoscopy because these are patients that are above the average population risk for having polyps and for having colon cancer. So these patients might not be the best patients to get a blood stool test or a flexible sigmoidoscopy because the chances of them having polyps that you need to remove are higher. So they probably should go right to a colonoscopy, which is the gold standard. And colonoscopies are offered at Roswell as well as many excellent places in the community, so I don't think there is a lack of places to get a good quality colonoscopy.
Tim: All right. Dr. Nurkin, this question again presented I think very simply, but I think the answer could maybe a little bit complex. "I have screening every three years. In that time I grew five polyps. Am I high-risk cancer?"
Dr. Nurkin: Yeah, so we see these kinds of patients all the time. They're just polyp makers. And again, sitting down and having a detailed discussion about if they have some modifiable risk factors that we can correct, like we discussed before. Some of the physical activities, some of the smoking, really encourage some of those changes in lifestyle and getting not just heart healthy, but colon healthy. And then obtaining a family history as well, if there is a family history of colorectal cancer, a lot of polyps that run in your family. If there are some of the associated cancers that may be sending off alarms that there’s a reason why you're a polyp maker, then we would try to identify those, and then go more in the direction of some possibly genetic testing.
A lot of the times people just like you that have multiple polyps, especially quite frequently, almost every single time a gastroenterologist will go and screen your colon, will identify a polyp. And it is important to ask what kind of polyp it is. There are some little inflammatory polyps that don't maybe have as much as the risk as adenomatous polyps, maybe perhaps a hyperplastic polyp for example. A single hyperplastic polyp here and there usually does not give you that risk that adenomatous polyps do. So it is important to distinguish what kind of polyps you have, and then try to risk assess you as well to determine if you are just simply a polyp maker that needs to have frequent colonoscopies, or if you're really in that higher risk group for developing colorectal cancer and potentially other cancers as well.
Tim: Dr. Bain, I think I just want to jump over to you a little bit because the so-called polyp maker is determined and identified by you and your team and elsewhere in the community. Need I be overly concerned if I'm simply a polyp maker?
Dr. Bain: I don't think you need to be overly concerned. I think the most important thing is that you've been identified as a polyp maker because you've had your screening colonoscopy. And if you continue to follow your gastroenterologist’s recommendations about when you should have your next one, whether it's three years or five years. The beauty of a colonoscopy is you're finding these polyps, but you're also removing them. And the more polyps you remove, the less there are in your colon that can potentially turn into cancer. So I wouldn't be overly concerned, but it should give you the right amount of worry to remind yourself that, "Oh, I need to get in to have my next colonoscopy in the recommended timeline."
Tim: It's Cancer Talk Live from Roswell Park Cancer Institute here in Buffalo, New York, as we continue our discussion about high-risk colorectal cancer. And the conversation continues with you out there online with Twitter, hashtag #CRCTalk, as the questions continue to come in. Feel free to do so, and they are coming in and our next one is going to go over to Dr. Voian. We've got Dr. Bain, Dr. Nurkin here at Roswell Park to answer your questions throughout our webinar here live from Roswell Park.
Dr. Voian, here's the question. "My father passed away from colon cancer at age 59. He was adopted, therefore there's no family history behind him. I am 30 years old. When should I begin screening?"
Dr. Voian: So this is a special situation. What we also offer here at Roswell Park Cancer Institute is every patient who is diagnosed with colorectal cancer during the time of the surgery, they are doing the screening for Lynch syndrome. So they are looking at a tumor, and they offer MSI and IHC which is the microsatellite instability and immunohistochemistry. They look for some protein and some abnormalities in the colon tumor to screen if there's any abnormality there that would trigger further genetic testing.
So I'm not sure if the father of our caller had that done or not because it is not implemented in all of facilities, but we are doing this universally. So regardless of the age of diagnosis of the colon cancer, we are offering MSI and IHC to screen for Lynch syndrome. Now the age of over 50…in genetics, we consider young age under 50, so over 50 would make probably closer to the general population risk.
But in the case of the caller, having a first degree relative with colon cancer, he would have an increased risk based on the family history. And we would recommend to have an assessment, a GI assessment, usually at the age 40 to discuss the timing of the colonoscopy. And definitely the interval would be adopted based on the family history, and also on the finding of the baseline colonoscopy.
Tim: It makes a lot of people happy and a lot of people sad when you say 50 is the determiner of old.
Dr. Voian: Well, I didn't establish this cut-off, and that's why colonoscopy for general population will start at average risk at age 50. That was the determination made that this will be the age when people will have the increased risk and the number of polyps identifiable will be an increased risk number and risks, so the age 50 is usually cut off.
Tim: Dr. Nurkin?
Dr. Nurkin: Yeah. I think we also need to hit on some of the emerging data that's been coming out over the past year or so. And some of our audience maybe have seen this on some of the news broadcasts. There's been some database reviews, some population database reviews, finding that the incidence of colorectal cancer is rising in early onset, meaning younger than the age of 50.
And some of these are quite alarming, some of the rates that are increasing. And it's estimated that we may be even seeing a rise in colon cancer over the next, say 15 years of 90% and of rectal cancer maybe even as high as 120%. And it's not entirely clear why this is. It's clearly not all related to some of these inherited cancer syndromes.
Some of the concern, or at least the presumption is due to some of these modifiable risk factors that we discussed earlier such as the sedentary lifestyle, lack of exercise, the diets, those processed meats and other things, obviously smoking and alcohol use. But it might not just be that. We're not entirely clear as to why this is happening.
So what I think we really need to do, and we should take this moment to kind of not just educate our public but also our primary care physicians and gastroenterologists and others, to kind of be aware that some of the younger patients that are coming in to see us that may have some of these symptoms that you just would push off to say hemorrhoids or other things, like bleeding in your stool, crampy abdominal pain, unexplained weight loss…things like that really should start sending alarm.
If some of these symptoms just aren't going away, that should prompt some more investigation because the last thing that we want is for this younger group that you really don't identify any obvious risk factors for putting them in a high-risk group, that may go unchecked and end up coming in at a later stage. So I think it's important to be aware of some of this early onset colorectal cancer and even know that some of the national societies are starting to talk about even going a little earlier in surveillance in starting the screening.
There are clearly some other increased risk groups. We hit on some of those before such as inflammatory bowel disease. Also African-Americans are at an increased risk of developing colorectal cancer, and some societies are really encouraging to start screening in this population group even at age 45. So it is important to go out there. It is important to talk to your primary care docs. And if some of those symptoms just aren't going away, getting better, and are really unexplained, get checked.
Tim: It's always a key when something is persistent and does not go away. I hear that a lot.
Dr. Nurkin: Yeah.
Tim: Okay. You've brought up, it's interesting to me and I think interesting to a lot of the people out there that are joining us tonight -- diet. You've brought it up several times and we have a specific question about it. "What is the best diet for colon cancer prevention?"
And they mentioned gluten-free. They mentioned low carb. Is there a diet that people should be concerned about, and is it for everybody? Or is it for those who we've identified as high-risk?
Dr. Nurkin: Again we hit on some of those a little bit before. There's some research, some small series looking at some different things that you can add to your diet. We do know that good diets, like I said earlier, include heart healthy eating. Fruits and vegetables are one of the major critical components of your diet as well. Red meats, try to avoid it. Again, in moderation here and there but trying to avoid it as one of the major staples in your diet.
Higher fiber diet has been associated with reducing maybe rates of colorectal cancer, and it's hard to say there. But these are some of the things that keep coming up over and over again of ways of kind of preventing some of the colorectal cancer risk.
Tim: I suspect our post-webinar dinner is going to kind of boring tonight.
Dr. Nurkin: Yeah, exactly. Salads for everybody.
Tim: Dr. Bain, this one came in. I was going to bring it up, but someone did. So here we go. They're using that hashtag out there #CRCTalk. If you're out on Twitter, feel free to do so. And we'll try to get to these questions as we continue along through our web discussion here from Roswell Park Cancer Institute.
"What can I expect from my colonoscopy prep?" It's the $50 million question that everybody wants to know.
Dr. Bain: Yeah. I think the most common thing you're going to expect is that it's not going to be pleasant. It's sort of the dreaded part of the colonoscopy. In fact, most people say that after the prep, the actual procedure is really not a problem at all. Most people fall asleep during the procedure with sedation and wake up afterwards and remember very little of it.
But unfortunately, the prep is a necessary part of not only colonoscopy but a lot of other different colon cancer screening tests. So some people will say, "Well, I don't like the prep. I'm going to get a CT colonography."
Well, that requires a prep too. Newer capsule colonography where you swallow a capsule, and it takes pictures – it sounds great, too, but it also requires a prep. So unfortunately, there's no real way to get around doing the prep. And I think the important part is really to devote time and effort into doing the prep because the better your prep is, the better your gastroenterologist can see while they're doing your colonoscopy.
So let's say your prep is fair. You may miss some small polyps and your gastroenterologist may not feel confident enough to say that you're good for ten years and do your next one in ten years. If your prep is very, very good and your gastroenterologist is very sure that they saw every corner of the colon, you might be good for ten years. So it's worth putting in the extra effort. It's not going to be pleasant.
There are a number of different formulations, large volume of liquid, half of the volume. There's MiraLAX®, there's GoLYTELY®, there's a lot of different pills, there's a bunch of different preps. Some are more tolerable than others, some do a better job than others. There's a lot of options. So if you have a lot of questions about your prep prior to a colonoscopy, that would probably be worth seeing your gastroenterologist in the office and talking about your concerns. And if you've had a colonoscopy in the past and the prep didn't go well, that would be good to bring that up so that they can change the type of prep used so that you can get the best colonoscopy possible.
Tim: There are people all over Roswell Park. It's a big campus. Is someone working on getting rid of prep? Is someone working on that? I'm kidding. Of course we can't. I'm going to pepper you with some questions here. It's the lightning round so to speak. You've brought up a couple of things there that came in on our pre-submitted questions. "How effective are mail-in colorectal screening tests?" I've never heard of such things.
Dr. Bain: Yes. So these are tests, and it depends on the type. There's a number of different types of these mail-in tests. And what they're doing is they're detecting trace amounts of blood in the stool. These are good because they are readily available. They are fairly cheap, and they're easy to do. You don't have to take a prep for this type of screening. They're good for average risk patients, but probably not so good for high-risk patients where you have a pretty high likelihood of finding polyps.
The downside of these is if you think of screening for colon cancer, there's tests that look for polyps that you can remove and potentially prevent a cancer from forming, and then there are tests that look for the presence of colon cancer. The best screening test will detect polyps which are precursors to colon cancers so you can intervene on those and prevent someone from getting cancer.
These tests that detect blood in the stool, those are detecting blood that's coming from a colon cancer or a very large polyp. So these are better than doing nothing, but the gold standard really remains doing a colonoscopy because this is the test that finds small polyps that you can remove and prevent cancer from forming in the future. But if this is what's available, doing this is absolutely better than nothing.
Tim: We've covered it pretty completely, but two other people have submitted a question regarding the pill colonoscopy and the virtual colonoscopy. Maybe briefly touch on each of those.
Dr. Bain: Sure. Virtual colonoscopy has been around a little bit longer, and this is included as an option in a lot of the different society guidelines. So this is a non-invasive way of screening for colon cancer. Again, it fits more into average risk rather than high-risk. It's a CAT scan that you get to look for polyps in the colon. It's pretty good at detecting colon cancer or large masses and even large polyps, but it can miss smaller polyps, especially those flat polyps which just won't show up on a CAT scan.
It also requires a prep, so don't think that I'm going to get the CAT scan and avoid the prep, because you'll need a prep for that too. And if you do see polyps on a CT colonography, you're probably going to have to get another prep to have a colonoscopy to get them removed. So that's sort of the downside of that.
The capsule endoscopy that looks at the colon is a newer technology. We use capsule endoscopy often to image the small bowel, but there's a variation of that technology that allows you to look at the colon as well. And this is sort of under investigation, and not a lot of the societies are currently recommending widespread use of this until it's been further tested. But it's an interesting technology, and we’ll have to keep an eye on it.
Tim: Dr. Nurkin, some thoughts on those procedures?
Dr. Nurkin: Oh, yeah. It wasn't in that person's question, but I think there was another one that was written or submitted a week or so ago. Just with regards that also some of the new things that are still coming out, we're learning about, such as ColoGuard, which is testing actually the DNA within the stool. So it's a fecal test similar to what Dr. Bain was mentioning before, as well as a blood test that's available. There may be some things that are released into the bloodstream, this ColoVantage®. Somebody wrote about that question.
Again these are not in the formal guidelines of what Dr. Bain was mentioning, and we're learning a little bit more and more about them. They do a pretty good job at detecting some polyps, some advanced polyps and maybe some cancers, but there's a high false positive rate, meaning it was incorrect. And really a lot of times if it comes back as being either faulty or unclear or it's coming back abnormal, you're going to need your colonoscopy anyway.
So there were some pre-submitted questions. Again, all of us would agree that any screening is better than none, but just to reiterate also that colonoscopy is probably the best bet.
Tim: Genetic testing, Dr. Voian, we've talked a little bit about it tonight. And one of our webinar viewers out there is wondering, is genetic testing covered by insurance?
Dr. Voian: If it's appropriate, the majority of the insurance carriers will cover the genetic testing. And for every patient that we are seeing in our clinic, we ask them to check with their insurance to see if the consult is covered. But if they're appropriate for testing, that will be our job. So we will work on the pre-authorization, and the patient shouldn't be worried that they will end up with thousands of dollars. They will know ahead of time before the test will start if the test is covered or not. And as I've mentioned, the majority of the insurances will cover if it is appropriate, and if there are definitely some criteria are met.
Tim: From RoswellPark.org as we've been collecting these questions over the past several weeks. We've had some very specific ones come in, and I think Dr. Voian, I can direct this one at you. "I've completed my chemo for colorectal cancer, and since my mother passed from ovarian cancer, I did genetic testing to see if I was at high-risk for other cancers. The result of the genetic test said I had the gene MSH6, uncertain clinical significance." What does that mean?
Dr. Voian: So I would assume that this person was identified with a variant of unknown significance. And when we meet with our patients, we discuss the possible results that every genetic test can have. And if the first one is positive when a mutation is identified, which means an alteration of the gene is identified, therefore the patient is at increased risk to develop certain types of cancers.
A negative result means it depends, if there is a mutation known in the family or if it is not known in the family. If their mutation is known in the family, having a negative result is usually good news. That patient shouldn't be worried about the risks associated with that specific mutation that runs in the family.
But if there is no known mutation in the family, we call a negative result a non-informative. So this means that we still do not know, and that patient needs to follow screening based on the family history or personal history.
Now the third possible result is called a variant of unknown significance. This means that the laboratory identifies the change in the DNA of the gene, but they cannot tell for sure is that a harmful or a benign change. Therefore they call it a variant of unknown significance. Medical management should not be based on that variant of unknown significance because again we do not know what this means, and no clinical testing for other family members should be offered.
Now this patient, MSH2 gene is a gene associated with Lynch syndrome, and appropriately this patient was tested for Lynch because she or he had colorectal and the mother had ovarian cancer. But I want to mention and to make aware the caller because he or she needs to be tested also for BRCA1 or BRCA2, because everybody who has a first or second degree relative with ovarian cancer, BRCA1 or BRCA2 should be also tested.
So we encourage the caller to have a consultation with us to make sure the appropriate genetic testing was performed. Or if she or he needs further testing, we can offer that.
Tim: Next question regarding screening came in before our webinar tonight. Dr. Bain, this one is for you. "Fecal occult blood screening, FOB, is being increasingly promoted in our areas, the preferred screening tool for those with an average risk. I have a two part question related to this. What does average risk mean, and can you discuss the merits and shortcomings of FOB?"
Dr. Bain: Sure. Average risk, like we discussed before, is when there is no strong family history of colon cancer. It's someone that has turned of age where they're at risk for cancer, which is 45 if you're an African-American or 50 if you're not. So that's really what average risk is. There's no family history of colon cancer or any other types of cancers where you would think of one of these genetic syndromes. And what was the other question?
Tim: Just related to the average risk and then the second follow-up was can you share the merits and shortcomings of that test.
Dr. Bain: So these are tests that detect blood in the stool. And like I said before, these are easy and they're cheap, and they're widely available. They are good at detecting cancers in very large polyps. But they're not very good at finding small polyps. So if this is something that's readily available in your area and colonoscopy may not be, this is absolutely an acceptable screening test for you being average risk. But if you're at high-risk or if doing a colonoscopy is an option, I would recommend doing the colonoscopy because it does have a lot of the benefits over the blood testing kits.
Tim: Dr. Nurkin, at the beginning I know we did address some general issues regarding colorectal cancer, but our next live question that came in from Twitter in our hashtag tonight, "Are there symptoms to watch for with colorectal cancer?" It's a simple question but it really is on the minds. What do we watch for? What should we be aware of?
Dr. Nurkin: So often, and that's why we've been hitting on screening and starting your screening early, so to try to identify or prevent these cancers before they even come up. But once they do, there are some recurring symptoms that may often not resolve. And as was mentioned before, was blood in your stool, unexplained, so not like a hemorrhoid that you're suffering from that doesn't go away. This is an ongoing bleeding kind of in your stool that you see either on your paper or dark stools, that's one.
Two, kind of recurring crampy maybe abdominal pain, some unexplained symptoms like unexplained weight loss, maybe loss of appetite that's also unexplained, unexplained anemia in people especially over the age of 50. These are some of the recurring symptoms that some folks experience with the new diagnosis. Sometimes if the tumor gets large enough, that crampy abdominal pain more of distention people may be suffering from. And again, that goes with some of that feeling full, bloating, maybe vomiting and others.
But if you really start to develop a decreased maybe even caliber of your stool. So you go from having normal, regular everyday stools to starting to become more and more constipated, that is definitely a frequent symptom that people present with. This unexplained "I don't know why. I just assumed it was related to my diet," or "I was just more constipated." But a change in the caliber of the stool, the frequency of their stools, those are some of the things that you look for.
Tim: We hear, the phrases tossed around quite a bit with regards to cancer as far as slow-growing, fast-growing cancers, and this viewer writes this question to us. "Is colon cancer slow-growing? And is it okay to leave a portion of the polyp, but monitor it?" It sounds like they underwent a procedure, and are asking that specific question.
Dr. Nurkin: Yeah, and maybe Andy can chime in also. More and more we are advancing some of our endoscopic techniques. There are some endoscopic techniques that are becoming more and more available such as endoscopic mucosal resection or endoscopic submucosal dissection, and what that allows for are removal in the entirety of polyps to remove it all often in just one shot.
In the past, people that had large polyps went straight to surgery. But there are more advancing techniques that we can use such as these endoscopic resection techniques that allow for removal of some of these larger benign polyps, not truly really large cancers or anything, but some of these larger polyps that in the past weren't able to be removed can now be removed with some of these techniques.
There are some times that gastroenterologists will be able to go, or endoscopists, will be able to go in and get a couple of shots at removing the polyp in its entirety. And it does sometimes take a couple of rounds of endoscopic management to be able to remove these benign polyps in their entirety. So sometimes you can get a couple of colonoscopies to be able to do that, but if you get to the point of where every time you go in there and you continue to have this recurring polyp that's not going away, sometimes those people are referred to surgeons to have that section of colon removed.
Tim: Dr. Bain, any thoughts on that?
Dr. Bain: Yeah. And I think that the beginning question of, “Is colon cancer a slow-growing?” In the majority of patients, colon cancer starts as a very small polyp, and that's the precursor of colon cancer. And it takes many, many years for that polyp to get bigger and eventually it undergoes some sort of a change and develops into a cancer. And we think that that takes several years, maybe up to ten years for a polyp to turn into a cancer. And that's why we say if you're at average risk and you've had a colonoscopy with a great prep, you're good for ten years because even if the day after your colonoscopy you start growing a polyp, it's going to take more than ten years for that to grow into a cancer.
So cancer usually forms in a very predictable way where there's a polyp, it gets bigger very slowly, and then turns into a cancer. So I think if there is a small part of a polyp that's been left in place and it's a benign polyp, it might not be unreasonable to bring you back into a colonoscopy in six months or a year to try to remove the rest of it. You don't want to forget about that because as long as there is part of a polyp left inside your colon, that could always undergo change and grow slowly and turn into a cancer. But polyps usually grow very slowly, and so I think in a year's worth of time depending on the polyp features and the size of it, I think you probably have to go with your gastroenterologist's recommendation. But that's not unheard of.
Tim: Well, over here a couple more quick hits for you that have come in here. "How accurate is the ColoVantage blood test as a screening for colon cancer?" And then also we have another viewer writing about "How accurate is the genetic blood stool fit test?"
Dr. Bain: So the one that most of the guidelines are recommending because it's cheap and accurate and readily available is the fit test. And this is one of the tests that detects microscopic blood in the stool, and these are pretty accurate. They're upwards of 80% to 90% sensitive and specific, so that means they do a pretty good job at detecting blood in your stool. And unlike older tests, they're better at detecting human blood. So if you eat a hamburger the night before, these are less likely to show blood that isn't truly from your body or from a polyp or for cancer. And certain dietary things and vitamins are less likely to give you a false positive with this test. So it is fairly accurate, but again these are tests that are meant to detect cancer or very large polyps. They're not necessarily screening tests that prevent cancer from forming.
Tim: All right. Dr. Voian, this one for you. "My family has a pattern of who is affected and who is not. Have you seen other families with patterns? In my family it seems to be two out of every three per generation." Is this a common question?
Dr. Voian: Definitely what we see in our clinic are people at high-risk, and having multiple family members that span in different generation is a red flag. And what the caller mentioned having two out of three in every generation raises a flag of a possible autosomal dominant condition. So definitely it's very appropriate to be seen in genetics clinic, and also to have assessment, a colonoscopy as having a family history.
Tim: All right. And we just had another question come in on our Twitter feed here and this basically is a woman who has Lynch. "What other screenings and preventative tests are encouraged?"
Dr. Voian: So Lynch syndrome is one of the most common genetic syndromes that predispose for colorectal cancer, and we see a Lynch syndrome in about two to three percent of all colorectal cancers. People who have Lynch syndrome, they have an increased risk to develop colorectal cancer. Women with Lynch also have an increased risk to develop endometrial cancer, ovarian cancer. And many women have also increased risk for stomach cancers, small bowel cancer, urinary tract cancer and other cancers.
So for this lady who called and has Lynch syndrome, definitely colonoscopy would be absolutely recommended, and it usually starts in the 20s. It depends on the gene, because there are like five genes associated with Lynch syndrome. But screenings with colonoscopy usually starts in their 20s.
Also for women the risk for uterine cancer and ovarian cancer should be mentioned. And there are no clear guidelines in regards of the screenings because uterine screening with uterine sampling, it can be offered. But it's not very well known, the efficiency of this. And after the woman is done with child bearing, so after 35, 40, she can consider to have salpingo-oophorectomy. So removing the uterus and ovaries to reduce, or for the uterus, to remove the risk for uterine cancer and ovarian cancer.
Tim: Dr. Bain, our last quick question just came in off of our Twitter feed as we continue here live from Roswell Park. "Can a colonoscopy miss a polyp or a cancer?"
Dr. Bain: It can. It's not a perfect test. It's the best we have, but it's very possible that a polyp can be missed. A big part of that is the prep. So if the prep is not a great prep where you're able to see every corner and around every turn, you can absolutely miss a polyp. But even with a great prep, there is a miss rate for colonoscopy. And not every polyp is shaped like a mushroom where it's a big obvious polyp in the colon. Some are very subtle and flat, and so it's very important to look very carefully and have up-to-date technology and endoscopes with high definition and all the bells and whistles on it to really detect these subtle polyps. But it is possible to miss a polyp, but this is the best test that we have right now.
Tim: All right. That's Dr. Andy Bain, Chief of Endoscopy and an Assistant Professor of Oncology here at Roswell Park. Thank you for being here tonight. I appreciate it. I appreciate the time. Dr. Steve Nurkin, Surgical Oncologist, thanks for being here and some parting words for you. What's important for people to walk away from our webinar tonight with?
Dr. Nurkin: I think we hit on some of the major factors and heart healthy, good colon healthy living. And we know what some of the modifiable risk factors are, not for just reducing colorectal cancer, but of course other cancers. And get your screening. Get your screening.
Dr. Voian: Yes. And I want to complete the answer that I previously gave. So people with Lynch syndrome, people with familial adenomatous polyposis, people with other hereditary cancer syndrome that predispose them to colon cancer and other cancers, the best way to have care would be in a multidisciplinary clinic. Because having a colonoscopy and having GYN screenings and having upper scopes and having thyroid screenings under the same roof, it's very easy. Make sure that you didn't miss any of those screenings.
And also, we’ll mention to you, “Is there anything new in the guidelines in regards to the screening? Is there anything new in regards to genetic testing?” Because the testing that we offer ten years ago for Lynch syndrome covered only two or three genes. Now we have five genes. We have better tests, so that's why a multidisciplinary clinic is essential.
Tim: Dr. Voian, thank you so much. Dr. Nurkin, Dr. Bain, just three of the incredible resources here at Roswell Park. There are so many more, and we'll continue our webinar discussions here live from Roswell Park.
If you have any questions at any time, you can always call Roswell Park. It's a toll free line at 877-ASK-RPCI. That's 877-275-7724. This webinar will be available at RoswellPark.org. Thank you so much for joining us, and we'll be back soon.