Colonoscopy, virtual colonoscopy or stool test: Which colon cancer screening is right for me?

Colorectal cancer is the third most common cause of cancer related death for both men and women. However, if it is caught early, colorectal cancer has a 90% survival rate. This is why screening is so important.

Coming up on At The Forefront Live, we'll talk about screening and the different types of tests that are available. And we'll take your questions for our experts. That's coming up right now on At The Forefront Live.

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Gastroenterologist Dr. Sonia Kupfer and Dr. Neil Sengupta join us to talk a little bit about colorectal cancer. And they will take your questions live on the air. We want to remind our viewers that today's program is not designed to take the place or an actual visit with your physician. So let's start with each of you introducing yourselves and telling our audience a little bit about what you do here at UChicago Medicine. And Dr. Sengupta, We'll start with you.

It's my pleasure to be here. So my name is Neil Sengupta. I'm a assistant professor here at the University of Chicago Medicine. And my specialty is general gastroenterology, but I have a special interest in colon cancer screening, and also quality improvement as it relates to colon cancer screening and surveillance.

Perfect. Dr. Kupfer.

My name is Sonia Kupfer. I'm an associate professor here at the University of Chicago. And I direct the Gastrointestinal Cancer Risk and Prevention Clinic where we evaluate individuals who are at high risk for gastrointestinal cancers, including colorectal cancer, and do genetic testing and counseling.

I want to start a little bit with the statistics because it's interesting to me that that is the third highest cancer rate, or cause of death with cancer. I had no idea, first of all, that that was the case, and it's largely preventable, which we just saw in the intro. Why is it still such an issue with people?

Well, I think number one, many people aren't aware that colon cancer can be present even in the absence of having symptoms. And so oftentimes patients feel well. They're not having any specific symptoms. Yet they choose not to get screened, whether it's through a colonoscopy or through another test. So I think that's one barrier, is making sure patients are aware that they need screening for colon cancer even if they're feeling well and not having any digestive symptoms.

And Dr. Kupfer, one of the things that-- and I'll admit this. I'm in my 50s. And I need to schedule a colonoscopy. And it scares me to death. What would you tell somebody like me to get them in and get that done?

Yeah. I think that it's a routine procedure that we do every day. And certainly we can talk about it here on the air for the viewers as well. But I think that the important thing is that it's not the only procedure that's available for early detection of colorectal cancer. There are stool based tests and other types of tests. So it's not the only test, but certainly is one of the best tests that we have.

And you mentioned the stool based test. We're going to get more in depth on the various tests and things that are available. But that's an interesting one too because a family member of mine who also happens to be in their 50s, my wife-- she was talking with her physician about this very, having the very same conversation we're having today, and he mentioned that test. But there is a difference in, and there are some different schools of thoughts on the varying tests. Can we talk a little bit about that? Because I think anybody, when they hear that, they think, oh, I don't have to get a colonoscopy. Great.

So our recent guidelines were updated. And the two preferred tests are a colonoscopy, and then stool based test called the fecal immunochemical test, or we shorten that as FIT. And the main difference, I would say, is that a colonoscopy is a preventative test. So we can find what are called polyps or specific polyps called adenomas, that by removing them, we can actually prevent colon cancer from even developing.

A fecal immunochemical test, or a FIT test is something that is designed to detect cancer early but not to prevent it. So that's one of the main differences. The other differences are how frequently you need to do it. So a FIT test needs to be done annually. A colonoscopy, if it's normal, can be done every 10 years.

So let's talk about a colonoscopy, and an example of what that entails. I think we all have a general idea, but it's maybe not quite as bad as what we make it out to be in our minds.

Yeah. I'll tell you that the vast majority of my patients typically are fearful of a colonoscopy. And by the time they finish it, they say, oh, that wasn't too bad. I'll tell all my friends to get screened for colon cancer.

Big picture, colonoscopy involves restriction of your diet for a few days before the procedure. And then the most important thing is basically drinking a laxative to purge your colon so that we can actually get a very good look while we're inside. And it turns out that that is actually the most important determinant of the success of the colonoscopy, is drinking a bile preparation, and then allowing us to essentially get a very good look so that we can find small polyps. The recovery process is also very straightforward. Patients can essentially go back to work the next day and are back to normal.

And it's funny because some of the people I've talked to say, actually, drinking the stuff is the worst part of it. And if that's the worst part of it, it's not that bad. There's a little tiny camera that you actually will guide into the person. And you can look around and see exactly what's going on there.

Yes. So we have a flexible camera that we're basically able to insert. And we traverse basically the extent of the colon. We can get to the end of the colon and sometimes can get into the small intestine, where we can then come back slowly as we look carefully for small polyps. Then we have the ability to put instruments through our colonoscopy scope to remove those polyps, and thereby prevent future colon cancer.

Maybe just to say that this is done with sedation.

Correct.

What we call moderate sedation. So most people are either asleep, they don't remember, they're comfortable during the procedure. And that's obviously one of the things that we emphasize is that we want to make sure people are comfortable. But as Dr. Sengupta said, most individuals wake up and they say, that's it. Done. Just to let everybody know that this is not done without sedation.

That is a very important point. I think I'm glad you brought that up. So when you look around in there and you see a little polyp-- I imagine they're tiny, right?

Yes. I mean, everything is magnified obviously when we're in there. But we're looking for polyps. And we can remove the vast majority of polyps that we see in the colon. And again, that's where the benefit comes from, prevention of colon cancer is by identifying these polyps and then removing them.

And you do it right then at the same time?

Yeah. As I mentioned, we have the ability to essentially put instruments through our equipment to basically remove polyps. And that's not something patients feel during the procedure. It's not painful at all. And we can identify polyps and remove them right then at the time of the procedure.

Maybe that's another benefit of colonoscopy. It's an all in one test. So that's another difference with a fecal immunochemical test, or any of the stool based tests, or any of the tests that we have for that matter. They all converge on colonoscopy. So if a screening test like a FIT test is positive, the next step will be a colonoscopy. So it's a 2-step process versus an all in one. So that's just another difference between the two tests.

Perfect. I want to remind our viewers, just type in your questions there in the comments section and we can take as many as possible over the next half hour. So when Dr. Kupfer, when people hit their 50s, is that the magic age? Or has that changed?

So it has been 50 for a long time. Recently, the American Cancer Society came out with what we call a conditional recommendation that individuals can consider starting colorectal cancer screening at age 45. I'll say that not every professional society has followed suit. 50 is still the age that we consider everybody should be talking to their doctor and start their screening.

For individuals who have a family history, who we consider at higher risk, we would be starting them at age 40. And then the other group that we start screening earlier than 50 is African-Americans. And there is a recommendation to start at age 45 for all individuals who are African-American.

So that brings me, that's a great follow up on this severe question. So if you do have that history of colon cancer in your family, you start at 40. And then how often do you get tested after that?

So it starts to come down-- so the recommendation for starting at 40 is if you have a first degree relative, and that is a parent, a sibling, or a child who had colorectal cancer.

A child? Really? So I guess you would, that would go to-- you would have probably passed it along potentially.

So those individuals with a first degree relative would start at 40. And then if that individual, if your first degree relative was under the age of 60, you would do your screening every five years. Whereas if your first degree relative was 60 years or older, then you can follow more of our general recommendation.

So there are nuances to this. So I think this is something where you want to discuss this with your physician because the type of tests that you start with at 40 also depends on how old your relative was. And so I don't want to have a blanket statement for everybody because everybody's family history is unique.

And if I can expand on that point. I think one question patients have a lot is, well, I just needed done every 10 years. And that's not always the case. The frequency with which we recommend colonoscopies depends on, number one, how good we got a look at the time of the first colonoscopy-- how good the quality of the clean out was, how many polyps were found, and then an individual's family risk. So all of those variables are really important. And then the gastroenterology or the patient's primary provider kind of make a decision on what the best surveillance plan is.

I think you just hit the nail on the head as far as why this is so important to talk to your physician because there are a lot of factors that are involved. And you can work with your physician. You can come up with a plan of what you need to do and how often you need to do it.

It is a point though that maybe one of our advocates in the community always says family secrets kill families. And so I think one thing that is important, and this goes for other cancer types as well, is talk to your family. Try to elicit their medical history, their cancer history. Because that certainly not knowing about this can impact your screening and surveillance.

The other important point is for patients who are under 50 or around that age of 45, we would be much more likely to recommend doing a colonoscopy if patients were having any symptoms at that point. So I think for younger patients who are under 50, who are having any symptoms of blood in their stools, for example, or anemia, low blood counts, they should really talk to their doctor about whether they would benefit from doing a colonoscopy earlier. Because as we may talk about later, we have noted that the rate of earlier onset colon cancer has been increasing in recent years. And so that's something that we certainly want to prevent by identifying patients who are having symptoms.

So the rate is increasing. Do we know what to attribute that to? Diet, I would imagine.

So there have been a lot of theories as to why this might be happening. So diet, obesity, changes in the bacteria that live in our large intestine. We don't know, is the short answer. But this is happening across the world. So there are data from really everywhere where this increase is happening. So it seems to be worldwide, not just something that happens in countries that have what are called Western diets of meat and potatoes, so to speak.

But we're working hard to try and figure out what are the causes, and hopefully help to prevent some of those environmental factors and triggers. But I think as Dr. Sengupta mentioned, the best thing that we can do now is try and find those individuals who are presenting with symptoms, and not attributing it to hemorrhoids or something else. And saying, you know, is there a reason that we need to screen for colon cancer in this patient?

So let's talk about symptoms. You mentioned some people may think they have hemorrhoids. I would imagine you're talking about blood in the stool. So what are some of the symptoms that people need to be aware of?

I think first and foremost, no symptoms. So Dr. Sengupta mentioned this, and that's why we have age criteria. Certainly as these polyps are growing into tumors, we can see blood in the stool. We can see a change in bowel habits. So people can start having a change in the size or the shape of their stool. They can develop diarrhea or new constipation. And as the tumor is growing and starting to go to different places in the body or metastasize, then we start to see people losing weight, and some of the later stages of cancer.

But of course, that's why we're here talking about this. We don't want to get to that point. We want to catch people even before the first symptom starts.

Such a fantastic point you made-- no symptoms. If you wait and wait for something bad to happen that you could have prevented a year or two or five prior, it's so much better to do that.

And one of the barriers too I think is that we don't talk about our bowel habits very often. We don't like--

Not a fun topic obviously

--share it with family members, friends, et cetera. But I think it's so important to be aware of these things, and to share them at least with your doctor, and to get over the stigma because we face a lot of stigma in colorectal cancer and screening. And especially among women, there seem to be women who think it's a male disease. It's not something that affects women. But that's absolutely not true. So women need to have their colorectal cancer screening just like men.

The earlier in the symptom process that you see a gastroenterologist and you get your screening exam, that means we have the opportunity to actually potentially treat even cancers and remove them completely at an earlier stage than they would be diagnosed later on if the screening were delayed.

I love the fact too that you mentioned that this is a difficult conversation to have potentially with a family member. But with your physician, you tell your physician all kinds of things anyway. So be honest, be open. And certainly if there's any doubt in your mind, make an appointment. Go see a doctor. It'll be such a fantastic thing if you catch it earlier.

So we have some more questions from viewers. And I always want to get to these when we can. So this is an interesting one. So if there is a history of ulcerative colitis, how often do you need to screen with colonoscopy?

Well, ulcerative colitis or inflammatory bowel disease is a condition that can increase the risk of colon cancer more so than the average person. So if someone has a history of ulcerative colitis or Crohn's disease, they really need to talk to their treating doctor. And talk to them about when they need to start colon cancer screening, and how often it needs to be done. For patients with ulcerative colitis who have severe disease in the colon, we often do screening every year. And so it's just something that you need to talk to your doctor about because there might be an increased risk of screening over the average individual.

Interesting. So here's another one. So what should you do if you have a redundant colon? And I'm not familiar with that.

So a redundant colon just means that there's colon that has a lot of twists and turns so to speak. And that can sometimes make a colonoscopy more challenging because we have to get this scope through the colon. And with all these twists and turns, there can be some technical challenges.

I'll say that most of us can deal with these technical challenges. And we even have certain tools that we can implement if the procedure is very difficult. But I wouldn't let that necessarily be a barrier. There is also as we said a number of options for colon cancer screening. And so that would be something to discuss with their doctor. But in most cases, we can complete a colonoscopy without a problem.

And I think let's say for the rare patient that we can't complete a colonoscopy, rather than trying over and over again, those patients-- assuming that they don't have an increased risk of colon cancer because of their family members. They would be perfect candidates for non-invasive testing with the stool FIT test that we already described. Because patients who have a FIT test that's negative every year may never need a colonoscopy.

That's one of the things too about being part of an academic medical center in an institution like UChicago Medicine. We have very capable folks here. The people that do the work here are very, very good at what they do. So if you do have some challenges, certainly you guys have probably seen it all, I would imagine.

Yes.

I have a few other questions here. When people talk about colon cancer and depending I guess on what stage it is, how curable is it?

So it can be completely curable if it's caught at an early stage. I think it depends on if a colon cancer is diagnosed, then usually what we do is, first of all, we take biopsies of the cancer. In certain circumstances, we can actually cure a cancer at the time of the colonoscopy. That's usually less often. But then it usually involves getting some form of imaging and then sending patients to a surgeon and potentially an oncologist to determine what the stage is. So in general, the earlier we diagnose, the earlier the stage is, and certain stages can be curable.

And Dr. Kupfer, you mentioned diet earlier. Not that we know that is a cause or is not a cause, but it seems interesting because whenever we do the show, we speak with the various physicians, it seems like diet and obesity almost always have an impact. And it's always a negative impact when it comes to obesity. What would you tell someone that's watching this and maybe has no symptoms, they're fine, but they want to never get to that stage where they do have symptoms. What do they need to do?

Well, get screening. That's first and foremost. I think that the lifestyle factors and the medical conditions that are associated that we know about-- obesity, lack of physical exercise, lack of fresh fruits and vegetables, smoking, excessive alcohol use. All of these are factors that have been found to be associated with an increased risk of colorectal cancer.

In fact, when we look at the diet, things like red meat and especially processed meat are considered carcinogens by the World Health Organization for colorectal cancer. So I certainly would say things in moderation regarding health in general. But specifically for colorectal cancer, limiting red meat and processed meats, fruits and vegetables, exercise. In some cases, we can use some medicines that can help to prevent polyps and colon cancer, but those are specific situations. And again, you'd need to talk to your doctor about those.

I think the key point to stress the Dr. Kupfer mentioned is that all of these are good-- to modify your diet, to live a healthy lifestyle. But those do not substitute being up to date with screening and surveillance with the colonoscopy or Fit test.

Absolutely. And you were talking about processed meats. Our last program that we did, we were talking about chest pain. People were writing in about processed foods because, again, we live in a society now where it's kind of challenging sometimes.

You work a lot of hours. You're on the way home. You want to grab something quick for your family and your kids. You hit a drive-through. Or even if you do go to the grocery store, you buy something in a box. It's a good idea to try to steer away from that as much as possible. When you talk about processed meats, and you want people to avoid that, what should they go for? So things like chicken, things like--

Lean meats--

--things that you prepare.

Yeah. Lean meats. And again, this is not to say you can never have these things. But our sense I think in the United States of what a portion size is, is also kind of totally out of proportion, so to speak. So just moderation. I always tell patients, think about the periphery of a grocery store and stick to that, and very limited sort of in the inside aisles.

But it's moderation. It doesn't mean you can never have these things. And again, just to stress, you can do all of these things and those individuals may still develop colorectal cancer just because of age and other factors that we don't maybe know about entirely. So that's why screening is so important.

Let's talk about age for a moment, because I think you see most cancer rates increase as folks age. So how much more common is colorectal cancer as you get older? Do you see the curve extend?

Age is the most important factor, I would say. I mean, I think that's why we had started screening patients at 50. And then until recently, the recommendations came to potentially start at an earlier age. That's why for patients who are older than 50 who have never been screened, the people that we may actually really help are patients in their 60s or 70s who have never had screening before. I think those patients, it's really important to have a screening examination because we have the opportunity to reduce their risk of dying from colon cancer in the future.

On the flip side is the question of when to stop screening.

Good point.

That becomes somewhat controversial. And I think it's an individualized decision, certainly to discuss this with your doctor. After the age of 75, every 75-year-old is not the same. And so if they would be driving a benefit over the next five to 10 years from a screening procedure, we can continue screening in an older population. But that is individualized.

Exactly. One thing, the colonoscopy is a procedure. Again, as we mentioned, it involves sedation. And so there are some risks of the procedure that we always discuss. And so for patients who have a lot of cardiac comorbidities, who are sick for other reasons, they need to talk to their doctor about whether a colonoscopy is the best option for them.

And that's one of these situations where you want to get somebody else to drive you home afterwards.

Exactly.

So again, we're taking questions from viewers. If you have any, if you need to put those fears to rest, type something in and we'll do our best to do that. So if a polyp is found during the screening, does that mean automatically that you have cancer? Or is it just not necessarily?

No, not at all. So the vast majority of polyps are benign. What we look for are certain type of polyps that carry risk of growing into cancers over time. A very small minority of polyps are at risk of developing into colon cancer. But that risk occurs over the course of many years. And so the benefit of colonoscopy is to identify those pre-cancerous polyps early and remove them completely.

Now the question from a viewer. Are certain ethnicities more likely to be diagnosed with colon cancer than others? And do we know why is that's the case?

Yeah. So I mentioned that there are recommendations that African-Americans should consider starting to screen at age 45. And that is because there is a higher risk, or the rates are higher I should say in the African-American population. Also it seems that there tends to be a younger age of onset if you look at large studies.

Why that is, there's probably a lot of different reasons that again we could theorize. I don't think that we really know that for a fact. So that's why when we identify high risk groups, we try to make sure that we get them in, in this case, in earlier to get screened. So other than that, I would say there are no recommendations other than that. As I mentioned, family history is the other main high risk group that we target.

So another question, and I know this is probably wishful thinking. But you go in for your annual physical. And you have some bloodwork done. Could it possibly show up in that blood work?

Yeah. As of right now, the main tests that we look at in terms of blood work are the blood counts and iron levels. Because if a patient has a history of iron deficiency, low iron levels, that can sometimes be a sign of slow bleeding from cancer in the colon. So if someone does have a history of iron deficiency, they should definitely talk to their doctor about whether they need a colonoscopy.

I know that currently there's a lot of research underway to look at other blood test markers to screen for colon cancer. As of 2020, that's still not recommended yet as a top tier screening option. But down the road, that might change.

And I know what you're going for on this. Just go get the colonoscopy. Because you're hoping that it's-- don't wait. I totally understand it. But just to get the colonoscopy because it'll be better to catch it earlier.

So these are all great tips. And again, I think if people would understand-- how much more likely are you to catch this with a colonoscopy than not? Probably 100% more likely, obviously. And just get it done. I mean, what's a final message? We've got about two minutes left. That you would like to share each one of you with patients out there.

I think the best test is the one that gets done and gets done well. So speak to your doctor. Understand that there are-- symptoms come later in the disease process. And so age and perhaps some other factors, including family history for example, might put you into a group that needs to be screened early.

So start this conversation early. It's never too early. You can be in your 20s, your 30s. Get that conversation started. But really, the best test is the one that gets done well.

I wholeheartedly agree with that point. For the patients who do choose to do a colonoscopy, I just want to stress that the bile preparation is the most important part. We want to make sure that if we are doing the test, we want to do the best possible tests that we can for patients.

But it's not that bad. The vast majority of patients have a good experience I would say after their colonoscopy. And don't find it to be a painful procedure. They can get back to their normal life in a day or so.

So follow the instructions they give you. Then just get it done. And you'll be much better off.

So we are out of time. You guys did a fantastic job, by the way. That was really interesting and I think very helpful to people. So I'm so glad we did this.

Thank you.

And it's a fitting month for it too.

Yes.

It's important to get that information out. That's all the time we have for the program. Check out At The Forefront Live on WGN on Saturday mornings. That's something fairly new. We'll do that at 10:30 every Saturday morning, so please tune in.

And remember to check out our Facebook page for future programs and helpful health information. Also, if you want more information about UChicago Medicine, take a look at our website at uchicagomedicine.org. If you need an appointment, give us a call at 888824-0200. Thanks again for being with us today. Hope you have a wonderful week.