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Q. How common is colon cancer -- it's more common in men, right?
Wrong! Colon cancer is like an equal opportunity employer. Women have exactly the same chance of getting it as men. Somehow colon cancer seems like the type of thing my husband has to worry about, but I don't. However, there's a 6 percent lifetime risk for men and women, exactly the same.
When you look at cancer deaths in nonsmoking men and women you see that, for women, breast cancer is the number one cause of cancer deaths and colon cancer is actually the second leading cause. The order changes if you count skin cancer or not, and whether there are smokers in the mix, but the risk for colon cancer is certainly higher than cervical cancer. Most women would never think of missing their pap smear, but they think, "I'll just think about colonoscopy another time." The test is not that frequent -- every decade is not such a big deal. So I think the biggest impediment for screening is women not realizing they are at risk.
Q. Ninety percent of colon cancers are found in people 50 and over, so we know that after you turn 50 you should get screened. But recent reports show an increase in colon cancers found in younger women. Any idea why?
Well, first, that's right. You should get a colonoscopy at age 50, and every 10 years thereafter. If you have polyps, it's every three to five years.
For women, screening at 50 is an important issue, especially because there have been a lot of studies that suggest we should be doing screening in women earlier, maybe at 45.
The other phenomenon that I've been seeing, and I'm not sure exactly what the numbers are but just anecdotally in my practice, is women as young as in their 30s being diagnosed -- and with no family history. It's really frightening because we're not sure what's responsible. And if you don't have any of the risk factors, you're not going to come in earlier to be screened. I have a colleague, also a gastroenterologist, who was diagnosed with colon cancer at 36. She went under the radar and didn't fit into any screening guidelines.
The important thing is to not ignore symptoms. The alarm symptoms are blood in the stool, weird abdominal pain, a change in how often you have to go to the bathroom, anemia, and unexplained weight loss. Talk to your doctor. If you have any of these symptoms or are otherwise high-risk, your insurance will cover a colonoscopy, even if you're way younger than 50.
Q. So what is it that makes you high-risk for colon cancer?
You're considered high-risk if you have a first-degree family member (that's mom, dad, brother, sister) with colon cancer or polyps. If that's the case, we start the screening 10 to 15 years before your family member was diagnosed or by age 50, whichever comes first. So let's say your mother was diagnosed with cancer or polyps at 55, we'd start your screening at 45 or even 40.
Another high-risk group is people who've had breast cancer or another malignancy. A lot of these risk factors for colon cancer apply to multiple cancers. The same environmental things, genetic things, some of which are as of yet undiscovered, that increase your risk for one cancer can also increase your risk for another type of cancer. We follow our ladies who've had breast cancer very carefully, and we frequently start to screen them for colon cancer earlier than 50.
Also high-risk are people who have inflammatory bowel disease or IBD -- not to be confused with IBS, irritable bowel syndrome. We're talking Crohn's disease or ulcerative colitis, and these two conditions, which are frequently diagnosed before your 30s, increase the risk of colon cancer dramatically. If people have had either of those, we recommend annual colonoscopy in those patients at any age.
There is also a higher incidence of colon cancer in African-Americans, and we're not sure why. Our genetics are 99 percent the same, so it's very hard to say whether there's a genetic reason or if it's about lifestyle. It could be about less access, if African-Americans are less likely to get screened, or it could be about diet or physical activity. There have been studies that suggest we should do screening at 45 in African-Americans too. But again, the guidelines haven't changed.
Q. A colonoscopy requires sedation, and you have to take a day off from work. Aren't there other screening tests that are effective, but less invasive?
Think about it this way: as inconvenient as it can be, it's a lot more inconvenient to have colon cancer. Colonoscopy remains the gold standard because not only can we detect cancer and the precursor, polyps, we can remove them at the same time.
Virtual colonoscopy is exciting because it's less invasive. But it still requires a prep, which is really the turnoff for most people. You still need to drink that half-gallon of solution to clean out the colon for virtual colonoscopy. And there are three other things about virtual colonoscopy that I think are not-so-great:
Number one is the radiation involved. If you think about this as a test you're getting done over and over again, that radiation can add up. Number two, virtual colonoscopy is not good at detecting small polyps. Small polyps turn into bigger polyps, which turn into cancer. So we're not so thrilled about a test that leaves these small polyps behind. Number three, if you have a virtual colonoscopy and you do have polyps, then you have to repeat the process to have the lesions removed during a regular colonoscopy.
Then, there's sigmoidoscopy. This is a test insurance companies love because it's cheap. But the problem is that it only examines the first third of the colon, and we know that polyps can occur throughout the colon.
There are also stool blood tests, which look for what's called fecal DNA. They look for traces of DNA in the stool from cancers. But we don't want to detect cancer. We want to find the polyp before it becomes cancer and remove it.
Another really exciting thing that's coming soon is the colon capsule. It's not FDA-approved yet, but it's a pill that has a little camera inside. There's one for the esophagus and one for the intestine already. The one for the colon takes pictures throughout the colon. That's very exciting. It should come before the FDA again next year.
A lot of these tests, I think, are still in their infancy. But the bottom line is that no matter how easy it is to do a colonoscopy -- in terms of the prep, it's not that bad. It's very safe. It's very easily done. It can remove lesions, and so on -- there's still going to be some people who say no way. So we need to have something to offer those people. If they're not going to do it, then we need to have some kind of screening for them.
Also for people who can't be sedated for medical reasons or something, stool blood tests and the others that are on the horizon can be very helpful. I think in the next decade or so we'll see a lot of therapeutic colonoscopy where people are having these other tests first. But for now, colonoscopy is still your best bet.
Q. What do you say to women who are uneasy about having a colonoscopy done?
Well, there have been great advancements in the prep recently. Up until a year ago, the prep was still a gallon of stuff to drink to clean out your colon. Now it's half that.
I tell my patients, "look, you can put your skinny pants on the morning of and you'll feel great. You're going to have your skinny pants on and a six-pack!"
It sounds silly, but people are really into these cleanses. And the colonoscopy is sort of the ultimate cleanse. It sounds tongue-in-cheek, but in all seriousness, putting it in that context, "Let's do a good cleanout, take a look and start fresh with a clean colon," is a reasonable way to convince them.
I also encourage women to come with a girlfriend. Get your girlfriends and do it together. I have a very good friend that I get my mammograms done with every year, and it's fun!
But in all seriousness, colon cancer is a very real risk. Most of us would never think about driving without our seatbelt, but you're actually more at risk to get colon cancer than you are to get in a car accident. There are a lot of things that we do because we agree that this is safe and so on, and we really need to get that message out about colonoscopy.
Q. Research suggests that taking a baby aspirin daily can reduce your risk of colon cancer significantly. Should we all be taking an aspirin every day?
A recent article in the Lancet looked at all the data about this, and it looks like there may be some real protective benefit. The study was what's called a meta-analysis. It wasn't an original study but a study of all the pooled data from different studies on the topic, so there are a lot of different variables that we have to consider. The problem is that most of the studies showed a reduction in risk for people who were already high-risk, not the general population. While the news is exciting, we have to balance that with the fact that aspirin can cause stomach bleeding. If your doctor has already put you on aspirin for heart disease or another reason, then great, you might be getting a two-for-one benefit. Other than that, it's unfortunately still too soon to make that general recommendation for everyone.
Q. Are there any other ways to prevent colon cancer?
Yes! Phytonutrients, the nutrients in fruits and vegetables that make them so good for you, are what help prevent cancer, heart disease, diabetes, and a whole lot of other diseases, too. There's a lot of evidence that a high-fiber diet -- I mean a whole-foods diet rich in whole grains, fruits, and vegetables -- is helpful for preventing colon cancer.
This doesn't mean you have to be a vegetarian. You can still eat meat, but really I can't stress this enough: a plant-based diet with minimal amounts of animal products and refined carbohydrates.
The second thing you can do is exercise. A lot of studies show that a sedentary lifestyle is a risk factor for colon cancer. There are a number of reasons why that might be, but when you think about it, the digestive tract is the main way for the body to eliminate waste. And if you're sedentary, and you don't eat a very high-fiber diet, chances are you're constipated.
That means all those toxins that are supposed to be coming out of are sitting there in contact with the lining of your colon for days and days. Some of those toxins might be cancer-causing agents. So regular bowel movements, which you will have if you're eating a high-fiber diet and exercising, is really how you prevent it.
At the end of the day, the screening is important, but if you eat a really healthy diet, exercise regularly, and control your stress, your chances of living a long and healthy life increase dramatically. You'll still need to get screened, but that's the ultimate prevention.Additional Resources
Calculate your risk for colon cancer with the Cleveland Clinic's assessment tool.
Watch Dr. Chutkan explain what to expect before, during, and after your colonoscopy.