Colorectal cancer screening saves lives. Despite its proven significance, several myths still cloud public perception of these screenings, particularly colonoscopies. Some believe that colon cancer is a disease that only older people get. Other prevailing myths suggest that colonoscopies are painful and invasive, deterring patients from getting screened. The truth is that there are several different types of colorectal cancer screenings. Over the last decade, there have been advancements in how we understand, screen, and treat colorectal cancer.
Dr. Ali Khan, a gastroenterologist and an Advanced and Therapeutic Endoscopist at Baptist Health, sheds light on some of these innovations.
Celeb backing has increased awareness.
The myth that colonoscopies are painful, uncomfortable, or invasive has often caused patients to put off or even avoid their colonoscopy appointments altogether. However, thanks to increased awareness and support from A-list celebrities over the last decade, Dr. Khan says he has experienced less resistance toward the procedure.
"Due to the increasing visibility of colon cancer through educational workshops and media efforts undertaken by various healthcare societies, I encounter less resistance when I bring it up, Dr. Khan says. "But this could also be due to greater comfort and familiarity with social media for the generation entering the screening age. The resistance is there, of course, but perhaps so is the increased awareness."
Back in 2000, Katie Couric underwent a live colonoscopy on the Today Show, changing people's perception of the procedure and removing the mystery that often shrouded the screening exams. "We saw an increase in the number of patients signing up for screening exams after that," Dr. Khan says.
Since then, many other celebrities have followed Katie's lead to shine the spotlight on colon cancer. "Chrissy Teigen and Gayle King posted their colonoscopy exams live on Instagram. Ryan Reynolds and Rob McElhenney posted videos of their colonoscopies on YouTube in partnership with the Colorectal Cancer Alliance and the organization' Lead from Behind', which even partnered with Terry Crews, the NFL player," Dr. Khan adds.
I encourage providers to suggest that your patients watch these videos, which are still available online. "Apart from providing some riveting TV, it does tend to put the patient's mind at ease and removes the fear of the unknown," Dr. Khan says.
Patients commonly say that they have heard prepping for a colonoscopy is the worst part (and they may be correct). Still, Dr. Khan mentions that when his mother kept delaying her colonoscopy due to concerns about prepping, he volunteered to do the prep with her. "That always seems to break the ice with most patients," Dr. Khan says.
There are other screening options besides colonoscopy.
Colonoscopy is the most effective one-step screening tool, reducing colorectal cancer incidence by over 69% and colorectal cancer mortality by 68%.3 "I do agree, however, with my gastroenterology colleagues that the best screening test may be the one that actually gets done," Dr. Khan says.
For the last several decades, researchers have pushed for less invasive techniques, such as a fecal occult blood test. However, early randomized control trials in 1993 revealed that these tests are often fraught with problems, which would be affected even by your diet.1
"Other techniques are more quantitative than qualitative, such as the single-sample Fecal Immunochemical test (FIT), which does not require the patient to adjust their diet or medication regimen," Dr. Khan adds. "More recently, multitarget stool DNA tests combined with FITs (also known as Cologuard) screen for hemoglobin that may be shed by cancerous lesions in the colon and perform additional molecular analysis to test for genetic mutations by amplifying the methylation biomarkers associated with neoplasia."
This technique has been shown to have 92% sensitivity and 87% specificity for colorectal cancer.2
Other screening methods, such as CT colonography (made famous in 2010 when President Obama opted for a CT colonography over a colonoscopy), still require prep and remain limited due to poor sensitivity for flatter (sessile serrated) lesions and limited radiology expertise across the country. "CT colonography can also result in extracolonic findings, which may add to the patient's anxiety without adding clinical benefit," Dr. Khan explains.
Thus, an entire menu of patient options is based on their risk profile, comfort level, and clinician recommendations.
Surveillance and treatment methods have also developed.
The most exciting frontier for colon cancer surveillance and treatment remains personalized treatment regimens customized to individual patients' specific genetic and molecular profiles. "Clinicians commonly focus on microsatellite instability (MSI) linked to Lynch syndrome, which is a well-known example," Dr. Khan says.
Yet, advancements extend beyond histology to molecular signatures like consensus molecular subtypes (CMSs) or driver mutations (APC, KRAS, and BRAF). "We're approaching a phase where precise immunotherapy and chemotherapy based on individual genetic traits will be standard," Dr. Khan says. "Hence, collaboration with our gastroenterologist and oncologist colleagues is paramount."
Colon cancer has begun to affect younger patients.
One of the critical changes clinicians have recognized about colorectal cancer over the last few decades is the demographic shift to a younger population. Colorectal cancer is the leading cause of cancer death among men ages 20-49 and the second leading cause of cancer death for women ages 40-49. Still, it is unclear why there is an increasing shift to a younger population.
"Millennials (those born between 1981 and 1996) have twice the risk of colorectal cancer development than those born in 1950, for example," Dr. Khan explains. "The same data found that people under the age of 55 are almost 60% more likely to be diagnosed with late-stage disease than older adults." 4
The obesity epidemic, a more sedentary lifestyle, and dietary factors are believed to be the factors that contribute most to this trend. Thus, the signs and symptoms we typically associate with colorectal cancer (change in bowel habits, blood in or on the stool, rectal bleeding with bright red blood, etc.) cannot be discounted in a younger patient anymore."
Telehealth has increased access to screening and consultation in rural areas.
The COVID-19 pandemic changed telehealth, providing more widespread access to remote or virtual healthcare. Patients who could not take a trip to see their doctor can now visit with them virtually. Dr. Khan's clinical team utilized telehealth to enhance patient access to vital information and ease the transfer of medical records.
"Our office provides access to telehealth visits, which have also been incorporated into the clinic's electronic medical records," Dr. Khan says. "Patients with smartphones or smart devices can arrange virtual visits with healthcare providers. Especially in more rural areas of the state, patients may not often need to drive two hours into the city for care and counseling that can be provided through a telehealth visit. As patient access increases and technology advances toward remote care, I hope telehealth use will continue expanding."
Cutting-edge technologies should augment personalized care.
While advancements in medical technology and procedures are exciting, it's important to ensure that we still provide compassionate and individualized care to our patients. Continuing healthcare education focuses on utilizing technology to enhance (not replace) patient-focused care.
"To maintain our licensing and credentials and promote personal and professional growth, we must maintain continuing medical education," Dr. Khan says. "Our gastroenterology societies provide a platform that allows us to familiarize ourselves with cutting-edge technologies and procedures and their roles in patient care."
One example of cutting-edge technology is the expansion of Artificial Intelligence in gastroenterology. "AI often takes the form of software loaded onto existing endoscope' towers,' allowing more precise and accurate detection of smaller polyps during a colonoscopy through visual prompting," Dr. Khan explains. "This has been demonstrated to improve detection of precancerous polyps in several studies."
Other AI applications include software that evaluates the gland's structure within the polyp, categorizing it to help determine the best technique to remove it. This technique and several others are prime examples of how technology moves from science fiction to standard practice, allowing for more personalized care.
Ask the right questions.
"Often, the patient may not be aware that there are several options to choose from when it comes to colorectal cancer screenings," Dr. Khan says. "They may only know about colonoscopies or stool tests, but there are several options that may be tailor-cut to the patient's risk profile, family or personal history, and personal comfort level."
In other words, the patient needs to ask their doctor or specialist what options they have and decide on pursuing the best screening method after discussion. "Providers may sometimes recommend a particular screening test that the patient is not comfortable with, increasing the likelihood that the patient will not complete any screening at all," Dr. Khan says. "Perhaps providers should focus on providing a more complete array of options to help patients decide the best screening option for the patient's situation."
As time has passed, colorectal cancer has become more prevalent in men and women under the age of 50. This emphasizes the need for colorectal cancer screenings that can help identify and remove polyps that can become cancerous. While widespread awareness has helped increase screening numbers, colorectal cancer remains one of the leading causes of cancer death for people under 50. Technological advancements and continued discussion with our patients will hopefully lead to lower mortality rates.
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[1] https://pubmed.ncbi.nlm.nih.gov/8474513/
[2]https://journals.lww.com/ajg/fulltext/2021/03000/acg_clinical_guidelines__colorectal_cancer.14.aspx
[3] Brenner H, Stock C, Hoffmeister M. Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: Systematic review and meta-analysis of randomized controlled trials and observational studies. BMJ 2014;348:g2467.
[4] https://academic.oup.com/jnci/article/109/8/djw322/3053481?login=false
Meet Dr. Ali Khan
Dr. Khan is a gastroenterologist and Advanced and Therapeutic Endoscopist at Baptist Health. He has residency training in anatomic and clinical pathology and internal medicine. Dr. Khan has fellowships in gastroenterology and hepatology, inflammatory bowel disease, and advanced endoscopy. He also has experience as a chief resident and an MSPH in epidemiology and healthcare outcomes.
