Colon and Rectal Surgery

June 07, 2021

Information

June 6, 2021

Yale Cancer Center

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00:00Support for Yale Cancer Answers
00:03comes from AstraZeneca, dedicated
00:05to advancing options and providing
00:08hope for people living with cancer.
00:11More information at astrazeneca-us.com.
00:15Welcome to Yale Cancer Answers with
00:17your host doctor Anees Chagpar.
00:19Yale Cancer Answers features the
00:21latest information on cancer care by
00:23welcoming oncologists and specialists
00:25who are on the forefront of the
00:27battle to fight cancer. This week,
00:29it's a conversation about colon and
00:31rectal cancer with doctor Amit Khanna,
00:33doctor Khanna is the director of
00:35Colon and rectal surgery for the
00:37Bridgeport region and an associate
00:39professor at the Yale School of
00:41Medicine where Doctor Chagpar is a
00:43professor of surgical oncology.
00:46Amit, maybe we can start
00:48off by you telling us
00:51a little bit about yourself and what you do.
00:56So I'm a colon and rectal surgeon
00:59and I treat diseases both benign and
01:02malignant of the colon and the rectum
01:06and also help to organize programs for
01:10our digestive health service lines.
01:12So it includes all digestive
01:16health disorders.
01:17And largely also a lot of what we do is
01:20educate the community on prevention.
01:23So let's pick
01:24up on that and put two of those
01:27things together so you know when
01:30we talk about colorectal cancer,
01:32tell us a little bit more about it.
01:35How common is it?
01:37How lethal is it? Who gets it?
01:40Why should we care?
01:41So it's a huge public
01:44health issue for us.
01:46We're probably going to see, the
01:48predicted number of cases by the
01:51American Cancer Society is
01:54approaching 150,000 new cases of colon
01:56and rectal cancer in the United States.
02:00Right now, it's the third most
02:03commonly diagnosed cancer in the
02:05United States in men and women.
02:08The good news is that we're seeing
02:11lower incidence rates in older populations,
02:14but unfortunately,
02:15we are also seeing some trends
02:19or increases in younger adults,
02:21so we're making progress in a lot of areas,
02:25and we're also facing new challenges
02:28and others.
02:30When you say younger adults, how
02:32young is young?
02:35Classically our screening
02:36guidelines have been aimed at
02:39the population older than 50,
02:42so the classic age of getting
02:44your first colonoscopy if you
02:47don't have a family history or
02:49other risk factors has been 50,
02:52and that's largely been designed
02:54because we know that the incidence
02:56of colorectal cancer rises
02:58significantly after the age of 50,
03:01and that's been the way it's been
03:06for many, many years. In 2018 though,
03:10a recognition of changes in our cancer
03:13statistics showed that we were
03:16seeing patients in their younger years,
03:20meaning under 50 having
03:22a rise in their incidence,
03:26and so we were very concerned about
03:30that from about 2012 to 2016 we
03:33were seeing about a 2% increase
03:36in younger populations under 50
03:39developing colorectal cancer.
03:40And so organizations like the
03:43American Cancer Society in 2018 dropped
03:45the age of recommendation to 45.
03:47Not all of the societies
03:49have gone along with that,
03:51but there's an increasing recognition
03:54that it's becoming a greater
03:56issue than just those over 50.
03:58And do we
03:59know why that is? I mean, why are
04:02young people now getting colon cancer?
04:04So it's a great question,
04:06and I think that we don't
04:09know the answer, we have
04:11some data and some evidence that suggests
04:14that a significant portion of the
04:17younger population has a family history,
04:20and there's some genetic component,
04:23but that's not the whole story,
04:26so only about 40% of those patients
04:28have a family history and an even
04:32smaller percent actually have a genetic
04:35predisposition that we're aware of
04:38to put them at increased risk so
04:41it's got to be something that is not
04:44related to those specific family
04:46history risks and those genetic
04:49disorders which predispose patients to
04:51get colon cancer at an earlier age.
04:54In fact, the majority of those
04:57patients don't have those risk factors.
04:59So what we really think is that it
05:02could be related to what we call
05:05the lifestyle risk factors and
05:07environmental factors.
05:10Tell me more about what those lifestyle
05:12and environmental factors are.
05:16Obviously the big one whenever we're talking
05:20about digestive diseases is our diet,
05:25and the younger population under 50s
05:27it may impact their risk for
05:29colorectal cancer is being studied,
05:31and we don't know exactly how that is,
05:34but we do have some surrogates for that,
05:37and one of them is obesity,
05:39which we know increases the
05:41risk of colorectal cancer.
05:43We also know that physical inactivity
05:45increases the risk of colorectal cancer.
05:49We also know that there's
05:51data that the microbiome,
05:52meaning the bacterial flora,
05:55the balance of different bacteria that
05:58reside in the colon and in the GI tract,
06:01may play a role in the development
06:04of colorectal cancer.
06:06And there is a lot of research
06:08going on now to help us understand
06:11what those factors are,
06:13but at this time it's not entirely clear what
06:17about other factors I mean.
06:20Smoked meats, particular fats in the diet,
06:24anything like that increase
06:26your risk of colorectal cancer.
06:29Absolutely great point, yeah,
06:31I think that we know that processed
06:35meats just as those you described
06:39are associated with an increased
06:42risk of colorectal cancer.
06:44And now you know we are
06:48looking to understand.
06:50In younger populations,
06:52how much of a factor those are playing
06:55in the development of colorectal
06:58cancer in these younger age groups and
07:01of note identifying patients earlier
07:04with early stage disease affords
07:06that patient a better survival,
07:09and so if we can catch lesions early,
07:12we have a much better chance of
07:15helping that patient through
07:17their cancer journey and having.
07:20An ultimate great outcome for that patient,
07:23but the later they present or the
07:26later we diagnose those patients
07:28and their stages more advanced it
07:31becomes increasingly harder to get
07:33those patients a good outcome,
07:35and so in the younger populations
07:38particularly it's it's a challenge
07:40because it's a paradigm shift
07:42you know within within,
07:44not only the patient themselves,
07:46but also in the healthcare community to
07:49recognize that patients under the age of 50.
07:53You know,
07:53are a group of patients that are
07:56still at risk for colorectal cancer,
07:59and it's not just
08:0150 plus folks. What are the signs
08:04and symptoms that people should be
08:06looking for that they should
08:08go and see their doctor? Yeah,
08:11so I think there's such a important thing.
08:14I think for patients to understand
08:17is that rectal bleeding being
08:19a very very common thing,
08:21but it's abnormal, it's always abnormal.
08:24And so if you're having rectal bleeding,
08:26that's something that needs to
08:28be investigated by your provider.
08:30A change in your bowel function,
08:32so if your bowel function is I'm regular,
08:34you know, once or twice a day,
08:37and now you're going 6 times today.
08:39That that's something that you want
08:42to communicate to your provider.
08:44And weight loss is a really
08:46important one too.
08:47If you're not trying to lose
08:49weight and you're losing weight,
08:50or you have a significant
08:53change in your appetite.
08:55Change in bowel function may also be
08:58just discomfort when you're moving
09:01your bowels or a change in the
09:04character of your stools or the color,
09:07and those are all signs that
09:10you should communicate to your
09:13physician and be aware of that.
09:15Those changes really do need
09:19to be discussed and evaluated.
09:22I think it's also really important
09:24to understand your family history.
09:26So if you've got siblings or older
09:29siblings and you know you're 35 and you're,
09:32you know may have an older sibling
09:35or your parents or other family
09:37members that have a history of polyps,
09:40and so having a family history
09:42of polyps can also impact how you
09:45should be screened.
09:47And so I think the paradigm of screening
09:50patients just based on their age.
09:52Is is not adequate and what we
09:54really need to think about is
09:56personalized screening for each
09:57patient and then educating patients
09:59on the importance of recognition of
10:01symptoms regardless of their age.
10:03And so I'm going to pick up on
10:06screening in a minute but but
10:08getting back to these symptoms,
10:09I mean for many of our listeners out there,
10:12they may be thinking, you know,
10:14if I have a little bit of rectal bleeding,
10:17it might just be hemorrhoids.
10:19If you know I have a little bit of diarrhea,
10:22it might be you know, the meal that I.
10:25Late last night that just
10:28didn't agree with me.
10:29You know, is there is there a time
10:32frame that these symptoms should be
10:35continuous for or present for before
10:38people start sounding the alarm bells?
10:41I think it's a great point.
10:44I usually tell patients that if
10:46you've noticed a consistent if
10:49you've noted consistent symptoms
10:50over a period of two weeks,
10:53that's probably enough for you to seek care.
10:58And sometimes patients are very
11:00astute in saying you know what I ate,
11:02something that was bad yesterday and I got
11:05sick and then two days later I felt fine.
11:08I think it's the patients that are
11:11having a sustained set of symptoms
11:13over a period of two weeks or more,
11:16and those are the patients were
11:18real concerned about period.
11:20I mean if we think about patients
11:22who have rectal pain for example,
11:24over a period of at least.
11:27You know two to three weeks.
11:29An rectal bleeding that can be a
11:32significant issue and not every one
11:35of these patients that's having
11:38these symptoms is going to have.
11:40A colorectal cancer.
11:41In fact, the majority or not,
11:43but we know you're at increased
11:45risk when you have those symptoms,
11:47and I think that it's also sort of
11:50the engine warning light of the body.
11:53And I always say this to patients
11:55who may come in with a benign
11:57anorectal disorder which may cause
11:59bleeding hemorrhoids or anal fissure,
12:01which is a tear in the anal mucosa,
12:04but that warning system we want to
12:06treat that bleeding so that that
12:09warning systems intact right so?
12:11If you do have hemorrhoids and
12:12you're bleeding every so often
12:14if it's happening all the time,
12:16then you really lose that as a
12:18warning signal because it's happening
12:19every so often and you blow it off.
12:22So we really want to get those other
12:24benign diseases treated so that
12:25we still have that warning system
12:27in place. We're going to take a short break
12:30for a medical minute when we come back.
12:32We're going to talk more about screening
12:34with my guest doctor Amit Khanna.
12:37Support for Yale Cancer Answers
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12:42eliminate cancer as a cause of death.
12:45Learn more at astrazeneca-us.com.
12:49This is a medical minute about breast cancer,
12:53the most common cancer in
12:55women in Connecticut alone.
12:56Approximately 3000 women will be
12:58diagnosed with breast cancer this year,
13:01but thanks to earlier detection,
13:03noninvasive treatments, and novel therapies,
13:05there are more options for patients to
13:08fight breast cancer than ever before.
13:10Women should schedule a baseline mammogram
13:13beginning at age 40 or earlier if they have
13:16risk factors associated with breast cancer.
13:19Digital breast Tomosynthesis or
13:213D mammography is transforming
13:22breast screening by significantly
13:24reducing unnecessary procedures
13:26while picking up more cancers and
13:29eliminating some of the fear and anxiety
13:32that many women experience.
13:33More information is available
13:35at yalecancercenter.org.
13:36You're listening to Connecticut public radio.
13:40Welcome
13:41back to Yale Cancer Answers.
13:43This is doctor Anees Chagpar and
13:45I'm joined tonight by my guest,
13:48doctor Amit Khanna.
13:49We're talking about surgical care of
13:51colorectal cancer and right before
13:54the break we were talking about this
13:56increase that we've seen in terms of
13:59young people getting colorectal cancer.
14:00And we talked a little bit about the symptoms
14:04that people should be on the lookout for.
14:07Whether that's a change in bowel
14:09habit or whether it's feeling full
14:12or whether it's rectal bleeding.
14:14But oftentimes am I mistaken,
14:18that oftentimes if you've got symptoms and
14:20you're presenting with colorectal cancer,
14:23you're picking up colorectal cancers
14:26later than if you were asymptomatic?
14:29Is that right?
14:32Absolutely, depending on where the colon lesion,
14:35or polyp, which is early changes
14:38or abnormal changes, or growths in
14:42the colon that are not cancer yet.
14:47You may be completely asymptomatic,
14:49and if they are on the
14:52right side of the colon,
14:55you may not ever develop any symptoms at all,
15:00and that's the fundamental
15:02benefit of doing screening for
15:06colorectal polyps and colorectal cancers
15:08using a variety of
15:10modalities because you can be
15:13asymptomatic and so one of
15:14the things that I always think
15:17is great about colorectal cancer
15:19screening is that you can pick
15:21up these cancers like you can
15:23with many screening modalities.
15:25You can pick up these cancers
15:27before they become a cancer,
15:30and you can potentially eliminate
15:32them right then and there during
15:34that screening test so that
15:37it's not just screening,
15:38it's also prevented it.
15:44When I was in medical school and I was trying
15:46to figure out what it is I wanted
15:49to do with with my life in terms
15:52of my profession and my focus,
15:54that was really very appealing to me.
15:56Was the idea that you could
15:58identify disease in its early
16:00form and intervene and change
16:02the course of someone's life and
16:05prevent them from having to go through
16:08cancer or potentially improve their
16:10quality of life.
16:14We're able to use a variety
16:17of different tests to
16:18identify early stages
16:20of the disease, so let's
16:22talk about these
16:25screening modalities, and
16:27first off the indications for screening
16:30and who needs to get screening.
16:33So you mentioned that the
16:35American Cancer Society,
16:37because we've seen an increase
16:39in colorectal cancer,
16:41in young patients has moved their
16:44guidelines down to asymptomatic
16:47people starting at the age of 45.
16:50But you also mentioned that
16:52it shouldn't just be age.
16:54So if you do have a family history,
16:57let's say when should you
17:00get screened, the general thought
17:02is that personalized screening is
17:04going to be a much more high yield
17:07approach to screening patients.
17:09So what are those things that
17:11are important with a personal
17:13history of colorectal cancer?
17:15If you've had a history of polyps yourself,
17:18or you personally had colorectal cancer
17:21that's a much higher risk group.
17:24A family history of colorectal cancer,
17:26personal history of inflammatory
17:28bowel disease.
17:29Whether that's colitis
17:31or Crohn's disease.
17:33And then, if you've had a suspected
17:36history of some familial syndromes
17:38that puts you at high risk for
17:41having polyps and then also things
17:44like having a history of radiation,
17:46those are all things that put
17:49you at a higher risk,
17:51including
17:51family members that have had
17:54colorectal cancer or polyps
17:56on their colonoscopies.
17:58And if you fit into any of those criteria
18:02when should you be getting screened?
18:04So depending on your risk category,
18:07it's not the same for every patient,
18:09but if we look at patients that
18:11have a strong family history
18:13or have a known family member,
18:16it depends on how close that
18:18family member is to you.
18:19So a first degree relative might be
18:22different than you know a cousin,
18:24but generally what we say is if you
18:26have a first degree family member
18:29who's developed colon or rectal cancer,
18:31we should be screening that patient at least
18:3410 years prior to when that patient's
18:37family member was diagnosed.
18:39So 10 years prior to their
18:42diagnosis or 45 years of age.
18:46You mentioned radiation.
18:47So if you've
18:48had a previous history of radiation,
18:51you're in a higher risk category.
18:53What do you mean by a history of radiation?
18:57Is that going to a tanning Salon?
19:00Is that getting a chest X ray?
19:03Is that having
19:04radiation therapy for ovarian cancer?
19:06What is that and how does that
19:10play into when you should be getting
19:13screened for colorectal cancer?
19:16We're talking about radiation for
19:19pelvic or abdominal cancers,
19:22so radiation to treat a prior cancer
19:25in the abdomen those are the
19:28patients that we tend to want
19:32to identify and screen more frequently.
19:35The lower dose radiation patients
19:39maybe having perhaps more frequent exposure,
19:42we don't know enough about those patients
19:45to justify screening them at a
19:48different or more aggressive interval.
19:50It's more for patients that
19:52have had treatment for a prior
19:54cancer with radiation to the
19:56abdomen or pelvic region.
19:58When you talk about
20:01screening it at different intervals,
20:03it really brings up this whole bugaboo
20:06of the different screening modalities
20:09so people have heard about things like
20:14stool tests that are advertised
20:16on TV all the way up to colonoscopies,
20:20and then these are all
20:22recommended at different intervals.
20:24So can you walk us through
20:27what are the recommended
20:29tests for colorectal screening?
20:31How frequently we should be getting them,
20:33and how you decide what
20:35test you should be getting?
20:37I mean, should everybody be
20:40getting colonoscopies or is it
20:42just simpler to do a stool test?
20:45How do we make these decisions?
20:48It's a great question and it's
20:51honestly the most frequent question
20:53I get asked by family members
20:56and friends,
20:58what test should I get and the answer
21:00I always have is the same which is
21:03the test that you're willing
21:06to get is the best test,
21:10so often patients I see are very
21:13hesitant to have a colonoscopy in
21:17the interval for an average risk
21:20patient is at age 45.
21:29And then if you have a normal exam,
21:32it's to have a follow up colonoscopy at
21:3510 years, but there are other options.
21:38Some patients don't want to
21:40undergo a colonoscopy.
21:41The cost is an issue.
21:43They may not have access to a
21:46colonoscopy or it's quite
21:48costly for them and there are
21:51other ways to approach this
21:53for average risk individuals and I
21:55emphasize average risk individuals which is the most
21:58I think widely advertised one that
22:01you'll see on TV is a stool DNA test,
22:05and that's one that is sent as a kit to
22:08your home and then you send a stool
22:11sample back and that's generally
22:13supposed to be performed every three years.
22:17If it is positive,
22:19it's important that patients understand that,
22:22then they are going to be
22:25recommended to have
22:26a colonoscopy,
22:27so those two tests combined
22:29can be more expensive.
22:31than having a colonoscopy alone.
22:35The other two tests that are stool
22:38based tests are what we call fit
22:41tests or fecal immunochemical tests,
22:44which are sensitive for detecting
22:46blood in the stool,
22:48and then something called a
22:51fecal occult blood test or
22:54an FOBFOBT test which is done
22:56annually both of those other two tests,
22:59the fit test and the FOBT tests
23:01are done annually,
23:02so those are cards you get sent home with,
23:05and then you send back to your doctor and they
23:08process for the presence of blood.
23:11I mean the other two tests that we
23:13call structural exams include,
23:15CT COLONOGRAPHY,
23:17which is a CT scan,
23:18that creates images of your colon,
23:21and that's sort of been termed
23:23the virtual colonoscopy.
23:24And then there's a more limited
23:27colonoscopy,
23:27which is known as a flexible
23:30sigmoidoscopies and those other
23:32two tests the CT colonography and
23:34the flex SIG as we refer to it,
23:36a flexible sigmoidoscopies the intervals
23:38on those are every five years,
23:40but I want to make clear that the
23:43flexible sigmoidoscopies have limitations
23:44because it's only exposing or it's
23:47only visualizing the rectum in the
23:49sigmoid colon and we know that
23:51lesions can grow in the middle part
23:54and on the right part of the colon,
23:57and those can be missed.
23:59So we emphasize that a colonoscopy
24:01has some significant advantages
24:03over flexible sigmoidoscopies,
24:05and then the limitation of the CT
24:08colonography is that if you do see a polyp,
24:12you can't intervene at that time.
24:15And so the colonoscopy has
24:17the opportunity to be both
24:18diagnostic and therapeutic.
24:20If polyps are identified,
24:21they can be removed in the
24:23same setting.
24:25Many advantages and disadvantages
24:27of all of these different tests.
24:29So let's go over them
24:31just a little bit more.
24:33So the fit test and the FOBT.
24:36These are both stool based tests,
24:38and they're both annual.
24:40So if somebody says, well,
24:41I don't mind doing a stool based test,
24:44which one is better?
24:46Well, I think that the cost of the fit tests
24:50and the FOBT tests make it very scalable.
24:54So doing an annual exam for one
24:57of these tests is actually,
24:59inexpensive.
25:04The problems with some of these
25:06is that a lot of patients
25:08don't send them back,
25:10and so the yield on those can be an issue,
25:14but it's a reasonable test.
25:17It's good for detecting blood,
25:19but it's also a cross sectional test,
25:22so if you're not bleeding at that
25:25instance when you do the test from,
25:28say, a polyp that's present,
25:31or potentially an early lesion,
25:33you might miss it.
25:34The stool DNA test is a bit more
25:38sensitive because it's looking for
25:40specific changes in stool DNA,
25:43and it's quite good at
25:45picking up cancers above 90%
25:48sensitive,
25:48the downside of the stool DNA tests are that
25:54they're not as specific,
25:55so it isn't that uncommon that we will
25:58find patients who have positive
26:00stool DNA tests and they get a
26:02colonoscopy and we don't find polyps
26:05it's not as specific
26:07as we would like it to be,
26:10but it's still a pretty
26:12reliable test and
26:13I think we're going to see more and
26:16more patients take advantage of
26:18stool DNA based tests as sort of a
26:21filter before they go to colonoscopy.
26:24And those stool DNA tests you said are
26:27only three years versus the fit test
26:29And the FOBT which is every
26:31year, right?
26:34And an important misconception that I often
26:36hear with patients is they'll think
26:38that the stool DNA test is equivalent
26:41to a colonoscopy, and it's not.
26:43The interval is very different.
26:45The stool based DNA test is every three
26:47years and a colonoscopy every 10 years,
26:50and so it's really up to the patient
26:53to decide well do I want to do
26:56Colonoscopy and be done with
26:57this for 10 years
26:58if it's normal or do I want to have to
27:01keep going through this every three years?
27:04And if they are positive,
27:06any of the DNA tests, then I'm going
27:08to have to have a colonoscopy anyway.
27:13And then if it is
27:15positive I have to have colonoscopy.
27:18If I get a colonoscopy to start
27:20off with and it's normal,
27:22I could go to 10 years,
27:24but if they do find something,
27:26they would
27:27also be able to treat it at the
27:29same time in most cases.
27:31So my final question just really quickly
27:34in the 30 seconds that we have left,
27:36you mentioned that colonoscopies are
27:38really expensive,
27:38but aren't they covered by insurance yet?
27:41They are covered by insurance
27:42and Medicare covers, colonoscopy,
27:44and most insurance plans cover colonoscopy.
27:46We also have state by state
27:48variation in colonoscopy,
27:49but most Medicaid in most
27:53states covers colonoscopy and there
27:55are actually a lot of resources to
27:58help patients access colonoscopy,
28:00but sometimes the out of pocket
28:03expenses for colonoscopy,
28:05even with insured patients,
28:07can be significant and so
28:09one of the goals
28:11I think for us as a healthcare
28:14system is to realize that
28:17the return on the investment for us
28:20increasing our screening colonoscopy
28:22rates has been borne out in the data,
28:25and that colorectal cancer in the
28:2750 and above age group has
28:30really been impacted by the advent of
28:33aggressive screening colonoscopy programs.
28:36Doctor Amit Khanna is director
28:38of Colon and rectal surgery
28:40for the Bridgeport region
28:41and is an associate professor at
28:43the Yale School of Medicine.
28:44If you have questions the address is
28:46cancer answers at yale.edu and
28:48past addition to the program are
28:50available in audio and written
28:52form at yalecancercenter.org.
28:53We hope you'll join us next week to
28:56learn more about the fight against
28:58cancer here on Connecticut Public Radio.