Colon and Rectal Surgery

Transcript

00:00 --> 00:02Support for Yale Cancer Answers
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00:15 --> 00:16Welcome to Yale Cancer Answers with
00:16 --> 00:19your host doctor Anees Chagpar.
00:19 --> 00:21Yale Cancer Answers features the
00:21 --> 00:23latest information on cancer care by
00:23 --> 00:24welcoming oncologists and specialists
00:24 --> 00:26who are on the forefront of the
00:26 --> 00:28battle to fight cancer. This week,
00:28 --> 00:30it's a conversation about colon and
00:30 --> 00:32rectal cancer with doctor Amit Khanna,
00:32 --> 00:34doctor Khanna is the director of
00:34 --> 00:37Colon and rectal surgery for the
00:37 --> 00:38Bridgeport region and an associate
00:38 --> 00:40professor at the Yale School of
00:40 --> 00:42Medicine where Doctor Chagpar is a
00:42 --> 00:45professor of surgical oncology.
00:45 --> 00:48Amit, maybe we can start
00:48 --> 00:51off by you telling us
00:51 --> 00:55a little bit about yourself and what you do.
00:55 --> 00:58So I'm a colon and rectal surgeon
00:58 --> 01:02and I treat diseases both benign and
01:02 --> 01:06malignant of the colon and the rectum
01:06 --> 01:09and also help to organize programs for
01:09 --> 01:12our digestive health service lines.
01:12 --> 01:15So it includes all digestive
01:15 --> 01:16health disorders.
01:16 --> 01:20And largely also a lot of what we do is
01:20 --> 01:22educate the community on prevention.
01:22 --> 01:24So let's pick
01:24 --> 01:27up on that and put two of those
01:27 --> 01:29things together so you know when
01:29 --> 01:31we talk about colorectal cancer,
01:31 --> 01:35tell us a little bit more about it.
01:35 --> 01:36How common is it?
01:36 --> 01:39How lethal is it? Who gets it?
01:39 --> 01:41Why should we care?
01:41 --> 01:43So it's a huge public
01:43 --> 01:46health issue for us.
01:46 --> 01:48We're probably going to see, the
01:48 --> 01:51predicted number of cases by the
01:51 --> 01:53American Cancer Society is
01:53 --> 01:56approaching 150,000 new cases of colon
01:56 --> 01:59and rectal cancer in the United States.
01:59 --> 02:02Right now, it's the third most
02:02 --> 02:05commonly diagnosed cancer in the
02:05 --> 02:07United States in men and women.
02:07 --> 02:11The good news is that we're seeing
02:11 --> 02:14lower incidence rates in older populations,
02:14 --> 02:15but unfortunately,
02:15 --> 02:19we are also seeing some trends
02:19 --> 02:21or increases in younger adults,
02:21 --> 02:25so we're making progress in a lot of areas,
02:25 --> 02:27and we're also facing new challenges
02:27 --> 02:30and others.
02:30 --> 02:31When you say younger adults, how
02:31 --> 02:34young is young?
02:34 --> 02:36Classically our screening
02:36 --> 02:39guidelines have been aimed at
02:39 --> 02:41the population older than 50,
02:41 --> 02:44so the classic age of getting
02:44 --> 02:46your first colonoscopy if you
02:46 --> 02:49don't have a family history or
02:49 --> 02:51other risk factors has been 50,
02:51 --> 02:53and that's largely been designed
02:53 --> 02:56because we know that the incidence
02:56 --> 02:58of colorectal cancer rises
02:58 --> 03:00significantly after the age of 50,
03:00 --> 03:04and that's been the way it's been
03:06 --> 03:09for many, many years. In 2018 though,
03:09 --> 03:13a recognition of changes in our cancer
03:13 --> 03:16statistics showed that we were
03:16 --> 03:19seeing patients in their younger years,
03:19 --> 03:22meaning under 50 having
03:22 --> 03:25a rise in their incidence,
03:25 --> 03:29and so we were very concerned about
03:29 --> 03:33that from about 2012 to 2016 we
03:33 --> 03:36were seeing about a 2% increase
03:36 --> 03:38in younger populations under 50
03:38 --> 03:40developing colorectal cancer.
03:40 --> 03:42And so organizations like the
03:42 --> 03:45American Cancer Society in 2018 dropped
03:45 --> 03:47the age of recommendation to 45.
03:47 --> 03:49Not all of the societies
03:49 --> 03:51have gone along with that,
03:51 --> 03:53but there's an increasing recognition
03:53 --> 03:55that it's becoming a greater
03:55 --> 03:57issue than just those over 50.
03:57 --> 03:58And do we
03:58 --> 04:02know why that is? I mean, why are
04:02 --> 04:04young people now getting colon cancer?
04:04 --> 04:06So it's a great question,
04:06 --> 04:08and I think that we don't
04:08 --> 04:10know the answer, we have
04:10 --> 04:14some data and some evidence that suggests
04:14 --> 04:17that a significant portion of the
04:17 --> 04:20younger population has a family history,
04:20 --> 04:22and there's some genetic component,
04:22 --> 04:25but that's not the whole story,
04:25 --> 04:28so only about 40% of those patients
04:28 --> 04:31have a family history and an even
04:31 --> 04:34smaller percent actually have a genetic
04:35 --> 04:37predisposition that we're aware of
04:37 --> 04:40to put them at increased risk so
04:40 --> 04:43it's got to be something that is not
04:43 --> 04:46related to those specific family
04:46 --> 04:48history risks and those genetic
04:48 --> 04:50disorders which predispose patients to
04:50 --> 04:54get colon cancer at an earlier age.
04:54 --> 04:56In fact, the majority of those
04:56 --> 04:59patients don't have those risk factors.
04:59 --> 05:01So what we really think is that it
05:01 --> 05:04could be related to what we call
05:04 --> 05:06the lifestyle risk factors and
05:06 --> 05:08environmental factors.
05:09 --> 05:12Tell me more about what those lifestyle
05:12 --> 05:13and environmental factors are.
05:16 --> 05:19Obviously the big one whenever we're talking
05:19 --> 05:21about digestive diseases is our diet,
05:25 --> 05:27and the younger population under 50s
05:27 --> 05:29it may impact their risk for
05:29 --> 05:31colorectal cancer is being studied,
05:31 --> 05:34and we don't know exactly how that is,
05:34 --> 05:37but we do have some surrogates for that,
05:37 --> 05:39and one of them is obesity,
05:39 --> 05:41which we know increases the
05:41 --> 05:42risk of colorectal cancer.
05:42 --> 05:45We also know that physical inactivity
05:45 --> 05:48increases the risk of colorectal cancer.
05:48 --> 05:50We also know that there's
05:50 --> 05:52data that the microbiome,
05:52 --> 05:54meaning the bacterial flora,
05:54 --> 05:57the balance of different bacteria that
05:57 --> 06:00reside in the colon and in the GI tract,
06:00 --> 06:03may play a role in the development
06:03 --> 06:05of colorectal cancer.
06:05 --> 06:08And there is a lot of research
06:08 --> 06:11going on now to help us understand
06:11 --> 06:13what those factors are,
06:13 --> 06:17but at this time it's not entirely clear what
06:17 --> 06:20about other factors I mean.
06:20 --> 06:24Smoked meats, particular fats in the diet,
06:24 --> 06:26anything like that increase
06:26 --> 06:29your risk of colorectal cancer.
06:29 --> 06:31Absolutely great point, yeah,
06:31 --> 06:35I think that we know that processed
06:35 --> 06:38meats just as those you described
06:38 --> 06:41are associated with an increased
06:41 --> 06:44risk of colorectal cancer.
06:44 --> 06:48And now you know we are
06:48 --> 06:50looking to understand.
06:50 --> 06:51In younger populations,
06:51 --> 06:55how much of a factor those are playing
06:55 --> 06:57in the development of colorectal
06:57 --> 07:01cancer in these younger age groups and
07:01 --> 07:03of note identifying patients earlier
07:03 --> 07:06with early stage disease affords
07:06 --> 07:08that patient a better survival,
07:08 --> 07:12and so if we can catch lesions early,
07:12 --> 07:15we have a much better chance of
07:15 --> 07:17helping that patient through
07:17 --> 07:20their cancer journey and having.
07:20 --> 07:23An ultimate great outcome for that patient,
07:23 --> 07:25but the later they present or the
07:25 --> 07:27later we diagnose those patients
07:27 --> 07:30and their stages more advanced it
07:30 --> 07:33becomes increasingly harder to get
07:33 --> 07:35those patients a good outcome,
07:35 --> 07:37and so in the younger populations
07:37 --> 07:39particularly it's it's a challenge
07:39 --> 07:41because it's a paradigm shift
07:41 --> 07:43you know within within,
07:43 --> 07:45not only the patient themselves,
07:45 --> 07:49but also in the healthcare community to
07:49 --> 07:52recognize that patients under the age of 50.
07:52 --> 07:53You know,
07:53 --> 07:56are a group of patients that are
07:56 --> 07:59still at risk for colorectal cancer,
07:59 --> 08:00and it's not just
08:00 --> 08:0350 plus folks. What are the signs
08:03 --> 08:06and symptoms that people should be
08:06 --> 08:08looking for that they should
08:08 --> 08:10go and see their doctor? Yeah,
08:10 --> 08:14so I think there's such a important thing.
08:14 --> 08:16I think for patients to understand
08:16 --> 08:19is that rectal bleeding being
08:19 --> 08:21a very very common thing,
08:21 --> 08:23but it's abnormal, it's always abnormal.
08:23 --> 08:26And so if you're having rectal bleeding,
08:26 --> 08:27that's something that needs to
08:27 --> 08:29be investigated by your provider.
08:29 --> 08:31A change in your bowel function,
08:31 --> 08:34so if your bowel function is I'm regular,
08:34 --> 08:36you know, once or twice a day,
08:36 --> 08:38and now you're going 6 times today.
08:38 --> 08:41That that's something that you want
08:41 --> 08:44to communicate to your provider.
08:44 --> 08:46And weight loss is a really
08:46 --> 08:46important one too.
08:46 --> 08:48If you're not trying to lose
08:48 --> 08:50weight and you're losing weight,
08:50 --> 08:52or you have a significant
08:52 --> 08:54change in your appetite.
08:54 --> 08:58Change in bowel function may also be
08:58 --> 09:00just discomfort when you're moving
09:00 --> 09:04your bowels or a change in the
09:04 --> 09:07character of your stools or the color,
09:07 --> 09:10and those are all signs that
09:10 --> 09:12you should communicate to your
09:12 --> 09:15physician and be aware of that.
09:15 --> 09:18Those changes really do need
09:18 --> 09:21to be discussed and evaluated.
09:21 --> 09:23I think it's also really important
09:23 --> 09:26to understand your family history.
09:26 --> 09:28So if you've got siblings or older
09:28 --> 09:32siblings and you know you're 35 and you're,
09:32 --> 09:34you know may have an older sibling
09:34 --> 09:37or your parents or other family
09:37 --> 09:40members that have a history of polyps,
09:40 --> 09:42and so having a family history
09:42 --> 09:45of polyps can also impact how you
09:45 --> 09:46should be screened.
09:46 --> 09:49And so I think the paradigm of screening
09:49 --> 09:52patients just based on their age.
09:52 --> 09:54Is is not adequate and what we
09:54 --> 09:55really need to think about is
09:55 --> 09:57personalized screening for each
09:57 --> 09:59patient and then educating patients
09:59 --> 10:01on the importance of recognition of
10:01 --> 10:03symptoms regardless of their age.
10:03 --> 10:05And so I'm going to pick up on
10:05 --> 10:07screening in a minute but but
10:07 --> 10:09getting back to these symptoms,
10:09 --> 10:12I mean for many of our listeners out there,
10:12 --> 10:14they may be thinking, you know,
10:14 --> 10:17if I have a little bit of rectal bleeding,
10:17 --> 10:18it might just be hemorrhoids.
10:18 --> 10:22If you know I have a little bit of diarrhea,
10:22 --> 10:25it might be you know, the meal that I.
10:25 --> 10:27Late last night that just
10:27 --> 10:29didn't agree with me.
10:29 --> 10:32You know, is there is there a time
10:32 --> 10:34frame that these symptoms should be
10:34 --> 10:37continuous for or present for before
10:37 --> 10:40people start sounding the alarm bells?
10:40 --> 10:43I think it's a great point.
10:43 --> 10:46I usually tell patients that if
10:46 --> 10:48you've noticed a consistent if
10:48 --> 10:50you've noted consistent symptoms
10:50 --> 10:52over a period of two weeks,
10:52 --> 10:57that's probably enough for you to seek care.
10:57 --> 10:59And sometimes patients are very
10:59 --> 11:02astute in saying you know what I ate,
11:02 --> 11:05something that was bad yesterday and I got
11:05 --> 11:08sick and then two days later I felt fine.
11:08 --> 11:11I think it's the patients that are
11:11 --> 11:13having a sustained set of symptoms
11:13 --> 11:16over a period of two weeks or more,
11:16 --> 11:18and those are the patients were
11:18 --> 11:19real concerned about period.
11:19 --> 11:22I mean if we think about patients
11:22 --> 11:24who have rectal pain for example,
11:24 --> 11:27over a period of at least.
11:27 --> 11:29You know two to three weeks.
11:29 --> 11:32An rectal bleeding that can be a
11:32 --> 11:35significant issue and not every one
11:35 --> 11:37of these patients that's having
11:37 --> 11:39these symptoms is going to have.
11:39 --> 11:41A colorectal cancer.
11:41 --> 11:43In fact, the majority or not,
11:43 --> 11:45but we know you're at increased
11:45 --> 11:47risk when you have those symptoms,
11:47 --> 11:50and I think that it's also sort of
11:50 --> 11:52the engine warning light of the body.
11:52 --> 11:54And I always say this to patients
11:54 --> 11:57who may come in with a benign
11:57 --> 11:58anorectal disorder which may cause
11:58 --> 12:01bleeding hemorrhoids or anal fissure,
12:01 --> 12:03which is a tear in the anal mucosa,
12:03 --> 12:06but that warning system we want to
12:06 --> 12:08treat that bleeding so that that
12:08 --> 12:10warning systems intact right so?
12:10 --> 12:12If you do have hemorrhoids and
12:12 --> 12:13you're bleeding every so often
12:13 --> 12:15if it's happening all the time,
12:15 --> 12:17then you really lose that as a
12:17 --> 12:19warning signal because it's happening
12:19 --> 12:21every so often and you blow it off.
12:21 --> 12:23So we really want to get those other
12:23 --> 12:25benign diseases treated so that
12:25 --> 12:27we still have that warning system
12:27 --> 12:29in place. We're going to take a short break
12:29 --> 12:32for a medical minute when we come back.
12:32 --> 12:34We're going to talk more about screening
12:34 --> 12:36with my guest doctor Amit Khanna.
12:36 --> 12:39Support for Yale Cancer Answers
12:39 --> 12:42comes from AstraZeneca, working to
12:42 --> 12:45eliminate cancer as a cause of death.
12:45 --> 12:47Learn more at astrazeneca-us.com.
12:49 --> 12:52This is a medical minute about breast cancer,
12:52 --> 12:54the most common cancer in
12:54 --> 12:56women in Connecticut alone.
12:56 --> 12:58Approximately 3000 women will be
12:58 --> 13:00diagnosed with breast cancer this year,
13:00 --> 13:02but thanks to earlier detection,
13:02 --> 13:04noninvasive treatments, and novel therapies,
13:04 --> 13:07there are more options for patients to
13:07 --> 13:10fight breast cancer than ever before.
13:10 --> 13:12Women should schedule a baseline mammogram
13:12 --> 13:16beginning at age 40 or earlier if they have
13:16 --> 13:18risk factors associated with breast cancer.
13:18 --> 13:20Digital breast Tomosynthesis or
13:20 --> 13:223D mammography is transforming
13:22 --> 13:24breast screening by significantly
13:24 --> 13:25reducing unnecessary procedures
13:25 --> 13:29while picking up more cancers and
13:29 --> 13:31eliminating some of the fear and anxiety
13:31 --> 13:33that many women experience.
13:33 --> 13:35More information is available
13:35 --> 13:36at yalecancercenter.org.
13:36 --> 13:40You're listening to Connecticut public radio.
13:40 --> 13:40Welcome
13:40 --> 13:42back to Yale Cancer Answers.
13:42 --> 13:45This is doctor Anees Chagpar and
13:45 --> 13:47I'm joined tonight by my guest,
13:47 --> 13:48doctor Amit Khanna.
13:48 --> 13:51We're talking about surgical care of
13:51 --> 13:53colorectal cancer and right before
13:53 --> 13:56the break we were talking about this
13:56 --> 13:58increase that we've seen in terms of
13:58 --> 14:00young people getting colorectal cancer.
14:00 --> 14:04And we talked a little bit about the symptoms
14:04 --> 14:06that people should be on the lookout for.
14:06 --> 14:09Whether that's a change in bowel
14:09 --> 14:11habit or whether it's feeling full
14:11 --> 14:13or whether it's rectal bleeding.
14:13 --> 14:16But oftentimes am I mistaken,
14:17 --> 14:20that oftentimes if you've got symptoms and
14:20 --> 14:23you're presenting with colorectal cancer,
14:23 --> 14:25you're picking up colorectal cancers
14:25 --> 14:28later than if you were asymptomatic?
14:29 --> 14:32Is that right?
14:32 --> 14:35Absolutely, depending on where the colon lesion,
14:35 --> 14:38or polyp, which is early changes
14:38 --> 14:41or abnormal changes, or growths in
14:41 --> 14:46the colon that are not cancer yet.
14:46 --> 14:49You may be completely asymptomatic,
14:49 --> 14:52and if they are on the
14:52 --> 14:54right side of the colon,
14:54 --> 14:59you may not ever develop any symptoms at all,
14:59 --> 15:02and that's the fundamental
15:02 --> 15:05benefit of doing screening for
15:05 --> 15:07colorectal polyps and colorectal cancers
15:07 --> 15:10using a variety of
15:10 --> 15:12modalities because you can be
15:12 --> 15:14asymptomatic and so one of
15:14 --> 15:16the things that I always think
15:16 --> 15:18is great about colorectal cancer
15:18 --> 15:20screening is that you can pick
15:20 --> 15:23up these cancers like you can
15:23 --> 15:25with many screening modalities.
15:25 --> 15:27You can pick up these cancers
15:27 --> 15:29before they become a cancer,
15:29 --> 15:31and you can potentially eliminate
15:31 --> 15:34them right then and there during
15:34 --> 15:36that screening test so that
15:36 --> 15:38it's not just screening,
15:38 --> 15:39it's also prevented it.
15:43 --> 15:46When I was in medical school and I was trying
15:46 --> 15:48to figure out what it is I wanted
15:48 --> 15:51to do with with my life in terms
15:51 --> 15:53of my profession and my focus,
15:53 --> 15:56that was really very appealing to me.
15:56 --> 15:58Was the idea that you could
15:58 --> 16:00identify disease in its early
16:00 --> 16:02form and intervene and change
16:02 --> 16:04the course of someone's life and
16:04 --> 16:07prevent them from having to go through
16:07 --> 16:10cancer or potentially improve their
16:10 --> 16:13quality of life.
16:13 --> 16:16We're able to use a variety
16:16 --> 16:17of different tests to
16:17 --> 16:19identify early stages
16:19 --> 16:22of the disease, so let's
16:22 --> 16:25talk about these
16:25 --> 16:27screening modalities, and
16:27 --> 16:30first off the indications for screening
16:30 --> 16:33and who needs to get screening.
16:33 --> 16:35So you mentioned that the
16:35 --> 16:36American Cancer Society,
16:36 --> 16:39because we've seen an increase
16:39 --> 16:40in colorectal cancer,
16:40 --> 16:44in young patients has moved their
16:44 --> 16:46guidelines down to asymptomatic
16:46 --> 16:49people starting at the age of 45.
16:49 --> 16:51But you also mentioned that
16:51 --> 16:54it shouldn't just be age.
16:54 --> 16:57So if you do have a family history,
16:57 --> 16:59let's say when should you
16:59 --> 17:02get screened, the general thought
17:02 --> 17:04is that personalized screening is
17:04 --> 17:06going to be a much more high yield
17:06 --> 17:08approach to screening patients.
17:08 --> 17:11So what are those things that
17:11 --> 17:13are important with a personal
17:13 --> 17:15history of colorectal cancer?
17:15 --> 17:18If you've had a history of polyps yourself,
17:18 --> 17:21or you personally had colorectal cancer
17:21 --> 17:23that's a much higher risk group.
17:23 --> 17:26A family history of colorectal cancer,
17:26 --> 17:28personal history of inflammatory
17:28 --> 17:28bowel disease.
17:28 --> 17:31Whether that's colitis
17:31 --> 17:32or Crohn's disease.
17:32 --> 17:35And then, if you've had a suspected
17:35 --> 17:37history of some familial syndromes
17:37 --> 17:41that puts you at high risk for
17:41 --> 17:43having polyps and then also things
17:43 --> 17:46like having a history of radiation,
17:46 --> 17:48those are all things that put
17:48 --> 17:50you at a higher risk,
17:50 --> 17:51including
17:51 --> 17:53family members that have had
17:53 --> 17:55colorectal cancer or polyps
17:55 --> 17:57on their colonoscopies.
17:57 --> 18:02And if you fit into any of those criteria
18:02 --> 18:04when should you be getting screened?
18:04 --> 18:06So depending on your risk category,
18:06 --> 18:09it's not the same for every patient,
18:09 --> 18:11but if we look at patients that
18:11 --> 18:13have a strong family history
18:13 --> 18:15or have a known family member,
18:15 --> 18:17it depends on how close that
18:17 --> 18:19family member is to you.
18:19 --> 18:21So a first degree relative might be
18:21 --> 18:24different than you know a cousin,
18:24 --> 18:26but generally what we say is if you
18:26 --> 18:28have a first degree family member
18:28 --> 18:31who's developed colon or rectal cancer,
18:31 --> 18:34we should be screening that patient at least
18:34 --> 18:3610 years prior to when that patient's
18:36 --> 18:38family member was diagnosed.
18:38 --> 18:41So 10 years prior to their
18:41 --> 18:44diagnosis or 45 years of age.
18:45 --> 18:46You mentioned radiation.
18:46 --> 18:48So if you've
18:48 --> 18:50had a previous history of radiation,
18:50 --> 18:53you're in a higher risk category.
18:53 --> 18:56What do you mean by a history of radiation?
18:56 --> 19:00Is that going to a tanning Salon?
19:00 --> 19:02Is that getting a chest X ray?
19:02 --> 19:04Is that having
19:04 --> 19:06radiation therapy for ovarian cancer?
19:06 --> 19:09What is that and how does that
19:09 --> 19:12play into when you should be getting
19:12 --> 19:15screened for colorectal cancer?
19:15 --> 19:18We're talking about radiation for
19:18 --> 19:20pelvic or abdominal cancers,
19:22 --> 19:25so radiation to treat a prior cancer
19:25 --> 19:28in the abdomen those are the
19:28 --> 19:31patients that we tend to want
19:31 --> 19:34to identify and screen more frequently.
19:34 --> 19:36The lower dose radiation patients
19:39 --> 19:41maybe having perhaps more frequent exposure,
19:42 --> 19:44we don't know enough about those patients
19:44 --> 19:47to justify screening them at a
19:47 --> 19:50different or more aggressive interval.
19:50 --> 19:51It's more for patients that
19:51 --> 19:54have had treatment for a prior
19:54 --> 19:56cancer with radiation to the
19:56 --> 19:57abdomen or pelvic region.
19:58 --> 20:00When you talk about
20:00 --> 20:03screening it at different intervals,
20:03 --> 20:05it really brings up this whole bugaboo
20:05 --> 20:09of the different screening modalities
20:09 --> 20:13so people have heard about things like
20:13 --> 20:16stool tests that are advertised
20:16 --> 20:19on TV all the way up to colonoscopies,
20:19 --> 20:22and then these are all
20:22 --> 20:24recommended at different intervals.
20:24 --> 20:26So can you walk us through
20:26 --> 20:28what are the recommended
20:28 --> 20:30tests for colorectal screening?
20:30 --> 20:33How frequently we should be getting them,
20:33 --> 20:35and how you decide what
20:35 --> 20:37test you should be getting?
20:37 --> 20:39I mean, should everybody be
20:39 --> 20:42getting colonoscopies or is it
20:42 --> 20:45just simpler to do a stool test?
20:45 --> 20:47How do we make these decisions?
20:47 --> 20:50It's a great question and it's
20:50 --> 20:53honestly the most frequent question
20:53 --> 20:56I get asked by family members
20:56 --> 20:57and friends,
20:57 --> 21:00what test should I get and the answer
21:00 --> 21:03I always have is the same which is
21:03 --> 21:06the test that you're willing
21:06 --> 21:09to get is the best test,
21:09 --> 21:13so often patients I see are very
21:13 --> 21:16hesitant to have a colonoscopy in
21:16 --> 21:20the interval for an average risk
21:20 --> 21:24patient is at age 45.
21:29 --> 21:32And then if you have a normal exam,
21:32 --> 21:35it's to have a follow up colonoscopy at
21:35 --> 21:3810 years, but there are other options.
21:38 --> 21:40Some patients don't want to
21:40 --> 21:41undergo a colonoscopy.
21:41 --> 21:43The cost is an issue.
21:43 --> 21:46They may not have access to a
21:46 --> 21:48colonoscopy or it's quite
21:48 --> 21:50costly for them and there are
21:50 --> 21:52other ways to approach this
21:52 --> 21:55for average risk individuals and I
21:55 --> 21:57emphasize average risk individuals which is the most
21:57 --> 22:00I think widely advertised one that
22:00 --> 22:04you'll see on TV is a stool DNA test,
22:04 --> 22:07and that's one that is sent as a kit to
22:07 --> 22:10your home and then you send a stool
22:10 --> 22:13sample back and that's generally
22:13 --> 22:17supposed to be performed every three years.
22:17 --> 22:19If it is positive,
22:19 --> 22:21it's important that patients understand that,
22:21 --> 22:24then they are going to be
22:24 --> 22:26recommended to have
22:26 --> 22:26a colonoscopy,
22:26 --> 22:29so those two tests combined
22:29 --> 22:31can be more expensive.
22:31 --> 22:34than having a colonoscopy alone.
22:34 --> 22:37The other two tests that are stool
22:37 --> 22:40based tests are what we call fit
22:40 --> 22:43tests or fecal immunochemical tests,
22:43 --> 22:45which are sensitive for detecting
22:45 --> 22:47blood in the stool,
22:47 --> 22:50and then something called a
22:50 --> 22:53fecal occult blood test or
22:53 --> 22:56an FOBFOBT test which is done
22:56 --> 22:58annually both of those other two tests,
22:58 --> 23:01the fit test and the FOBT tests
23:01 --> 23:02are done annually,
23:02 --> 23:05so those are cards you get sent home with,
23:05 --> 23:08and then you send back to your doctor and they
23:08 --> 23:10process for the presence of blood.
23:10 --> 23:12I mean the other two tests that we
23:12 --> 23:15call structural exams include,
23:15 --> 23:16CT COLONOGRAPHY,
23:16 --> 23:18which is a CT scan,
23:18 --> 23:20that creates images of your colon,
23:20 --> 23:22and that's sort of been termed
23:22 --> 23:23the virtual colonoscopy.
23:24 --> 23:26And then there's a more limited
23:26 --> 23:26colonoscopy,
23:26 --> 23:29which is known as a flexible
23:29 --> 23:31sigmoidoscopies and those other
23:31 --> 23:33two tests the CT colonography and
23:33 --> 23:36the flex SIG as we refer to it,
23:36 --> 23:37a flexible sigmoidoscopies the intervals
23:37 --> 23:40on those are every five years,
23:40 --> 23:43but I want to make clear that the
23:43 --> 23:44flexible sigmoidoscopies have limitations
23:44 --> 23:46because it's only exposing or it's
23:46 --> 23:48only visualizing the rectum in the
23:48 --> 23:51sigmoid colon and we know that
23:51 --> 23:53lesions can grow in the middle part
23:53 --> 23:56and on the right part of the colon,
23:56 --> 23:59and those can be missed.
23:59 --> 24:01So we emphasize that a colonoscopy
24:01 --> 24:02has some significant advantages
24:02 --> 24:04over flexible sigmoidoscopies,
24:04 --> 24:08and then the limitation of the CT
24:08 --> 24:11colonography is that if you do see a polyp,
24:11 --> 24:15you can't intervene at that time.
24:15 --> 24:16And so the colonoscopy has
24:16 --> 24:18the opportunity to be both
24:18 --> 24:19diagnostic and therapeutic.
24:19 --> 24:21If polyps are identified,
24:21 --> 24:23they can be removed in the
24:23 --> 24:25same setting.
24:25 --> 24:27Many advantages and disadvantages
24:27 --> 24:29of all of these different tests.
24:29 --> 24:31So let's go over them
24:31 --> 24:33just a little bit more.
24:33 --> 24:35So the fit test and the FOBT.
24:35 --> 24:38These are both stool based tests,
24:38 --> 24:39and they're both annual.
24:39 --> 24:41So if somebody says, well,
24:41 --> 24:44I don't mind doing a stool based test,
24:44 --> 24:45which one is better?
24:46 --> 24:49Well, I think that the cost of the fit tests
24:50 --> 24:53and the FOBT tests make it very scalable.
24:53 --> 24:56So doing an annual exam for one
24:56 --> 24:58of these tests is actually,
24:58 --> 25:01inexpensive.
25:03 --> 25:05The problems with some of these
25:05 --> 25:08is that a lot of patients
25:08 --> 25:10don't send them back,
25:10 --> 25:14and so the yield on those can be an issue,
25:14 --> 25:16but it's a reasonable test.
25:16 --> 25:18It's good for detecting blood,
25:18 --> 25:22but it's also a cross sectional test,
25:22 --> 25:25so if you're not bleeding at that
25:25 --> 25:28instance when you do the test from,
25:28 --> 25:30say, a polyp that's present,
25:30 --> 25:32or potentially an early lesion,
25:32 --> 25:34you might miss it.
25:34 --> 25:37The stool DNA test is a bit more
25:37 --> 25:40sensitive because it's looking for
25:40 --> 25:42specific changes in stool DNA,
25:42 --> 25:45and it's quite good at
25:45 --> 25:47picking up cancers above 90%
25:47 --> 25:48sensitive,
25:48 --> 25:53the downside of the stool DNA tests are that
25:53 --> 25:55they're not as specific,
25:55 --> 25:57so it isn't that uncommon that we will
25:57 --> 25:59find patients who have positive
25:59 --> 26:02stool DNA tests and they get a
26:02 --> 26:04colonoscopy and we don't find polyps
26:04 --> 26:07it's not as specific
26:07 --> 26:09as we would like it to be,
26:09 --> 26:11but it's still a pretty
26:11 --> 26:13reliable test and
26:13 --> 26:15I think we're going to see more and
26:15 --> 26:17more patients take advantage of
26:17 --> 26:20stool DNA based tests as sort of a
26:20 --> 26:23filter before they go to colonoscopy.
26:23 --> 26:26And those stool DNA tests you said are
26:26 --> 26:29only three years versus the fit test
26:29 --> 26:31And the FOBT which is every
26:31 --> 26:34year, right?
26:34 --> 26:36And an important misconception that I often
26:36 --> 26:38hear with patients is they'll think
26:38 --> 26:40that the stool DNA test is equivalent
26:40 --> 26:42to a colonoscopy, and it's not.
26:42 --> 26:44The interval is very different.
26:44 --> 26:47The stool based DNA test is every three
26:47 --> 26:50years and a colonoscopy every 10 years,
26:50 --> 26:53and so it's really up to the patient
26:53 --> 26:56to decide well do I want to do
26:56 --> 26:57Colonoscopy and be done with
26:57 --> 26:58this for 10 years
26:58 --> 27:01if it's normal or do I want to have to
27:01 --> 27:04keep going through this every three years?
27:04 --> 27:05And if they are positive,
27:05 --> 27:07any of the DNA tests, then I'm going
27:07 --> 27:09to have to have a colonoscopy anyway.
27:12 --> 27:15And then if it is
27:15 --> 27:17positive I have to have colonoscopy.
27:17 --> 27:20If I get a colonoscopy to start
27:20 --> 27:21off with and it's normal,
27:21 --> 27:24I could go to 10 years,
27:24 --> 27:26but if they do find something,
27:26 --> 27:26they would
27:26 --> 27:29also be able to treat it at the
27:29 --> 27:31same time in most cases.
27:31 --> 27:33So my final question just really quickly
27:33 --> 27:36in the 30 seconds that we have left,
27:36 --> 27:37you mentioned that colonoscopies are
27:37 --> 27:38really expensive,
27:38 --> 27:40but aren't they covered by insurance yet?
27:40 --> 27:42They are covered by insurance
27:42 --> 27:43and Medicare covers, colonoscopy,
27:43 --> 27:45and most insurance plans cover colonoscopy.
27:45 --> 27:48We also have state by state
27:48 --> 27:49variation in colonoscopy,
27:49 --> 27:52but most Medicaid in most
27:52 --> 27:55states covers colonoscopy and there
27:55 --> 27:58are actually a lot of resources to
27:58 --> 28:00help patients access colonoscopy,
28:00 --> 28:03but sometimes the out of pocket
28:03 --> 28:04expenses for colonoscopy,
28:04 --> 28:06even with insured patients,
28:06 --> 28:09can be significant and so
28:09 --> 28:11one of the goals
28:11 --> 28:14I think for us as a healthcare
28:14 --> 28:16system is to realize that
28:16 --> 28:19the return on the investment for us
28:19 --> 28:21increasing our screening colonoscopy
28:21 --> 28:25rates has been borne out in the data,
28:25 --> 28:27and that colorectal cancer in the
28:27 --> 28:3050 and above age group has
28:30 --> 28:33really been impacted by the advent of
28:33 --> 28:35aggressive screening colonoscopy programs.
28:36 --> 28:37Doctor Amit Khanna is director
28:37 --> 28:39of Colon and rectal surgery
28:39 --> 28:40for the Bridgeport region
28:40 --> 28:42and is an associate professor at
28:42 --> 28:44the Yale School of Medicine.
28:44 --> 28:46If you have questions the address is
28:46 --> 28:48cancer answers at yale.edu and
28:48 --> 28:49past addition to the program are
28:49 --> 28:51available in audio and written
28:51 --> 28:53form at yalecancercenter.org.
28:53 --> 28:55We hope you'll join us next week to
28:55 --> 28:57learn more about the fight against
28:57 --> 29:00cancer here on Connecticut Public Radio.

Information

Colon and Rectal Surgery with guest Dr. Amit Khanna June 6, 2021 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095