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Caring for Your Colon: Healthy Lifestyle Cancer Prevention&Treatment Options

Online Health Chat with Dr. James M. Church and Dr. Dale Shepard

March 12, 2012

Introduction

Did you know colon cancer is one of the most common types of cancer? If detected early, it's also one of the most curable. Almost always it starts in a non-cancerous growth called a polyp that forms on the lining of the colon and rectum. Colonoscopies detect and remove polyps. So if precancerous polyps are found and removed cancer can be prevented before it gets started. Up to 60 percent of colorectal cancers could be prevented if everyone who was eligible for screening actually got screened. If cancer develops and is detected early, it can be cured by surgery. If it is more advanced, the additional use of chemotherapy or radiation therapy may be life saving.

Through a multidisciplinary approach, Cleveland Clinic specialists in the Digestive Disease Institute and Taussig Cancer Institute explore all medical and surgical options to ensure that our colon and rectal cancer treatment program will result in a successful outcome for each patient. Treatment plans are tailored to their patients’ needs, taking into account how advanced the cancer is, the age of the patient, and the degree to which the cancer has spread.

The Digestive Disease Institute is a globally recognized leader in colon cancer prevention, treatment and surgical innovation, attracting patients from all 50 states and beyond. Our gastroenterologists and hepatologists receive worldwide referrals, particularly for complex cases and severely affected patients. Our surgeons offer traditional approaches, and lead with numerous minimally invasive firsts.

Cleveland Clinic receives increasing worldwide referrals, particularly for complex hereditary colon cancer syndromes, whether for an expert opinion on medical therapies, access to clinical trials or for surgical expertise that consistently reports excellent outcomes.

The Taussig Cancer Institute provides outstanding multidisciplinary care to patients with solid tumors and hematological malignancies. Our exceptional clinical experience and extensive translational research programs allows us to offer patients individualized treatment plans based on the best standard of care and access to new and emerging treatment options. We also offer an extensive range of support services to patients with cancer and their family members.

Cleveland Clinic is ranked #1 in Ohio for gastroenterology and cancer care by U.S.News &World Report.

Would you like to know why the preparation for a colonoscopy is easier than ever? Or what are the latest advancements in surgical and medical treatment options for colorectal cancer? Take advantage of this rare opportunity to chat live with medical and surgical experts in the treatment and management of colorectal polyps and cancer.

Cleveland Clinic colorectal surgeon Dr. James Church and oncologist Dr. Dale Shepard are here to answer personal questions about colorectal polyps and cancer.

James M. Church, MD, is a Staff member in the Department of Colorectal Surgery at Cleveland Clinic. He has been Director of the David G. Jagelman Inherited Colon Cancer Registries and Head of the Section of Endoscopy at Cleveland Clinic since 1989. Dr. Church’s specialty interests include all aspects of colorectal cancer and polyps, molecular genetics of colorectal diseases, and functional colorectal and anal problems, including constipation and incontinence, perianal and perineal infections, and inflammatory bowel disease.

Dr. Church currently is Co-Investigator of the Collaborative Colorectal Cancer Family Registry, funded by a research grant from the National Cancer Institute. He also is Co-Investigator of a study examining the usefulness of CT colonoscopy in detecting colorectal polyps.

Dr. Church has been named to the Good Housekeeping Top Cancer Doctors for Women list (1999), Top Doctors in America (1999-2011), and Who's Who in America (2000-2011).

Dr. Church is actively involved in many scientific and medical societies. He is Past Chair of the Leeds Castle Polyposis Group and the International Collaborative Group on Hereditary Non-Polyposis Colorectal Cancer, and he is the current President of the Collaborative Group of the Americas on Inherited Colorectal Cancer. These international societies are dedicated to the care of patients with inherited colorectal cancer and to research into their disease.

Dr. Church is a Fellow of the American Society of Colon and Rectal Surgeons, American College of Surgeons, Costa Rican Society of Surgery, Royal Australian College of Surgeons, American College of Gastroenterology, American Surgical Association, and the Royal College of Physicians and Surgeons, Glasgow.

A frequent national and international lecturer at scientific meetings, Dr. Church has authored more than 180 articles in peer-reviewed journals and 22 book chapters on hereditary cancers, endoscopy, and molecular genetics of colorectal tumors. He is the author of two medical textbooks and has been Co-Editor of Diseases of the Colon & Rectum since 2000.

Dr. Church received his degree from Auckland University School of Medicine in New Zealand, where he also completed several postgraduate research fellowships. In addition, Dr. Church completed a special fellowship in the Department of Colorectal Surgery at Cleveland Clinic.

Dale Shepard, MD, PhD, received a PhD in Pharmacology from The Ohio State University with a focus on drug metabolism and pharmacokinetics and completed a clinical pharmacology fellowship at the University of Chicago. He subsequently received an MD from The Ohio State University and completed a residency in internal medicine and fellowship in hematology and oncology at the Cleveland Clinic.

Dr. Shepard is currently Associate Staff in Solid Tumor Oncology at the Taussig Cancer Institute at Cleveland Clinic where he is Co-Director of the Taussig Oncology Program for Seniors (TOPS) where he treats patients 75 years of age or older with gastrointestinal or genitourinary cancers.

He is also an Assistant Professor of Medicine at the Cleveland Clinic Lerner College of Medicine. He has published extensively on development of novel anticancer compounds and genitourinary cancer and is actively involved in developing clinical trials specifically for elderly patients with cancer.

To make an appointment with Dr. Church or any of the specialists in the Digestive Disease Institute at Cleveland Clinic, please call 216.444.7000 or call toll-free at 800.223.2273 ext. 47000. You can also visit us online at clevelandclinic.org/digestive.

To make an appointment with Dr. Shepard or any of the specialists in the Taussig Cancer Institute at Cleveland Clinic, please call 800.223.8100. You can also visit us online at clevelandclinic.org/cancer.


Cleveland_Clinic_Host: With March being National Colon Cancer Awareness Month, Cleveland Clinic is committed to educating the public on prevention, diagnosis, and treatment of this disease. Some important risk factors include age, African American race, personal and family history of colon cancer and polyps; ulcerative colitis or Crohn’s disease; smoking and being overweight or obese.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialists Dr. James Church and Dr. Dale Shepard. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.

johnnnita: I will be 63 this year (August) and am due to have my second colonoscopy in October of this year. My last colonoscopy (my first) was seven years ago. When I had my last colonoscopy, results were good with only minor diverticulosis identified. There were no polyps. I have read that colonoscopies should be every 10 years as a general rule. When I had my last colonoscopy, my gastroenterologist said my next one would be in seven years. Should I wait until ten years? My second question has to do with the latest tests for colorectal cancer: I've read recently about having a high-sensitivity fecal occult blood test first (called a fecal immunochemical test or FIT annually. What are your thoughts on this? Can this test preclude having the traditional colonoscopy?

Dr__Church: In general, we think it takes an average of 10 years for a small polyp to turn in to a cancer. Therefore, my practice is to do a follow-up screening colonoscopy 8 years after a normal screening examination in average risk patients. If you have a family history of polyps or cancers I would recommend a 5 year interval. So the 7 years proposed by your gastroenterologist is not too bad.

Secondly, the immunochemical fecal blood test is a pretty good way of detecting cancer. However, it does not prevent cancer. Colonoscopy actually prevents colon cancer by allowing diagnosis and removal of the precancerous polyps. Therefore, colonoscopy is the better test. Furthermore, if the fecal immunochemical blood test is positive, the next step is a colonoscopy.

sam23: Irritable Bowl syndrome will it lead to other problems in the future?

Dr__Church: Irritable bowel syndrome is a very ill-defined condition that includes various forms of functional bowel disease. This is mainly spasms of the colon leading to diarrhea and constipation, abdominal pain and bloating, and irregularity. It does not lead to colon cancer or colitis, or even diverticulitis. The main thing is to make sure that there is no cancer or colitis or diverticulitis causing the symptoms, then treat the Irritable bowel syndrome so that the symptoms are relieved.

clara: What is your advice about doing a colonoscopy if one is on Plavix and 2 81mg aspirin? I had 2 stents put in August 20011 and I need to get a colonoscopy. I am 2 years late getting the test. I had an adenomatous polyp 5 years ago. I was told that I need to be off Plavix and the 2 aspirin to do the test, and the cardiologist does not want me off of the medicine. I had 2 stents 2011.

Dr__Shepard: You are correct that you need a repeat colonoscopy due to your risk for colon cancer, with a history of adenomatous polyps. However, this must be done safely and with consideration of your cardiac problems. I would check with your cardiologist to determine when you can be off Plavix and aspirin. At 1 year after the placement of the stent, for example. While important to have timely follow-up for your polyp, it is best to be late for the colonoscopy and not risk cardiac complications.

Artistann: Oct of 2011. I came down with chronic diarrhea that stays with me all the time. Despite several tests my doc. can't explain why I am having these issues. I went to ER 2 wks.ago, my chest was hurting. They said I had Pleurisy, they sent me home on pain meds. They couldn’t give me anti inflammatories. I am a kidney donor. My lungs got better, but they have flared up twice since then. Leaving me wondering if my illness may involve more than just GI. At this point my doc. is stumped and I am frustrated. I have to take nausea & Spaz pills to be able to eat in the mornings; I am taking pain pills to be able to tolerate the pain from my bowels and my lungs. I have 15 to 20 loose bowel movements everyday. I have cramping, bloating& nausea. I am a wedding photographer. I can't function like this. if I don't get it figured out soon I will be closing my business & returning deposits. I know you can't diagnose me, but is there something we should test for or something we are missing? Thank you!

Dr__Church: Have you seen a gastroenterologist for the chronic diarrhea? I assume you have had a colonoscopy with biopsies. Microscopic colitis is a condition (actually 2 conditions) that cause significant diarrhea in middle aged patients with a normal-looking colon. They can only be diagnosed by biopsy. They need specific treatment. If you don't have microscopic colitis there must be something else going on with your GI tract that a consultation with a gastroenterologist would likely reveal.

Artistann: I am seeing a gastroenterologist Test Taken so far: colonoscopy, blood work, stool samples, Capsule Endoscopy. Everything looked normal except some swelling in the large intestine. I get the capsule scope results tomorrow. They also did a biopsy. My mother had Colon Cancer in her 60's but they removed it and she has been doing great. She was 82 yesterday :)

Dr__Church: Did they do a biopsy of the colon? It sounds as if your doctors are on top of things. The "swelling" in the colon is interesting.

Did you get a CT scan? Sometimes there are hormone producing tumors that can cause diarrhea.

Artistann: Is there an inflammatory disease that could cause inflammation in the GI tract and the lungs?

Dr__Shepard: Inflammation is often a very non-specific reaction of the body to a stressor. Therefore, yes a person can have an inflammatory response that affects both the lungs and the GI tract. Autoimmune disorders may also lead to inflammatory reaction in more than one organ.

Artistann: So could it be considered a GI problem or an Autoimmune problem

Dr__Shepard: Yes...regardless of the cause, you seem to be having a GI problem. I recommend you complete your current work-up and, if you still have no resolution to your problems you may benefit from a second opinion either to get or confirm the diagnosis.

barry: I have 2 1st degree relatives who died of colon cancer. As a result, I am on the Jagelman Family Registry; I have been on an every 3 year cycle for colonoscopies beginning at age 50. My doctor recommends moving to 5 years, I am 74. What do you think?

Dr__Church: Has anything been found? If you have had no polyps at all then I think moving to 5 years is perfectly fine. If you have had polyps, especially adenomas, then keep going with 3 years. The question of when to stop screening is often raised. I think it depends on a patient's life expectancy rather than their age. If you expect to live 10 more years that is plenty of time for a polyp to become a cancer, so screening should continue. If, heaven forbid, you are so sick from other conditions that you may not live a year, then colonoscopy is low priority.

hands_on: Family history of colon cancer – is it only parents, siblings and children? Do aunts & uncles matter?

Dr__Church: First degree relatives...parents, siblings and children, are the most important relatives when calculating your own risk of hereditary colorectal cancer. One first degree relative means your own risk is increased by 2.5 times. One young first degree relative (under age 50) means your risk is increased by 4 and a half times. Two first degree relatives affected means an increase in risk of 4 and a half times. Second degree relatives are also important. Sometimes cancer appears to "skip" a generation because of early deaths or deaths from other conditions. The whole family tree is necessary...for 3 generations, for a proper assessment. There is also a condition called MYH polyposis which is inherited by a recessive pattern, meaning that second and third degree relatives often give the clue.

jimmylanza: My dad was diagnosed with colon cancer 10 days ago. Should I ask him to get a second opinion?

Dr__Shepard: A diagnosis of cancer can be a life-altering event and a good understanding of your disease and treatment is crucial. A second opinion on treatment options is never a bad idea to ensure that you are comfortable with the physician team and the therapy they have suggested.

Mary: Does excessive alcohol contribute to colon cancer? Does excessive red meat contribute to colon cancer?

Dr__Church: Epidemiologic studies show that both red meat and alcohol are general risk factors for colorectal cancer. However, the connection between red meat intake and alcohol intake is quite weak. Both alcohol and red meat in moderation are fine. Avoiding these aspects of diet is by no means protective against colorectal cancer. The best thing to do is to eat a healthy diet from an early age, being aware of your family history, and getting colonoscopies at an appropriate age.

pattymz: My father had colon cancer so is the risk increased for me and if so, is there anyway to decrease those chances?

Dr__Shepard: Having your father (a first degree relative) diagnosed with colon cancer increases your risk for developing colon cancer. You should have screening for colon cancer 10 years before what is recommended for the general population (at age 40, for example) or 10 years before your father's age at diagnosis.

nutty: All 4 grandparents died of cancer (only one with colon cancer). Should I have genetic assessment done?

Dr__Shepard: Although only 1 of your grandparents died of colon cancer, some genetic susceptibility is also related to other tumors, such as breast or ovarian cancer. An assessment by a genetic counselor may be beneficial for a more thorough evaluation.

The Sanford R. Weiss, MD Center for Hereditary Colorectal Neoplasia is dedicated to advancing patient care, education and research for hereditary colon cancer. The center brings together Cleveland Clinic institutes involved in the research and treatment of colon cancer - Digestive Disease, Genomic Medicine, Lerner Research, Pathology and Taussig Cancer Institutes. This integration of specialties allows the Weiss Center to provide more efficient care, focused on hereditary colon cancer. The David G. Jagelman Inherited Colorectal Cancer Registries are part of the Weiss Center and have played a key role in uncovering critical information for treating all types of colon cancer. To contact us with questions about inherited colon cancer, please call the Weiss Center at 216.445.2050.

merrie: What are diet recommendations for healthy colon?

Dr__Church: In general what is good for the heart is good for the colon. Plenty of fresh fruit and vegetables, fish and white meat. Light on animal fats and red meat. Alcohol in moderation. In addition, plenty of exercise, maintaining a healthy weight.

Also, there is a misconception about the colon and roughage. Each person's colon has its own optimal dose of fiber. Fiber is needed to promote peristalsis and normal colon function. Too much fiber leads to bloating and cramps and excess stool. Too little fiber causes small, hard stool that are hard to pass. Try for the happy medium that produces and soft, formed stool that is easy to pass. Experiment.

Dr__Church: For more information go to clevelandclinic.org/score.

runnergirl: What can we do to be proactive in caring for our colons and do these colon cleanses really work and if so what is the best one?

Dr__Church: The colon is designed to process 1.5 liters of liquid stool a day into about 200grams of formed stool, to store the stool and then to evacuate it at a convenient time and place. It is very good at doing this if we treat it well. The normal time it takes stool to transit the colon is 36 hours, including the stool being stored in the sigmoid (left) colon until a daily mass movement pushes it into the rectum and we get the message that it wants to be evacuated. I replied to an earlier question about diet by saying that people’s colons are different, with differing anatomy and differing requirements for roughage. So the general dietary advice applies: fresh fruit and vegetables, roughage appropriate for your own colon, good bowel habits (don't put off the urge), exercise. Some other factors: stress does bad things to the colon so try and live a stress free existence. Medications can impact the colon so beware of colonic side effects from lots of medications.

Now for colon cleansers. In general, they are not necessary, and can even be harmful by their effects on the normal colonic bacteria. If you are constipated despite a good diet, you may need a laxative, but don't get in to colonic lavages.

screen_time: What is the difference in Adenomatous polyps and other polyps?

Dr__Shepard: While many types of polyps may be found during a colonoscopy, we know that adenomatous polyps are lesions that progress to colon cancer, often over a period of several years. This is why screening for colon cancer is important and why a colonoscopy, that can not only identify the polyps but also remove them, is important. A recent study shows that patient that had removal of adenomatous polyps did not die as quickly from their colon cancer.

helen: I heard this week that I have no genetic links to colon cancer with your study, Per a doctor in Vancouver. I just wanted to find out what they would do with a person that has a history of adenomas and hyperplastic, and serrated polyps. Would continued colonoscopies be good enough to keep track of new growths.

Dr__Church: All colorectal cancer and the polyps you mention are genetic...they all arise from genetic abnormalities in cells lining the colon. A few colorectal cancers and polyps are inherited, where some of the genetic abnormalities come from their parents. This applies to adenomas and serrated polyps. You can get an idea about how "fertile" your colon is by the number and size of the polyps that are removed and by the speed with which they grow. This pattern should be apparent over time with regular colonoscopies. Colonoscopy should protect you from colorectal cancer, with the exception that some polyps can be missed. This is especially the case for sessile serrate polyps, which are definitely premalignant and are often hard to see. If you have a good colonoscopist and one who is aware of the danger of serrated polyps, you should be OK.

jjb: If an adenoma has been removed, does this increase the risk of colorectal cancer in the future?

Dr__Church: Yes. Having an adenoma is an indication that the cells lining your colon have suffered enough genetic damage to produce a growth that is on the way to cancer. Therefore you are at risk of forming other adenomas, and if these are not found and removed, of one of them turning into a cancer. The risk of developing more adenomas gets higher, the more adenomas you have. If you have more than 3 adenomas you are at high risk.

harry: After surgery, with a shortened colon, what are the side effects?

Dr__Church: The normal colon and rectum (large intestine) is about 6 feet long. Different parts of the colon do different things. Most of the water is absorbed from the stool on the right side of the colon. Losing this will cause some temporary diarrhea. The left side of the colon is the reservoir where stool is stored. Losing this will cause more frequent, formed, stools. The rectum is the organ of defecation. Losing this will cause frequent small formed stools. In general the colon is good at adapting so that any changes that happened immediately after surgery tend to get better. You can lose your whole colon and have the small bowel connected to the rectum, and have an average of 4 pasty stools a day.

off_the_wall: Virtual colonoscopy – how useful? Is it recommended? Regular of traditional colonoscopy – what do you do if the patient is punctured? i.e, consequences & how treated?

Dr__Shepard: A virtual colonoscopy, a colonoscopy in which the colon is visualized with a CT scanner instead of a colonoscope in the colon, can detect polyps or cancerous tumors and is one of the methods for screening for colon cancer. Unfortunately, the preparation for the procedure (the part most patients dislike most) and the need to put air into the colon to expand it are the same for both a virtual and traditional colonoscopy. If an abnormality is discovered with the virtual colonoscopy, the patient must have a traditional colonoscopy (with a repeat of the prep procedure) to obtain a biopsy. While puncture of the colon is a risk of the traditional colonoscopy, this is a rare complication. Surgery is required for a puncture in the colon.

hardy: I have had surgery for colon cancer. At my last colonoscopy, 10 months ago, there were no growths in the colon. A few weeks age, I was told that a test showed blood in the stool. Could that indicate new growths in the colon?

Dr__Church: It could....more likely its from hemorrhoids, or fissures or something in your diet. It is extremely unlikely that something in your colon grew big enough and advanced enough to bleed over 10 months. It is possible however that something was missed. Therefore you should have another colonoscopy. My question is "why do the occult blood test 10 months after a normal colonoscopy?"

Albie: I am a 43 year old African American male. I keep hearing that minorities are at greater risk. Can you explain why this is the case and what I can do?

Dr__Church: It is interesting that African Americans typically develop colorectal cancer earlier than Caucasians, and that it is more aggressive...diagnosed at a later stage and therefore with worse outcomes. Although social factors such as access to care may play a role in this, it seems that tumor biology is different. My advice would be to start colonoscopy screening at age 45, instead of 50 as advised for Caucasians. Be aware of your family history and if there are people affected in your family, consider colonoscopy even earlier.

kellyp: I have a flat polyp the size of a nickel in the area of the appendix. It could not safely be removed during a colonoscopy. What are the odds of this becoming a problem? I am a 76 year old female.

Dr__Church: Hopefully the polyp was biopsied. If it is an adenoma or sessile serrated polyp I would love for it to be removed. Maybe getting a second opinion from another endoscopist would be good. However, at this stage I don't think its worth surgery. Only 1 in every 100 or 200 polyps will ever turn in to cancer so if the second opinion agrees that it cannot come out I would wait 6 months and have it checked again. I know its not nice to have frequent colonoscopies but surgery is a last resort.

carter_gray: Does it matter if polyps removed during colonoscopy were cancerous or not, in terms of how often to have a colonoscopy done?

Dr__Church: Sometimes a polyp has a cancer in it. If this is the case then the doctor must decide if taking the polyp out is enough treatment or if removal of that section of the colon is necessary. It depends on the risk that the cancer has already spread out of the colon. Factors that go in to that decision are whether the cancer has been completely removed with the polyp, and how wild the cells are, and if there is cancer in lymph vessels. Some polyps with cancer can be treated just with polypectomy. Some need resection.

In terms of follow up, cancer is treated differently to benign polyps. We follow cancers 3 yearly on average and polyps every 3 to 5 years depending on size, number and the rate at which new ones appear.

nystrom: Dr. Shepard - can you talk about treatment options for a newly diagnosed patient?

Dr__Shepard: When I see a new patient in clinic, there are 2 considerations. What is the diagnosis and where is the disease. Some patients have colon cancer that was confined to the colon with no positive lymph nodes and they need no additional treatment. These patients are followed with clinical exams and CT scans. Patients with locally advanced disease have tumor that has gotten out of the wall of the colon and involves local lymph nodes. These patients have no evidence of tumor in their body after the surgery, but are given chemotherapy to minimize the risk for recurrence. We are currently participating in a clinical trial with other hospitals around the country to determine how long to treat with chemotherapy. Finally, some patients have evidence of cancer that has spread to other parts of the body. These patients are treated with chemotherapy to control the size of the tumor, decrease the clinical effects of the tumor, and improve overall survival.

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialists Dr. James Church and Dr. Dale Shepard is now over. Thank you Doctors for taking the time to answer our questions today about Caring for Your Colon.

Dr__Church: Thank you for joining us today.

Dr__Shepard: Great questions. Thank you.

Cleveland_Clinic_Host: Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link clevelandclinic.org/webcontact to submit your suggestions. In the question/comment section, choose Health/Disease Information so that we receive your comments.

Cleveland_Clinic_Host: While you have many options for the treatment of your cancer, you should consider the experience of the program when selecting where to seek care. Cleveland Clinic specialists in the Taussig Cancer Institute work with gastroenterologists and colorectal surgeons in the Digestive Disease Institute to explore all medical and surgical options to ensure the most successful outcome for each patient.

Cleveland_Clinic_Host: The Taussig Cancer Institute and the Digestive Disease Institute are both No. 1 in Ohio according U.S. News and World Reports. For the past nine years, Cleveland Clinic also has been named one of the nation's top two digestive disease programs. Using a multidisciplinary approach, our experts customize treatment for each patient. This collaboration also means that you will get the care you need right away, rather than waiting for separate appointments with various specialists.

Cleveland_Clinic_Host: To contact us with colon cancer questions or to make an appointment, please call our Cancer Answer Line at 866.223.8100.

Cleveland_Clinic_Host: Visit clevelandclinic.org/score to take a free, quick and easy risk assessment to determine your personal risk for colon cancer. You’ll receive personalized recommendations for screening guidelines and lifestyle choice improvements. You’ll also find valuable information on digestive health and colon cancer prevention and treatment.