What You Can Do to Catch Colon Cancer Early with Dr. James Church

Podcast Transcript

Scott Steele: Butts N’ Guts is a Cleveland Clinic podcast exploring your digestive and surgical health, from end to end. Welcome to another episode of Butts N’ Guts. I'm Scott Steele the Chairman of colorectal surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. Today we're going to talk a little bit about colon polyps. I’m very pleased to have a mentor, a friend and a wonderful member of the Department of Colorectal Surgery here at Cleveland Clinic, Dr. James Church.

James Church: Hi, Scott.

Scott Steele: For the guests out there, obviously, I wish I had time to read all the things that you've done – books, hundreds of manuscripts published, spoke all over the world, probably one of the leading colon polyp and expert endoscopists in the nation, if not the world. But tell our listeners a little bit more about you.

James Church: Well, I'm really just a simple guy from New Zealand. That’s where I was born and brought up and went to medical school and surgical training. Then the opportunity came to do a fellowship here at Cleveland Clinic. At that time, Dr. Fazio was the Chair. There was another Australian and an Englishman here, so we formed a little British Commonwealth section. And after a couple of years they asked me to stay permanently. The opportunities offered here in Cleveland were so much better than anywhere else in the world that I couldn't resist. That was 34 years ago, and the rest is history.

Scott Steele: Wow, we're glad that you're still here. We’re going to talk a lot about colon polyps, something that you know very well, something that you've studied in depth and taking care of for many years. First and foremost, what is a colon polyp?

James Church: The word polyp just means a lump, and in particular a lump on the lining. So many organs can get polyps. I'm sure people are familiar with polyps in the nose, polyps in the stomach, polyps in the mouth. But we're talking about the colon and rectum, which also have a lining, and so polyps in the colon and rectum have a particular significance for us as colorectal surgeons and for our patients.

Scott Steele: How does a polyp develop?

James Church: Polyps develop because cells grow faster than they should. There are a variety of reasons for that. In particular, in the context of colon cancer, it's because of genetic abnormalities in the cells. But sometimes cells just overgrow because of dietary reasons or other random reasons, and anything that will cause an overgrowth of cells will potentially produce a polyp.

Scott Steele: There's a lot of different type of polyps, but if you can, can you clump them into a certain way and say what are the ones that are a little bit more worrisome, or what are the ones that are a little bit more routine.

James Church: Really the most important way of categorizing polyps is those that have something to do with cancer – potentially precancerous polyps and those that are never going to turn into cancer. The medical term for that would be non-neoplastic or neoplastic polyps.

Scott Steele: What are some routine names and things that would go along? I know a lot of times people may know a cousin or a brother or a family member or friend that might get a scope or get something done, and they come back and have a polyp. Or are there ones that are more common than others?

James Church: The most common precancerous polyp is called adenoma, which relates to its origin from the glandular cells of the colon. There's another type of precancerous polyp called serrated polyps, which relates to the way that the cells look under the microscope – like the teeth of a saw. And those are the two most important types of polyps because both of those can turn into cancer, and they're the ones that put us at higher risk of getting more polyps in the future. And if they're not looked after or removed, then even cancer.

Scott Steele: So one of the things that comes up all the time is do all polyps go on to become cancers? Because I know you mentioned precancerous and noncancerous, but that kind of the terminology gets confusing sometimes.

James Church: It sure does. A polyp, we have to remember, is just a description of a lump. If there's a lump, it's a polyp. So a polyp could be a cancer, it could be a polypoid cancer, which is a cancer that looks like a polyp. It could be cancer developing within a polyp. It could be a precancerous polyp or it could be benign and is never going to turn into a cancerous polyp. I think you also have to remember that sometimes cancers develop from flat tissue, what we would call a lesion. So just simply being true to the English definition of the word, a flat precancerous lesion is not really a polyp because it's not a lump. But usually they get included and analyzed and studied. When we talk about precancerous polyps, we usually mean the flat ones as well.

Scott Steele: But is it fair to say for most of the people out there, if you're talking about a polyp, you're not really talking about cancer. You’re more talking about the ones that are more benign or potentially precancerous lesions?

James Church: Yes, that's true but if you have a polyp taken off during colonoscopy, the first thing you want to know is if it has cancer in it.

Scott Steele: Right.

James Church: The second thing you want to know is could this have turned into cancer had it not been taken off?

Scott Steele: So you mentioned a little bit about potentially how we detect polyps, but before we get there, how do they know if they have polyps? Are their symptoms that may progress with polyps that patients should be aware of?

James Church: Yes. Almost all polyps start off small and get big. And the ability of a polyp to cause symptoms depends on its size, largely, and then its position in critical areas in the colon. Small polyps are never going to cause symptoms. So you’re never going to know. As they get bigger, the incidence of bleeding, for example, or sometimes the colon thinks that a big polyp – and by big I mean about an inch in diameter – is a piece of stool and tries to pass it, and that can cause cramping. It can also make the bleeding worse. Sometimes it can lead to obstruction if it's in a critical area of the bowel, say with diverticular disease. So the bigger polyps can certainly cause symptoms the smaller ones do not.

Scott Steele: You can have a patient that is as relatively asymptomatic; they may not have any symptoms at all. That leads us right into saying how do we detect these polyps and when should we explore these different options?

James Church: I should start off by just saying that it's really important to find these polyps. Because even though probably only about 1 in 200 of them are going to turn into cancer, all cancers come from a pre-cancerous polyp or lesion – all of them. So if we, by some magical process, could find all these polyps and take them all out, nobody would ever get colon or rectal cancer. Obviously that's not possible, but we can make a try at it. And so because polyps don't cause symptoms, we need to be screened.

Scott Steele: So what does screening involve?

James Church: To find polyps, really the only way to do that is with a colonoscopy. There are lots of recommendations out there that average people with no family history and no past history of polyps or colon cancer start colonoscopy screening at age 50.

Scott Steele: So if it's not everybody, that's the average risk people, but for the patients listening out there who may have a cousin or an aunt that had a cancer, or what about somebody that's a little bit closer to them like a brother or sister or a mom or a dad. Do those recommendations vary at all?

James Church: Yes, they certainly do. They change because a family history alters your risk of getting colon polyps and colon cancer, and certainly, the average population risk for colon cancer for people living in the United States for their lifetime is about 6 percent. If you have what we call a first-degree relative – that’s a parent, a sibling, brother or sister, or a child with colorectal cancer – that risk goes up by two-and-a-half times. So it goes up 15 percent. And if that relative is younger than 50 it goes up four fold. So that's a 24 percent lifetime risk of getting colorectal cancer. Our advice is to talk about that with your family doctor and to make sure you get screened because there's nothing as tragic as somebody coming in to see us with colon cancer and they have a relative with it.

Scott Steele: So let's talk a little bit about the dreaded colonoscopy. I'm sure you have patients out there or you know people that are like, “I'm not going to get one of those. I'm scared about that.” You had mentioned that the best way to get evaluated, and maybe even treated for these polyps, so you can both diagnose him and treat him through the scope is a colonoscopy. Talk a little bit about a colonoscopy for those people out there that are worried about a colonoscopy, or maybe haven't gotten one. What does this bowel prep involve? What is a colonoscopy? What can they expect to feel and experience going through that entire process?

James Church: It’s probably more sensible to worry about getting colon cancer than it is to worry about getting a colonoscopy because colonoscopy is not going to kill you. It’s 20 minutes out of your life, the actual exam. Whereas colon cancer is very serious. Colonoscopy involves cleaning the colon out of stool, that's step one, and then having somebody who's very expert at the procedure pass a six-foot-long colonoscope up the colon. Generally you don't use all six feet. Having gone all the way to the beginning of the colon, you withdraw gradually and do a good inspection of the lining, and any polyps that are found can be taken out. As I said, that usually takes about 20 to 30 minutes. Patients are generally sedated so they get comfortable, and then afterwards they go home.

Scott Steele: I know a lot of patients are more worried about the bowel prep itself than the colonoscopy. As a matter of fact, they'd say I know that I'm going to get sedation for the colonoscopy in many cases. But they’re so worried about the bowel prep. What do you say to those patients?

James Church: There are lots of varieties of bowel prep out there now. I think if one of the bowel prep makers wanted to be the richest company in the world, they would invent the prep that people want to actually take and enjoy taking and it tastes great. And we're getting there. But really, believe it or not, the initial bowel preps for colonoscopy were a gallon of sort of weird tasting fluid.

Scott Steele: That’s what I took.

James Church: Yeah.

Scott Steele: The salty fluid.

James Church: Right, you have to drink it over about four hours, and a lot of people can't tolerate that. So we've gone to lower volume preps and better tasting preps. The only caution I would give is that insurance coverage sometimes varies. But to me it's worth paying a few extra dollars to get something that is tolerable.

Scott Steele: There are a lot of things in the media that suggests that you don't have to undergo colonoscopy, that maybe you can undergo a CAT scan or something else – the virtual colonoscopy. What does that involve and is that for everybody?

James Church: The virtual colonoscopy is, as you said Scott, using CAT scan technology and using kind of space age programming to reconstruct a three-dimensional model of the colon from the information the CAT scan gives the computer. The operator can actually fly through the colon as if they were in a little submarine and look around and see if there are polyps, but there are some downsides to it. The colon still has to be cleaned out. It is quite intrusive for the patient because operators fill the colon up with gas, so a tube is put into the anus and the colon is pumped up with air. It's not that comfortable, and then it is not that accurate, especially for small polyps – and you can't do anything about what you see. So if that exam is positive, then the patient needs a colonoscopy as well.
 
Scott Steele: So what if the primary care doctor said you don't need to have a colonoscopy, we're going to do the shorter one, the flexible sigmoidoscopy. Is that still a useful tool? I know it's a useful tool for looking at parts of things, but would that be something that you would recommend?

James Church: In an ideal world, you should have the whole colon checked out. Colon cancer can occur on the right side of the colon as well as the left side of the colon. A flexible sigmoidoscopy just examines the lower three feet of the colon. It falls into the category of something's better than nothing, but it's a compromise exam. I've seen it described as having a mammogram of one breast. So better than nothing, but you still have a big chance of having a polyp that could turn into cancer.

Scott Steele: So one of the other things that patients may see either in an advertisement, or they may know somebody that has gotten this, is a stool test where they can have a stool sample and send it in and it can get run for all these different genes and determine if they have colon cancer. What is this all about?

James Church: Well we've talked about flexible sigmoidoscopy, screening colonoscopy and even C.T. colonography screening – those are semi-invasive tests. The other class of screening tests is the non-invasive tests, which involve looking at stool. For a long time we’ve been looking at blood and stool – the hemoccult test – as evidence of cancer. The hemoccult test is no good at finding polyps. They will only find cancer. The aim is to find the cancer at an early stage, before it causes symptoms, and then that may translate into a better chance of being cured. So it's not a preventative test at all. More recently, in the last couple of years, a test has come out looking at DNA and stool as evidence of the presence of a cancer that works pretty well. The accuracy of that test is about 92 percent sensitive. So it's going to find about 92 percent of cancers that are actually there. But again, it finds cancers. It is a little bit good at finding polyps. It will find about half of the serrated polyps, and it may find up to about 70 percent of the precancerous adenomas, at least the high-risk ones. So it's a reasonable alternative to colonoscopy if you can't get a good colonoscopy or can’t afford it it's not covered. But again, if it's positive you need a colonoscopy. So the only single test that will find polyps and cancer, and allow you to treat the polyps and prevent cancer, is colonoscopy, and that remains the gold standard. There's one thing that's coming that a lot of work’s going on now about and that's called liquid biopsy, which really means looking at DNA and blood. We know that patients with colon cancers have evidence of that and DNA that's made its way into the blood. This is not ready for primetime yet. But when I recommend patients that they have another scope in 10 years, I always say to them you may not need it because we may have a better test then.

Scott Steele: Let's go back to the colonoscopy itself. As an endoscopist, you go across the colon and you see a polyp. What do you actually do? How are colon polyps managed, and what can happen at that colonoscopy?

James Church: So you see a polyp and you instantly start assessing that, and it's almost by instinct that you assess it. So you’re thinking to yourself, is this a cancer already? Is it removable? And if it's removable, how should I remove it? It really depends on the size of the polyp, the location where it is, how the patient is doing at the time, and any other risk factors that the patient may have, such as maybe being prone to bleeding or something. And then you set about removing it, because that's basically why you’re there – you’re there to remove polyps. You choose the appropriate instrument and remove the polyp. That's a painless procedure for the patient because there are no nerves, no sensory nerves, going to the lining of the colon.

Scott Steele: And are there risks to having that done?

James Church: Yes, there are risks to pretty much everything we do. The risks of colonoscopy itself are very, very, very low. But the risk of polypectomy specifically is the same risks for any sort of surgery that may cause bleeding. Bleeding may develop later after the polypectomy, and that risk lasts for about two weeks. And you may make a hole in the colon. Those are the most serious risks.

Scott Steele: And those, obviously, happen very, very rarely. What about prevention of polyps? Is there anything that you can do to prevent polyps? Is there diet or a pill or something that you can take to prevent polyp onset?

James Church: There have been a lot of studies done looking at using medications to cut down the risk of polyps. Here at Cleveland Clinic, we’ve been involved in several of them. The first one we looked at was aspirin, and aspirin certainly has an effect on the risk for colorectal cancer, and it did seem to have a risk on the incidence in recurrence of these precancerous and non-cancerous polyps. Calcium also can affect the risk of polyps. It can reduce the risk of polyps. We know that hormone replacement therapy in women can reduce the risk of colorectal cancer significantly. In general terms, a healthy diet is good. It's a lot harder to prove that because dietary studies are so difficult to do. But avoid any processed meats, avoiding red meat, and focusing on fiber and green vegetables and fruits is certainly moving in the right direction.

Scott Steele: James, you were the director of the David G. Jagelman Inherited Colon Cancer Registries for many years here at Cleveland Clinic. One of the world leaders in terms of these hereditary cancer syndromes, specifically with colorectal cancer and polyposis. Can you talk a little bit about the importance of family history with polyps and kind of go back and touch on that a little bit, and maybe some certain types of things that may come up that may run in the family, that if you are aware of these things that run in the family that you should know a little bit further about.

James Church: Sure. If you think of all the colorectal cancers that have ever happened in the United States – and this year the estimate is about 140,000 – about 5 percent of those occur in patients who have an inherited syndrome of colorectal cancer. That is, they inherited a single gene mutation from mom or dad and it's caused their colon to be prone to producing often multiple cancers at often early ages. Sometimes, as you said, lots of polyps, sometimes not. And in that circumstance, everybody in the family is at risk of inheriting that mutation. And if they get it, they need early checks that could save their lives. Otherwise, they're going to get early cancers, and by the time they’re found they are often too far advanced for treatment. So it's very important to recognize these syndromes when they occur. The clues are a family history which includes multiple relatives affected with either polyps or cancer at a young age. That's the other key. The average age of colorectal cancer is in the mid-60s. But if you have a relative who's affected under the age of 50, that's a huge red flag and we refer such patients to genetic counselors here. Not everybody has access to a genetic counselor, but you could certainly have a chat with your family doctor about it.

Scott Steele: That's incredible insight into the world of colon polyps and colonoscopy and other things. I like to end with all my guests here on Butts and Guts with a couple of quick hitters. Favorite sport?

James Church: Rugby.

Scott Steele: Of course. Favorite meal?

James Church: Steak and chips.

Scott Steele: And what's the last book that you read?

James Church: Mortality.

Scott Steele: If you could tell me a little bit about what you like about living in Cleveland?

James Church: It's become my second home to me. We have adapted and been welcomed and it's really home.

Scott Steele: And if you could sum up colon polyps in 10 words or less.

James Church: Get a colonoscopy.

Scott Steele: Well, thank you so much, Dr. Church, for joining us here on Butts N’ Guts. And to learn more, download our colonoscopy treatment guide at clevelandclinic.org/colonoscopy. To schedule a colonoscopy here at Cleveland Clinic, please call 216.444.7000. That wraps things up here at Cleveland Clinic. Until next time. Thanks for listening to Butts N’ Guts.