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Colorectal cancer is typically the second or third leading cause of cancer-related death in the United States. Scott Steele, MD, Chair of Colorectal Surgery at Cleveland Clinic joins the podcast to discuss updated screening guidelines and recommended methods, as well as the alarming increase in early-onset colorectal cancer.

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Screening Guidelines and Incidence Rates for Colorectal Cancer

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest, innovative research and clinical advances in the field of oncology.

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic, overseeing our Taussig Phase I and Sarcoma Programs. Today I'm happy to be joined by Dr. Scott Steele, Chair of the Department of Colorectal Surgery in the Cleveland Clinic Digestive Disease and Surgery Institute. He's joining me to talk about colon cancer screening and colon cancer in younger patients. So welcome Scott.

Scott Steele, MD: Hi, great to be here.

Dale Shepard, MD, PhD: Maybe just start, just give us a little bit of a background on what you do here at the Cleveland Clinic.

Scott Steele, MD: So since 2016, late 2016, I have been the Chairman of Colorectal Surgery here within DDSI. I'd spent 25 years in the military, and then I had a brief stop at University Hospitals before being so lucky to take the chairman position here.

Dale Shepard, MD, PhD: Excellent. We're going to talk about colon cancer screening. So maybe to start, just to give us an idea and remind us about the impact of colon cancer. Can you give us a little bit about trends on the incidence and survival?

Scott Steele, MD: Yeah. So if you think about it, every year when they come up with the cancer statistics, it's typically the second or third leading cause of cancer-related death in United States alone. So this past year, it was third for a while, it was second so at least we're making some progress. Unfortunately, upwards of anywhere between 25% and a third of those patients who present with colorectal cancer, may unfortunately present in stage four, where the cancer is actually outside the walls or the lymph nodes, it's spread to another organ.
So I always try to tell people all the time, the critical importance about the topic that we're talking about today is the fact that colorectal cancer is one of the few cancers in the body we have a very good early detection, even at a pre-malignant stage. And even within that, when we talk about endoscopic management strategies, we can actually rid of it at that stage before it either becomes cancer, or becomes much more aggressive and catch it at an early stage.

Dale Shepard, MD, PhD: Just as a backdrop on our screening. So, there's colonoscopy and sigmoidoscopy and there's the fecal immunochemical test. Can you maybe just briefly go through each of the ways we can screen, and maybe what your thoughts are in terms of pros and cons?

Scott Steele, MD: Sure. So when you think about it, you should think about it in terms of things that you can do at home, things that you need to be able to go into, and then things that maybe are a little bit of more of a gold standard, but of which require a little bit more investment. So things that you can do at home oftentimes exactly what you're talking about in terms of the stool studies. That's when there's a couple of different types out there that are looking for blood or occult blood in the stool. One of the early presentations of colorectal cancer is to have blood or bleeding in the GI tract.

I think I should pause right here quickly and just say that it's important to understand that many of the symptoms that colorectal cancer may present with are oftentimes benign. They're not colorectal cancer in and of themselves, but it's important to be aware of. For example, hemorrhoids can bleed. Hemorrhoids can have some pain associated with certain types of hemorrhoids, and that could still be signs of colorectal cancer. So it's important to understand that what you're experiencing to bring up these symptoms with your doctor, don't be too scared to say, "I'm not going to bring them up because I'm worried about this." Could be just completely benign thing that you could deal with.

But some of the stool studies are testing for blood. It's a at-home stool kit that you can do drop off at the doctor's office, send in and be able to see if there is blood there. And then that would prompt a little bit more of further workup from that. There's also stool DNA studies. We know that tumors have a certain DNA with them, and they shed that DNA within the stools. These are probably a little bit more of the newer kids on the block, even though they've been around for years, but they're becoming much more ubiquitous and inability to get to, and they're becoming much more cost effective. And so you might see those that are out there, they're looking for specific types of cells that are out there, once again in the stool sample you can do.

And then there's some of the other studies that we used to do a lot more, that we don't do as much of anymore, especially as a screening. But you may hear a thing such as a barium enema or gastrografin enema, or an air contrast barium enema. That's simply when you go to a radiologist, they put a small catheter in your bottom and they inject either air and certain dyes in there to look at the outline of the colon itself to look for some changes that may be consistent with a polyp or a growing lesion within there. That's not something that we use a whole lot of anymore. You might still see that in some older guidelines or it might be an adjunct test done in a different way.

And then probably the most used on the block, the gold standard if you, was a colonoscopy. And remember, when you talk about a colonoscopy or a flexible sigmoidoscopy, a flexible sigmoidoscopy means that you're really looking at the rectum in the left-side of the colon. It's a smaller scope, and it doesn't go as far. The colon, just for those of you out there who may not be aware, it's about six feet in length in average, and that includes the rectum. And so a colonoscopy goes all the way around, and that's why when you do a colonoscopy, you want to get rid of the things that are in the colon naturally and that's the stool and stool particles so we can get a good view of things. And that's why you got to take a bowel prep.

And as a little side note that hopefully I can make a plug for everybody, is that in general, the prep may be the worst part of the entire procedure for those of you. And if you're worried about the scope itself, that's not bad. And even the prep itself isn't that bad. It makes you go to the bathroom and it cleans out that stool so that the doctor can get a good look at your colon and make sure that there's not any lesions that are growing in there.

Dale Shepard, MD, PhD: If you have a patient that expresses an interest in getting screening and that's half the battle, we'll talk about that in a minute. If you could have them get any of the tests, which one would you recommend?

Scott Steele, MD: So we would recommend if possible to get a colonoscopy. I should have mentioned that there's other things that people are aware of, that's a virtual colonoscopy, or also called a CT colonography. You do have to take a prep for that still, and they do instill some air into the colon. Remember the colon is typically collapsed. We provide air into it during the virtual colonoscopy, as well as for the colonoscopy itself, the actual endoscopic examination itself, to distend the colon so you can get a good look at the inner wall event.

The wonderful thing is, is that as it stands right now, the colonoscopy can magnify stuff at a point where you get a really good visualization of it. And you can also treat things at that time. You can get those early lesions, you can ablate them, you can resect polyps, you can get biopsies of things that you're concerned about. So that's why we think that the colonoscopy is still the gold standard.

Maybe we'll get to a point where you can maybe not have to have a prep, that our software can be so good that it can subtract out what is stool on a CT scan, and you can get what the colon actually looks like, but we're not quite there yet. And so finding those real small polyps, the things that may hide in nooks and crannies still, you can get within a colonoscopy probably better than all of the other adjuncts.

Dale Shepard, MD, PhD: So have the virtual or the CT-based studies, have those fallen out of favor? I don't seem to hear about them as often.

Scott Steele, MD: Yeah, they not necessarily fallen out of favor, but they've served a practical purpose. So there are, like most things, there are some centers in the world that may be out there listening to this where that's more highly utilized. Most places don't use it as much, where it falls into a particular pattern. And sometimes there's just some people that we can't get a real good colonoscopy for. They may have some twists or some turns, or they may have some areas of narrowing that you can't get by with a scope. And a virtual colonoscopy can do a good job at being able to evaluate those.

That's how a lot of centers use them, but still a true endoscopic colonoscopy versus the virtual or the CT colonography, the former, the endoscopic one, is still the gold standard that's used.

Dale Shepard, MD, PhD: Yeah, makes sense. Which of the tests do you think it's most common that you could talk someone into getting if they were on the fence and not quite sure? So, I mean, it seems to me as though the best test is the one that somebody will actually do. Which one would that be?

Scott Steele, MD: Yeah, wonderful point. And so I always try to tell people as a colorectal surgeon, "Hey, eat more fiber." And if they say they eat fiber in any way, shape or pattern, I wish I could get them to eat the 10 to 15 grams a day. So to go to your point, I say, give me anything. So I think it's important that if you're going to do something that's great, I would guess that most people would be much more comfortable doing a stool sample test that they can do in the comfort of their own homes, and drop that off or send it in to see if that's there.

But it's also understanding that there is a reason that endoscopic procedures are out there. They're highly sensitive. You're looking at the colon itself. You're able to deal with something that you're able to see. So to go to your point, the one that's probably much more utilized is probably the fecal occult blood test type stool samples, but we still do want to get people out there for screening colonoscopies.

Dale Shepard, MD, PhD: So you raise an important point earlier from a symptom standpoint, the fact that people should maybe not be dismissive of a particular symptom and come in and be looked at and have it be evaluated. How do we get the message out that when we think about screening, we're truly looking for cancers when there aren't symptoms?

Scott Steele, MD: I think it's very important that we talk about the difference between a diagnostic scope or a diagnostic test, a surveillance test and a screening test. To go to your point you're exactly dead on, that patients who are undergoing a screening one, you're hopefully dealing with an asymptomatic patient. There's no symptoms there, so hopefully there's nothing there, or you can catch it at an early stage. And so that's why, when you talk about screening tests, all of these same tests can be a screening type of a test to look for colorectal cancer.

If you're having symptoms, whether it be changes in your stool, weight loss, tenesmus, which is an urgency or a urgent need to have a bathroom or pressure to be able to push things out, bleeding rectum. Those things are what we would consider as having a test that is more of a diagnostic test, you're having symptoms. And so they don't really fall into screening guidelines. And the reason that I bring it up is we're talking a lot about screening here today. And as we talk about some of the recommendations to start screening, oftentimes they're tied into age or they're tied into risk profiles. But remember you can be at any age and if you're having these type of symptoms, you may find yourself in a situation where you want to go a test that may diagnose something, hence the diagnostic test.

And then finally, a surveillance test is something where they may have find polyps in the past. And so we're going to survey you for more polyps, and you may be on a little bit different schedule for how often you would undergo some of these tests or undergoing endoscopy, than you would under screening. So to get the word out for screening is critically important. And through podcasts like this, for understanding that March is Colorectal Cancer Awareness Month, you may see that the navy blue ribbons that people may wear.

Again, I'm a little bit biased, if you saw me today, I'm wearing a pink shirt. And I go back to breast cancer does a wonderful job at getting the word out. The runs, the walks, the breast cancer awareness, the ads that are on television. I long for the days where colorectal cancer is out there and being able to do that. I always try to tell people that our bowel habits aren't something that we talk about to each other. You can have a husband and a wife that may have been together for 50 years, and they may not talk about it. It's just, it's a very intimate part of your body. It's a very intimate process that goes along.

But understand that it is, as I said before, the second or third leading cause of cancer-related death in the United States alone. And it's also one of the ones that is preventable and it's detectable at an early stage disease. So we need to get that word out.

Dale Shepard, MD, PhD: Really is crucial. So I treat metastatic colorectal cancer, and it's just so frustrating when a lot of it could be preventable just by screening. And you mentioned, 25% or so may present with late stage disease. What are the numbers currently in terms of ... How many people are we looking at that could benefit from screening that just don't? What's that gap? Who do we need to capture?

Scott Steele, MD: Yeah, that's a great question. So I would say that's pockets. So you can have some systems where there's an equal access pocket where maybe up to 60% of people or even higher, get all of the screening tests that they're supposed to get. But there's other pockets, and a lot of this is socioeconomics, access to medical care and awareness of what they should do, and it can be low as 10 to 15%. And that's scary.

If you think about that, we know that there is a problem. We have something that you can do about it. I would hope that after listening to this, all of our listeners would go out and get a screening examination. But to your point, there is a significant, and in some sectors of the US, in some sectors of our city of Cleveland, in every city or town in America out there, where there's just pockets of people, for whatever reason, that don't get many of the screening tests. Whether it be for breast cancer or prostate cancer, or in our case, what we're talking about today, colorectal cancer. And that gap unfortunately is much greater, much larger than one would think it is.

Dale Shepard, MD, PhD: Has that gap narrowed by bringing screening into the home with the home-based testing rather?

Scott Steele, MD: Yeah, I think to a certain degree, but it's been pretty stagnant for a while. I do think that we would have some aspects that are improving. There's no question that dedicated targeting with educational platforms, things like walks and runs, things like TV advertisements, things like social media now, podcasts that are dedicated to it. It's just simply wearing the navy ribbon to as have people say, "Hey, what is that?" We have screening days. We have, for example here at the Cleveland Clinic, there's a Minority Men's Health Day that we talk and we participate in to try to reach out to some of the traditional socioeconomic and ethnic groups that have lower screening strategies.

And so at the end of the day, I think one of the thing that hurts colorectal cancer screening goes back to what I was talking about a little bit about before. And that's just, we just ... I try to tell my patients, when you hurt your arm, you can look at it, you can see it, you can touch it. It's maybe within cultural norms that that's fine. But for whatever reason, our bowels, when you think about when things go wrong with our bowels, you could feel some extra tissue, it could bleed, your bowel movements change. Or there's things that we just, we can't see what it is. It's hard to examine your backside. It's hard to look and see what's going on in your inner parts.

And so that is not a customary topic of conversation at the dinner table. Like, "Hey, mom, my arm hurts." Or, "My wife, my arm hurts." We're not talking about this. I think a lot of that really does go into the fact that we have missed opportunities that are there. So our goal, and why I appreciate you allowing me to come on so much is to say, "Listen, having a bowel movement is a normal human process." And when it hurts or it bleeds, that's one thing that you got to bring up to your doctor. You just got to have that conversation.

And also, even when it doesn't hurt or it doesn't bleed and you get to the point that maybe you're doing preventative health, and we all get to that point in our lives where we're looking more at preventative health to preventing the onset of disease processing happening, which is that screening recommendations that we're talking about. That's the time to make sure that you get those, and one of those screening process is exactly what we're dealing with today. And that's things such as fecal occult blood tests, stool-based tests, radiology tests geared towards it, the CT colonography. Or the structurally-based tests, the endoscopic tests, to be able to look into the colon and make sure that nothing is there.

Dale Shepard, MD, PhD: So part of those guidelines are like you say, how you get the testing done. The other is who. Who should we be thinking about screening for? You mentioned before a lot of it's age-based. At Cleveland Clinic, what guidelines do we tend to follow most?

Scott Steele, MD: Yeah. So I would just encourage everybody out there, there's a lot of valuable resources out there. You can go to Cleveland Clinic's website, go to the DDSI website within colorectal surgery and find these guidelines. The American Cancer Society has it. If you go to the American Society of Colorectal Surgeons, of the Diseases in Colon and Rectum, which is our national society's major premier medical journal, these guidelines are posted on there, and you can evaluate them.

At very broad strokes, think about it in terms of a couple of factors that can allow you to be able to say if you're in there. So you first look at what your age is. And so in general, most people remember the age 50. I would say that the American Cancer Society recently has recommended that adults age 45 and older who are near an average risk, undergo regular screening. So that has been something that has dropped, but historically that was the age of 50, but we're now thinking about 45. Note: as of May 2021 anyone age 45 and older should get a screening colonoscopy.

You also need to be able to think about your personal risk profile. So we know that patients that have multiple family relatives or one first degree relative, especially if they are at a younger age diagnosed with things, you're at a higher risk. So we would have a little bit different screening guidelines for you. Your recommendation for that might be something that's a little bit earlier than that. For example, if your mom got colorectal cancer at age 45, we want to screen you 10 years before that. So look at your own personal risk profile for what it is. You could have had polyps in the past, so that puts you at a little bit higher risk of what it is.

It's number one, what's your age is. Number two, a lot of times what your family history or your personal risk profile it is. We blend those things together and we come up with what is your age that you should start screening.

Dale Shepard, MD, PhD: So you mentioned before about the American Cancer Society changed to 45. And I know certainly on the metastatic side, we're seeing a lot of younger patients. The move to 45, what are your thoughts? Is that enough, is it the right age?

Scott Steele, MD: So we know that in general, that colorectal cancer incidents has pretty much steadily declined over the last couple of decades in the population age 50 years or older. There are some demographics that don't exactly follow those trends, but that's just a broad-based stroke type thing.
But unfortunately, what we've seen recently is we've seen an increase in the early-onset colorectal cancer. And the biggest question out there is why. Now it's important to understand that this is still a small percentage of people, but it's much of a trend that is alarming and concerning. It's something that we have seen over the course of individuals aged 20 to 49. And that's probably multifactorial, just like a lot of cancers, it's multifactorial.

You take the underlying risk profile of the patients. So we all have our own genetic makeup that puts us at a different risk profile for different disease processes. You combine that with potentially the foods we eat, maybe our body habitus or makeup. For example, we know that patients that have metabolic type syndrome such as obesity, they're at a slightly higher risk. Sedentary lifestyles, maybe some of the environmental aspects that they're exposed to, we combine all those together. And for whatever reason, we found that early-onset is going up.

And so now a lot of efforts are going into looking at patients, trying to identify the reasons why, and then trying to hopefully intervene and find out what is causing this, being able to intervene on that. And then also to see that on a screening, should we be dropping those, and the first aspect of that was to drop it from 50 to 45.

Dale Shepard, MD, PhD: But particularly between the 20 to 49s, the drop to 45 won't catch that. But it sounds like there's some efforts in play to maybe find some characteristics that could guide screening to that group in the future?

Scott Steele, MD: Yeah. Again, at this stage we know that it's multifactorial. And what I'm not talking about here is the people who have a true hereditary disposition. So we know that there are certain genetic chromosomal abnormalities or something like an FAP for example, the familial adenomatous polyposis, we're not talking about the genetic type or the hereditary syndromes. We're talking about just run-of-the-mill, spontaneous onset of colorectal cancer in the young. And that's what efforts are right now to be able to pick that out here.

And one of the things we're developing here at the Cleveland Clinic is an early-onset or young-onset colorectal cancer center, where we're going to be able to try to bring these patients in. We're going to try to be able to study them, we're going to try to be able to screen them. We're going to be able to try to track them so that it mixes in. We have, what I consider, one of the crown jewels of our department within colorectal surgery is the Sanford Weiss Hereditray Center for Colorectal Neoplasms, it's the Weiss Center that's geared towards these.

So when we deal with these hereditary neoplasms or surrounding colorectal cancer, we track them, we follow them. We're the leading center in the world in terms of dealing with that. And we get patients from all around the world. And we're incorporating on this early onset colorectal cancer into that as we start to evolve this process, so that we can bring patients in, we can screen them appropriately, we can figure out exactly what it's causing. And that's probably one of the most exciting thing that you're going to be seeing rolling over the next year or so.

Dale Shepard, MD, PhD: That's excellent. So Scott, you've provided us some great insights here today. Any additional thoughts?

Scott Steele, MD: Just don't be scared to get screened. I can't tell you the number of times I scoped today. And one of the things that I hear all the time when I scope is the patient says, "That wasn't bad at all. That was easy. Are we done yet?" And they're done. And it's just this fear of undergoing a screening test more than anything else.
And so harking back to those statistics that we talked about during this brief podcast, and understand the fact that there's something that you can do. Don't ignore the symptoms, don't ignore the recommendations for screening. It is something that may save your life one day.

Dale Shepard, MD, PhD: That's excellent. Well, thank you very much.

Scott Steele, MD: Thank you so much for having me on.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real-time updates from Cleveland Clinic's Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.

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