Why can’t we do more about colorectal cancer?
I gave a talk to a group of doctors today on the prevention and early detection of colorectal cancer. The main theme was that we could prevent about 30,000 deaths a year from this disease, if we only applied what we already know. Imagine for a moment: 30,000 people a year could avoid death from a disease that is the second leading cause of cancer deaths in the United States, and the third most common cancer that occurs in men and women. That represents over 50% of the people who are projected to die this year from colorectal cancer. And, it doesn’t require any new knowledge beyond what we already know, and have known for a number of years.
So the question is a simple one: why aren’t we doing better? Why can’t we help save the lives of 30,000 mothers, fathers, grandfathers, grandmothers, sons, daughters, aunts, uncles, friends, and colleagues among others?
There will always (ok, perhaps we can hope it will not always be “always”) be situations where we wouldn’t have found the disease because people are too young and wouldn’t fit into our normal screening recommendations (begin to get screened at age 50 if you are at average risk, meaning no significant family history or other illness such as ulcerative colitis which increases your risk of the disease. You can go to www.cancer.org or call 800-ACS-2345 to get more information on colon cancer screening in average and high risk people, as well as an explanation of who is at high risk. If you are at high risk, you will likely need to start screening at an earlier age, or perhaps more frequently that a person who is at average risk).
Or, as happens with every cancer, the cancer grows more quickly than usual so it appears between screenings (that does happen in colon cancer and more than occasionally in women with breast cancer who are screened with mammograms every 12 months). That is the nature of any disease, cancer or otherwise: we make recommendations for likely events, not the unusual ones. For example, even people with normal cholesterol who don’t smoke, have no family history, and exercise regularly still have heart attacks.
But let’s get back to the question: why aren’t we doing a better job of both preventing colorectal cancer or finding it early through screening programs that are known to be effective?
Part of the blame rests with people: they don’t ask for it. Part of the blame rests with doctors and other health care professionals who don’t recommend it, or don’t look their patients straight in the eye and say that this is a test the doctor thinks is important. Some of the blame is our health care system, which doesn’t provide insurance coverage or reasonable access for a large number of people. And part of the blame rests with companies or insurance companies that don’t include colorectal cancer screening in their benefit packages.
No matter, the basic fact is that depending on the study or the survey, less than half—and in some situations much less than half—of the people who should be screened for colorectal cancer are, in fact, getting screening in accordance with recommended guidelines.
The question still nags at me today the same way it has for many years: why? What would it take to save a life? And what would it take to see the number of colorectal cancer cases start decreasing tomorrow or the next day or the next year? And if screening is effective, in a short period of time—a couple of years at most—we could see a significant and perhaps dramatic decrease in the number of deaths from this disease.
Maybe part of the problem is the fact that colorectal cancer is a disease of the “elderly” so we sort of accept it as part of life and growing older. I put the quotes around “elderly” because 15 or 20 or 30 years ago age 65 and 70 was elderly. Now, 65 is becoming the end of “middle age”, and there are many very functional, very healthy 65 and 70 year old folks who are at high risk for this disease.
My mother was in her very early 80’s when she told me she had some rectal bleeding. She finally consented to go to the doctor, and what she had was a polyp in the colon with a small area of cancer that had begun to invade the polyp. Removal of the polyp actually removed the cancer—the doctor couldn’t find anything when he operated on her (appropriately) shortly afterwards. She passed away last year at the age of almost 92. She had been cured of her cancer, and my wife and I are grateful for the additional time we had with her.
A number of years ago when I was in practice I had a patient with breast cancer who had not had a recurrence for a number of years. She was otherwise in good health. I took care of her as her primary physician. Every year I asked her to get screened for colon cancer, and every year she declined. I made a little note in her medical chart.
One day, my patient came to the office for a regular visit. She told me she had a little blood in her stool. A rectal exam confirmed the presence of blood. A colonoscopy confirmed a large tumor just above the rectum in the part of the bowel called the sigmoid colon. She had surgery, the cancer had spread, and she died shortly afterwards.
I still vividly remember showing her family the medical record chart with the notations every year that she had declined to be screened for colorectal cancer. They actually ended up comforting me—this was a very personal situation for me as it was for them-- and told me they knew that I had asked every year because she had told them. And they too had not been able to get her to follow my advice.
I lost a patient; they lost a mother to whom they were very devoted.
As we age, we begin to realize that there are many things in life over which we have little control. There are diseases, illnesses, and tragedies that are going to happen. But, in some situations, we can move the odds in our favor. Seat belts are an example. Eating a healthy diet and maintaining a healthy body weight is another example. And, screening for cancer falls into that category.
We sometimes forget that we have made huge gains over the years with tests like the Pap test, which has had a remarkable effect on reducing deaths from cervical cancer (unlike other parts of the world, where it is still one of the leading causes of cancer deaths in women). We are seeing reductions in deaths from breast cancer due to mammograms and better treatment of the disease.
We need to make the same commitment about colorectal cancer. We have to get past the “squeamishness” we have about that part of our bodies, and get on with the job of reducing the chances that this disease will take us or our loved ones from this earth before their time.
I hope the doctors I spoke to today heard the message, and I hope you do as well.