In the interest of public service, here’s a confession: Through my 50s, I avoided getting a colonoscopy (I even share my silly reason in this interview). I finally had the procedure recently, at age 61, and fortunately for me, no polyps were found. I’ve since learned more about the unnecessary risk I took but also that I’ve hardly been alone with my neglect. With this story, I hope to encourage others via an interview with my gastroenterologist, Dr. Christopher Martin at Phelps Memorial Hospital in Sleepy Hollow.
Grace: As somebody who has performed so many of this recommended cancer screening, what are the reasons you hear as to why somebody may put off colonoscopies?
Dr. Martin: It’s usually something along the lines of, ‘well I have no symptoms and I have no family history.’ I’ve also heard ‘I don’t want to know if it’s there’ or someone may think it involves more than it does. So, any one of those things, or a combination.
Grace: How big a problem is colonoscopy avoidance?
Dr. Martin: Now that the screening age has been lowered to 45, easily fewer than half of people of screening age are getting screened for colon cancer. The bottom line is we really shouldn’t be seeing colon cancer. It’s a highly preventable cancer, but unfortunately, we still have more than half of people who are at risk who are not being screened.
Grace: So, when you say that less than half the people of screening age, can you clarify a bit?
Dr. Martin: The recommended age was 50 but it has recently been bumped down to 45. For most people with a family history or inflammatory bowel disease, screenings have their own set of guidelines because those patients are at increased risk. For the general population, the first recommended screening is now at 45 years old.
Grace: How often should you have this screening if you are going with the program?
Dr. Martin: With no family history, we recommend every 10 years. But again, that time span may be shortened when we require closer follow up, primarily in people with a personal or family history of colon polyps or cancer, or if you have inflammatory bowel disease.
Grace: Ok, so if you do have some other condition then you may end up going every two years or even every year?
Dr. Martin: There are some conditions where you go every 1 to 2 years, yes. But that’s for very special cases.
Grace: Would you say that both men and women are equally at risk in avoiding this screening?
Dr. Martin: Yes, I don’t see a gender difference. Very often too it’s a spouse who brings the more reluctant spouse in.
Grace: One male friend told me that he has a very healthy diet, no family history, and he works out, so he’s just not doing it. What’s your response to him?
Dr. Martin: Well, it is a common cancer. It is a preventable cancer, so it is very much a shame when it does happen. More than half of the cancer that we see is in people with no family history. It’s also an asymptomatic cancer in its early stages. There’s really nothing to protect you 100% from it. Factors associated with less colon cancer are things like a more active lifestyle and a high-fiber diet. But these are very mild, minor associations; we have seen marathon runners who have never smoked a day in their life get colon cancer. It’s really important that everybody get screened at the appropriate age.
Grace: I mentioned to you that I have a gag reflex at the dentist. I was sure I couldn’t get through the prep and that became my own ‘reason.’ Can you tell readers a little more about the prep and how to make it less stressful?
Dr. Martin: I tell people that if there is any nausea or anything during the prep, they should slow it down. I’d rather someone get through more of the prep than try to rush it down and get sick and maybe not finish it. It is extremely important that the preparation be good enough for a quality exam so we can detect even the smallest polyp. And then you don’t have to do it again for 10 years.
There are some situations in which people don’t do as well with the stimulant laxative component, especially if they have a history with constipation. For those patients, I will sometimes tailor the preparation a little differently. The goal is that you are eventually having diarrhea until it turns into water. That way we can assure that we will get a quality exam the next day. Most people have very little difficulty with the prep; it’s just not something they would choose to do on a regular day.
Grace: Many of us are hearing about Cologuard. Can you discuss how adequate an alternative it is to a colonoscopy?
Dr. Martin: In the big picture, I think having multiple screening options is a good thing. However, Cologuard is not appropriate for people at a higher risk for colon cancer. That would include people with a history of a colon polyp in the past, a personal or family history of colon cancer or inflammatory bowel disease. That’s the first thing I would say. Secondly, it is very good at detecting colon cancer; it’s about 92% sensitive for colon cancer. However, it will still miss more than half of significant pre-cancerous polyps. By missing more than half of the pre-cancerous polyps, we are losing opportunities to intervene and prevent colon cancer. So that’s why a colonoscopy really has the advantage as a preventive measure.
Grace: Some people are concerned about injury during the exam and internal injury. Is that a significant risk factor and how do you lower the odds of that happening?
Dr. Martin: There’s a risk with any procedure physicians do, colonoscopy among them, and the risk increases as removal of polyps becomes necessary. For example, the risk of a tear and bleeding is higher when you are taking out a large polyp. Unfortunately, the option of allowing them to develop into cancer isn’t a good option either – that would at best require surgery or possibly chemotherapy instead. The risk of complication does increase with age, but then again, so does the risk of colon cancer. We consider the whole patient and make sure the whole test is appropriate.
Generally speaking: if people are in good medical health and they have more than a 10-year life expectancy, a colon screening is appropriate. There are certain anesthesia risks as well which increase in patients who are obese or who suffer from sleep apnea, but anesthesiologists are attuned to these issues and well equipped to address anything that comes up during these procedures.
Grace: As far as choosing the right doctor, I imagine that is key?
Dr. Martin: I would start with consulting your primary care doctor. Most probably have a long-standing working relationship with their specialty gastroenterologist(s) – someone who has an established track record of not having any bad outcomes with people they refer to and that’s how referral patterns develop – because there’s a sense of trust. There are also metrics to consider – a key one would be the number of polyps detected. Some 20-25% of colonoscopies should result in a detection of a colon polyp and that would suggest that the given gastroenterologist is doing an adequate exam. Likewise, you can ask how quickly someone does an exam; the current standard is a minimum of 6-minute scope withdrawal time during the exam which should be sufficient for inspecting the colon. A gastroenterologist’s volume in procedures also can be a good predictor in terms of complication rates. Over 300 procedures a year seems to be the threshold for someone with fewer complications.
Grace: When you are talking about looking for polyps, are they certain kinds of polyps? Is there such a thing as a healthy polyp or is there just an unhealthy polyp?
Dr. Martin: There is no such thing as a healthy polyp. When people are told they had a benign polyp removed, the polyp can either be pre-cancerous or not pre-cancerous; both are ‘benign’. Most of them are pre-cancerous but all polyps are removed. Colon cancers start off as one of these pre-cancerous polyps that can look quite bland but are generally visible during a colonoscopy when there is adequate preparation.
Grace: Please tell us more about the beauty of this early detection.
Dr. Martin: Well, let’s say you find a colon cancer: Early-stage colon cancer survival is upwards of 90%. Late stage is more like 14%. That’s a huge difference and a treatment of an early stage can involve something relatively speaking less dire: the laparoscopic partial removal of the colon without any real change in lifestyle afterwards. While that involves a surgical recovery period, it won’t cause much of a change in bowel habits. Some chemotherapy may be necessary for some time afterwards, and that will also enhance the cure rate. It’s really in its late stage when colon cancer becomes symptomatic. It can spread to other organs which really brings survival down dramatically.
The essence to this conversation is to just get screened. If you ask anyone who has developed colon cancer, they really wish that they could go back in time and be screened a little bit sooner. It’s a shame when you hear their ordeal and you know that it was essentially preventable.
Grace: A final question: have you and your fellow physicians and staff and at Phelps… are you all getting your colonoscopies?
Dr. Martin: Yes, we are following our own advice here. I’ve had a couple myself, and everyone in my family who is supposed to be screened has been screened. It’s just one area of fighting cancer where we truly can make a difference in terms of outcomes.
PHOTO COURTESY OF Phelps Memorial Hospital