In our Ask a Doc series, we sit down with physicians and other clinical experts, including those at Allegheny Health Network (AHN), for a chat on an important health topic. In this post, we talk about colorectal cancer and screenings with Dr. Katie Farah, Chief Quality Officer for the AHN Division of Gastroenterology.
Colorectal cancer is the second leading cause of cancer-related deaths worldwide, but approximately 60% of colorectal cancer deaths could be prevented with recommended screenings. Unfortunately, screening is highly underutilized, in part due to apprehension and misconception about the procedure, as well as an awareness gap and lack of accessibility in underserved communities. To learn more about this important topic, I spoke with Katie Farah, MD, Chief Quality Officer for the AHN Division of Gastroenterology.
Emily Laubham (EL): Dr. Farah, what are the different screening options for colorectal cancer?
A colonoscopy is the best test for colorectal cancer screening. The GI Multi-Society Task Force guidelines provide tier-based testing to give practitioners guidance, and based on an overwhelming amount of evidence, colonoscopy is the number one test of choice.
The next best screening modality, FIT, is a stool-based test that has the highest sensitivity and specificity for picking up colon cancer and the majority of colon polyps.
EL: Are there other options that you would deter people from using?
KF: The tier-based classification that I mentioned represents the most up-to-date, evidence-based recommendations from the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy. We want patients as well as primary care providers (PCPs) and other referring physicians to use the tier 1 screening tests that’s colonoscopy as the first test of choice and, if refused by the patient, an annual standard FIT test as the second tier 1 option.
Another test that patients and PCPs may hear about is Cologuard (FIT-fecal DNA), an at-home product that combines FIT to detect blood in the stool with a DNA component. The guidelines currently consider Cologuard (FIT-fecal DNA every three years) among the tier 2 testing options due to disadvantages that include decreased specificity in patients older than 65, high cost relative to the standard FIT, and higher relative costs related to higher number of colonoscopies per test. The higher false positivity rate in older patients can lead to significant anxiety as well as the stress of cost from an unnecessary diagnostic colonoscopy in which the patient often has a copay since this is no longer considered a screening procedure. We are always glad to answer questions that patients or PCPs have about any options, but ultimately we follow tier 1 recommendations as set forth by the Multi-Society Guidelines and American Society for Gastrointestinal Endoscopy.
Getting back to the standard FIT, one issue that we’ve been trying to address is to close the loop between patients taking a test and getting it back to their physician. We found that 10% to 30% of standard FIT tests were not leading to colonoscopy, even if the test came back positive for colorectal cancer. Our FIT KIT campaign has the goal of increasing the rate of return to colonoscopy after a positive FIT.
EL: Can you explain the difference between a diagnostic colonoscopy and a screening colonoscopy?
KF: A screening colonoscopy is performed in a patient without any symptoms for purposes of preventative care. A diagnostic colonoscopy is guided by the patient's symptoms and/or abnormal imaging, or positive FIT. An example would be a CAT scan showing an abnormality in the colon, which would be investigated by performing a colonoscopy.
EL: When something is wrong, it’s easy to understand why you should get a procedure. But why are recommended screening colonoscopies important…even if you are healthy?
KF: The biggest misconceptions about colon cancer are, “I have no symptoms, so I don’t need a screening,” or “it’s not going to happen to me because I don’t have a family history.”
A screening colonoscopy is recommended for individuals at a specified age, even if they feel perfectly fine. It is used in an effort to detect and prevent colorectal cancer before symptoms develop. The timing of the screening is determined by the patient’s age and risk profile. The guidelines are set to maximize the risk-benefit ratio based on their risk factors.
If, during a colonoscopy, we find a polyp or pre-cancerous growth, we remove it at the same time, and in that case, we’ve prevented possible future growth which could develop into cancer down the road. Even if a mass is found, screening gives us an opportunity to catch colorectal cancer early. For stage-one colorectal cancer, long-term survival is similar to the overall population. And the majority of patients with early diagnosis will not require additional treatment such as chemotherapy or radiation.
EL: That seems pretty convincing. So, who needs a screening colonoscopy and when?
KF: There are two major categories normal risk and high risk for colorectal cancer. The major risk factors are family history of colorectal cancer, ulcerative colitis, Crohn’s disease, a personal history of colorectal polyps or colon cancer, and some rare hereditary colon cancer conditions such as Lynch Syndrome. Familial colon cancers pose a higher risk and therefore the patient is usually screened at age 40 or 10 years prior to the age that their first-degree relative was diagnosed. High-risk groups, including African Americans, should have their first colonoscopy at age 45.
If you are in the normal risk category, and do not have symptoms, guidelines are that you should get your baseline screening colonoscopy at age 50.
EL: I understand that the American Cancer Society suggested moving the first screening for colorectal cancer back to age 45, but there’s some disagreement about that. Can you give some insight on the debate?
KF: Based on an increase (numbers have doubled) in colon cancer patients between age 21 and 49, there has been a surge to evaluate for trends to determine the right age for screening. The ACS board made up of well-respected, highly-skilled thought leaders did research based on modeling in which a specific birth cohort was analyzed as an attempt to identify who is more at risk in the younger population. They concluded that perhaps age 45 is a good age to start screening for all asymptomatic patients. This was a “qualified recommendation,” and we simply do not have empiric evidence to show that this would be cost-effective or be high yield. There is a lot of controversy around this recommendation, which is not supported by the GI multi-society guidelines, and there is difficulty with insurance approval as well.
Perhaps risk stratification and identification of symptomatic young patients would make more sense at this time. It is important to keep in mind that for every 5-year age group added to screening recommendations, 20 million more people would need to be screened. There is a true concern that if this would occur that we would begin to shift resources from patients who need screening (age 50 and older) to patients who need it less. There simply aren’t enough physicians to be able to accommodate all the screenings if you move the age back. There is more to it, but our GI medical societies continue to recommend 50 as the starting point for average-risk patients with no symptoms.
Rather than scoping everybody earlier, I think we need to raise awareness around early symptoms. There are patients in their twenties and thirties with no risk factors showing up with colorectal cancer. When you look at how long they’ve been complaining of symptoms before diagnosis, it ranges anywhere from a few weeks to two years. That is why we are now educating primary care physicians (PCPs) to have heightened awareness that, regardless of age, if a patient comes in with anemia, rectal bleeding, change in bowel habits, and/or abdominal pain, then a referral to a gastroenterologist should be made.
EL: When you perform a screening colonoscopy, is identifying and removing polyps the main focus?
KF: We look for anything abnormal, including polyps. Most polyps can be removed endoscopically. If there is mucosal abnormality, biopsies are taken. We evaluate for diverticular disease which are little pockets in the colon that can lead to diverticulitis, as well as any evidence of inflammatory bowel disease, just to name a few.
EL: How often will a person need to get additional screenings?
KF: For the average-risk patient, if there is no polyp on first examination, typically a follow-up colonoscopy is in 10 years. However, surveillance intervals vary based on polyp number, polyp size, and pathology of the polyp. That interval may be sooner if the physician needs to evaluate the polyp site sooner or if there is a poor prep. Patients with hereditary colorectal cancer and prior history of colon cancer will get surveillance colonoscopy at more regular intervals.
Research is also being performed to evaluate the role of annual FIT testing in younger patients at this time.
EL: Why do you think people are apprehensive about colonoscopy screenings?
KF: We have surveyed people across Allegheny Health Network and there seem to be three main reasons: fear of complications, fear of anesthesia, and fear of the preparation.
EL: Ok, let’s address those. Are there possible complications associated with colonoscopy?
KF: Most risk factors happen in less than 1% to 2% of patients and would include but are not limited to perforation, bleeding, infection, complications of anesthesia, and injury to other organs. These are rare, but nonetheless, risks are reviewed with the patient prior to procedure.
EL: What about anesthesia can people choose to undergo the procedure without it?
KF: Generally, most patients receive monitored anesthesia. However, there will be an occasional patient who does not want anesthesia, and yes it can be done. Most gastroenterologists have performed colonoscopy on patients unsedated, albeit few. It is less favored due to patient discomfort and technical difficulty with a patient who is awake. My personal practice is that I schedule the patient as the last patient of the day as it may take longer due to the patient being awake. If they have discomfort, I either abort the procedure or ask that they be converted to anesthesia at that point. It would be the patient’s decision if we are faced with that type of situation. Reasons why a patient might be apprehensive about receiving anesthesia include a history of anxiety, sense of loss of control, and prior trauma in their life. I have found that most patients just want to be able to trust their physician, be able to have that discussion and be heard.
EL: Are there any revisions to the preparation process that would help people who struggle with that?
KF: We’re constantly revising the prep process, with our main concerns being safety, efficacy, and tolerability. Over the last few years, literature has shown that split-dose prep is the best option whatever type of prep you have, split it in two. Patients will take the first half the night before and the second half after midnight, with the goal of finishing about four hours prior to the procedure. This is helpful because your colon evacuates chyme and bile in those last few hours, and dumps them into the right colon the area where most flat polyps and cancers are missed. Therefore, we want to ensure evacuation of this region, and by splitting the prep, this is accomplished in most cases.
We also recently revised AHN’s prep to include being able to eat things like saltines. The idea is that if you are allowed to eat just that little bit, you are going to stimulate your colon to contract and be more cleaned out. Tips we give to make the prep more tolerable are to keep it in the fridge overnight, sip it through a straw, add lots of ice, and mix it with any clear liquid.
EL: What would you say to people who still feel uneasy about colonoscopies?
KF: First, I recommend seeing a gastroenterologist in the office, so they can establish a relationship, and have their questions answered in person. It’s important for people to make sure they trust their physician. In addition, proper education is of utmost importance. I always indicate that having colon cancer would be worse.
One thing about the Internet is that people can do a lot of research on their physician, and that can also be reassuring. I’ll add that we measure every gastroenterologist throughout AHN. They get a scorecard, so they know how they’re performing compared to standard national benchmarks and compared to their peers locally, regionally, and nationally.
EL: Can you talk about efforts to educate people about colorectal cancer and screenings?
KF: For many people, awareness and education starts with their PCP the vector of medical information. That’s why we’ve been conducting webinars across AHN to make sure PCPs have the best information.
But you also have to think about people who don’t have a PCP, especially people in underserved communities. So we promote education through community events, social media, and local media. For instance, we did a sponsorship event at a Pittsburgh Pirates game that stressed the importance of getting colorectal cancer screenings if you are older than 50 or have a family history. We handed out flyers, t-shirts, pens, bracelets we even had a 20-foot-wide inflatable colon. Every year, we also advertise at the Riverhounds soccer games at the Highmark Stadium.
EL: Tell me about the AHN Saturday screening initiative.
KF: Nationally, about 35% of people remain unscreened. When I asked my patients why they hadn’t been screened, one reason was that they couldn’t take a day off of work. Our team of physicians, nurses, managers, and researchers organized an effort to offer screening colonoscopies at several outpatient endoscopy centers on Saturdays throughout the year. Physicians get a day off if they volunteer, and staff gets overtime. We wanted to build a community-based solution which would benefit all.
We started the program in March 2018 with the intention to be annual, but the demand led to Saturdays quarterly. This last quarter, within 36 hours almost all the spots were filled.
Another barrier to screening that we identified was lack of reliable transportation. The PALS (People Able to Lend Support) volunteer program has been helping with that.
As important as screening is, I’ll emphasize that it’s just part of our comprehensive Care Model, which includes prevention, screening, diagnosis, treatment, surveillance, survivorship, and end-of-life care. Across that entire continuum, we’re working to understand what patients need and ask what we can do to meet those needs. Providing access and education fulfills a good proportion of those needs.