It was brought to my attention that March is National Colorectal Cancer Awareness Month, not to be confused with National Lung Cancer, Breast Cancer, Prostate Cancer, or any other cancer awareness month. As a practitioner and student of Cancer Medicine for the last 40 years, every month has been Any Cancer Awareness Month. Therefore, I was not caught oﬀ guard by this news. In the midst of (not the end of) the pandemic, renewed awareness of the illnesses not called COVID-19 is worthy of comment.
Repeatedly in the press and medical journals, we have been reminded of the shift away from routine medical care. Cancer prevention is an example of this shift in our behavior. By one estimate, the number of scheduled screening procedures for average risk colorectal cancer (CRC) dropped by 80 percent in March and April 2020. While this drop is gradually reversing itself, the eﬀect of the decrease in scheduled screening will translate into an increase in the number of advanced CRC that will be diagnosed at some time in the next 10 years. To avoid this increased risk of advanced illness, we should try to get back to the medical normal as soon as we can.
Screening tests for colon cancer will save lives
The impact of early detection of CRC is a 30 percent reduction in CRC mortality in the screened population. The return to regularly scheduled cancer screening, as well as screening for other medical diseases is of Importance to us all. As soon as it is safe to do so, regular screening for preventable and treatable diseases should be a priority for all adults and children.
Screening recommendations for CRC have recently been modified by some medical organizations. Both the American Society of Gastroenterology and the American Cancer Society now recommend CRC screening for average risks persons to begin at age 45. This change from age 50 results from the identified increase in incidence of CRC in adults under the age of 50. It is estimated that compared to the population born in 1950 or before, the population born in 1990 or later will assume a two-fold increased risk of colon cancer and a four-fold increased risk of rectal cancer with much of this increase occurring at early age, often before 50. This trend appears to be driven by the changes in modern western lifestyle, and the increased prevalence in obesity for our younger population.
The approach to CRC screening includes both a review of factors known to increase CRC risk and a plan for an effective screening program. You are considered of average risk if you are age 45 to 75, and DO NOT HAVE:
- A personal history for CRC or certain types of advanced polyps.
- A first degree family history (father, mother, sibling, child) of CRC or other cancers associated with inherited familial cancer syndromes such as LYNCH, HNPCC, or FAP.
- A personal history of inflammatory bowel disease, such as Ulcerative Colitis or possibly Crohn’s Disease.
- A personal history of systemic immunosuppression or abdominal/pelvic irradiation for previously treated malignancy.
The appropriate screening program depends on the assessment of your risk of developing CRC and the time interval between screening tests.
While complete colonoscopy is the best screening tool, alternatives exist but require full discussion with your physician. Factors such as age, concurrent illness and personal preference may guide the choice of testing but must be considered carefully. Tests such as virtual colonoscopy, barium enema, ColoGuard DNA testing every three years, or yearly FIT (fecal immunochemical testing) exist, but all must be confirmed by colonoscopy if positive.
The frequency of screening for CRC must also be individualized. For average risk persons, colonoscopy with normal colon and rectal findings should be repeated every 10 years. Patients with a positive family history as outlined previously or a personal history of advanced polyposis will require more frequent colonoscopy screening, usually at five years. More frequent colonoscopy may be recommended in certain very high-risk circumstances. Screening frequency for alternative tests must be discussed individually as there are no established standards.
The way back to normal will include taking care of your health
Vaccination for COVID-19 and maintaining responsible social behavior will assist us all in making this a safe and useful eﬀort. If you think wearing a mask and distancing is tough, changing your lifestyle to reduce the risk of CRC is not trivial. The three ways you can reduce your CRC risk are to eat a diet low in fats and red meat and high in fruits, veggies and fiber, avoid tobacco altogether and alcohol in excess, and get regular physical activity while maintaining a normal weight during your lifetime. So, get to work. Wear the mask, walk briskly away from food and everyone else, and limit the cocktail parties to a dull roar. Let’s get back to normal soon.
Thomas J. Ervin, M.D.
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