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Colorectal cancer is the 3rd leading cause of cancer death in both men and women in the United States. About 97,220 cases of colon cancer and 43,030 cases of rectal cancer will be diagnosed in the US in 2018. About 50,630 people will die from colorectal cancer in 2018. We have come a long way in our understanding of colorectal cancer. For a cancer that is preventable, we are far from grade A in our report card. What have we done right (the good)? What is wrong (the bad)? And what is unacceptable (the ugly)?
The Good
Between 2005 and 2014, the incidence rates declined by 3.8% annually for colon cancer and by 3.5% annually for rectal cancer among adults 55 years of age and older. From 2006 to 2015, death rates from colorectal cancer declined by 2.9% per year among adults 55 years of age and older. Overall, the colorectal cancer death rate in 2015 (14 per 100,000) was half of what it was in 1975 (28 per 100,000).
This success is due to increased awareness about colorectal cancer, increased screening rates and better treatment for patients diagnosed with colorectal cancer. Screening options for colorectal cancer have increased. These include guaiac-based fecal occult blood test (gFOBT), fecal immunochemical test (FIT), FIT-DNA test (cologuard), flexible sigmoidoscopy, CT colonography, capsule colonoscopy and optical colonoscopy.
The passage of the Affordable Care Act was a victory in the fight against colorectal cancer. The law waives the coinsurance and deductible for many cancer screening tests including colonoscopy thereby removing a major barrier against colorectal screening tests. The month of March is nationally recognized as colorectal cancer awareness month. This gives us an opportunity as a nation to increase awareness about colorectal cancer, promote screening, and celebrate survivors of colorectal cancer.
The Bad
Between 2005 and 2014, the incidence rates increased by 1.4% annually for colon cancer and by 2.4% annually for rectal cancer among people younger than age 55. Colon cancer increased by about 1-2% per year and rectal cancer increased by 3% per year for people in their 20s and 30s between the mid 1980s and 2013. From 2006 to 2015, death rates from colorectal cancer increased by 1% per year among people younger than age 55. Young patients are also 58% more likely to be diagnosed with metastatic colorectal cancer instead of localized cancer.
The reason for these unexpected trends in young people is poorly understood. Obesity, processed food and more diagnostic tests have been cited as possible reasons. Screening tests for colorectal cancer is recommended for average risk adults starting at age 50. Do we need to reduce this age?
Symptoms of colorectal cancer in young adults should prompt a visit to a physician and consideration for a diagnostic colonoscopy. Symptoms of colorectal cancer include blood in the stool, change in bowel habits, abdominal pain, abdominal fullness, and weight loss. The diagnosis of colorectal cancer in young adults should lead to genetic testing for Lynch syndrome. Lynch syndrome is an inherited condition that increases a person’s risk for colorectal cancer and other cancers. According to a published study, one in five patients diagnosed with colorectal cancer younger than age 50 showed an inherited genetic predisposition to the disease. More than half of these patients lacked a clinical or family history that would typically indicate the need for genetic testing.
The Ugly
There is a colonoscopy loophole in the current healthcare law. While the Affordable Care Act waives coinsurance and deductible for screening colonoscopy, patients may have co-pay if a polyp is removed. When a polyp is removed during colonoscopy, Medicare coding rules reclassify the test as a diagnostic test. This means patients may get a medical bill after colonoscopy when they expect to pay nothing. Colonoscopy prevents colorectal cancer because it allows physicians to remove pre-cancerous polyps before they grow into cancer. This loophole in screening colonoscopy policy should be fixed. We should remove all barriers to screening so that we can increase screening rates from less than seventy percent to over 80%.
The most unpleasant aspect of colonoscopy is the bowel preparation. Most of the bowel cleansing agents in the market are large volume salty preparations that are difficult to consume. There are efforts now to solve this problem. While we wait for the day when bowel cleansing agents are available as food snacks, there are things we can do to improve bowel cleansing experience prior to colonoscopy. Splitting the bowel cleansing agent into two by taking half the total dose the day before your colonoscopy and the second half on the day of the colonoscopy improves tolerability, bowel cleansing and polyp detection.
How do we increase colorectal cancer screening rates? How can we change the alarming trend of colorectal cancer in young people? Our journey is not complete until colorectal cancer is defeated. Our report card ten years from now should be different from what it is today. Let’s go.
Adewale Ajumobi, MD, MBA, FACP, FACG is a board certified gastroenterologist and founder of bowelprepguide.com.
