March is National Colorectal Cancer Month, a month devoted to bringing attention to the third most common cancer in men and women, as well as the third most common cause of cancer deaths in each birth gender.
Screening and improvements in treatment for colorectal cancer (CRC) have proven effective in reducing both incidence and death from the disease, yet despite the considerable progress that has been made over the past 30 years we still have a long way to go if we are to further reduce that burden. We often say that we want to make progress in cancer treatment, yet we aren’t doing such a great job in applying the knowledge we already have in our possession.
We need to pay attention to access to ensure that everyone has the opportunity to get screened for CRC and get the best available treatment if they are found to have the disease; where we need to recapture the progress in early detection that had been made prior to the pandemic; where we need to find new approaches to both early detection and to treatment; where we need to focus more of our attention on the rising incidence in younger folks.
Progress with “gee whiz” treatments is wonderful, but they are few and far between especially in CRC. And they won’t solve all the problems we have with access and awareness: Our reality is that there remains a considerable divide between the “haves” and the “have nots” when it comes to cancer care, especially for diseases where we have genuine options to reduce the burden such as for CRC. It is important going forward that we do everything within our power to reduce that divide and be certain that it does not widen even further.
Let’s focus for a moment on the rising incidence of CRC in younger people:
We continue to see declines in CRC deaths among older folks over 50, however in younger adults the rate of incidence and death is increasing. And although those rates in young people may seem low, they continue to rise year over year and that means we are headed on a trajectory where this is becoming a more serious problem for far too many in their prime of life.
We don’t have recommendations to routinely screen young adults at average risk of colorectal cancer and it is unlikely we will have such recommendations any time soon.
Although the recommended age to start screening for CRC in those at average risk—which generally means those who don’t have a predisposing condition such as family history, diagnosed genetic predisposition or an underlying medical condition such as ulcerative colitis—has recently been lowered to 45 years old from 50, that still won’t catch a lot of folks who may have advanced polyps or early-stage disease and are younger than 45.
For those people, awareness of symptoms remains key: changes in bowel habits, blood in the stool, a change in the appearance/size of the stool may be the only indication that a potentially fatal cancer is responsible. And I write “potentially fatal” because CRC can still be cured when caught early before it spreads elsewhere into the body. But you can’t catch something if you don’t pay attention to it. Waiting months or even years can make a huge difference on whether a colorectal cancer in a young person can be cured or not. Embarrassment to talk about it is not an effective strategy for success.
However, it is not just up to young people to seek medical help if they notice such a change. It is also the responsibility of the clinician who sees that young person to take their complaints seriously and either order necessary tests or follow up closely depending on the situation.
Sadly, too often one hears the refrain that “I had a problem and no one listened.” That is always difficult for anyone to deal with. On the other hand, we do have to recognize that some symptoms and signs such as blood in the stool are common, and not everyone who has that problem has a cancer. That’s why it requires the skilled clinician to make a judgment and share a plan with their patients to determine what the appropriate next steps are in the evaluation. Outright dismissal of such signs and symptoms, however, should not be one of those options.
There are other interesting changes in our early detection of CRC on the horizon.
For decades we have known that checking for blood in the stool with various tests has been an effective way to catch CRC early and reduce deaths. Those tests have advanced over the years, but still require someone to fish out a sample of stool from the toilet, smear it on a card and send it to a lab for analysis. And that should be done every year. Lots of steps, lots of places where the process can be interrupted (such as a patient not getting a test every year), so lots of opportunities for an effective test not to be so effective.
Then there is the stool DNA test, which is well-known to many from the ever-present television advertisements. That requires collection of an entire stool sample, mailing it to a lab and getting the report—although for the typical person that doesn’t have to be done every year.
And for both of those tests there is another critical step: if they are positive, that means a cancer may be present, so a follow-up colonoscopy must be done to check things out. Ignoring a positive stool` test is–once again–not an effective strategy to improve outcomes for CRC.
Many folks default to a colonoscopy as their screening “test of choice”, which is done every 10 years for those at average risk. However, colonoscopy requires an uncomfortable prep, time off from work not only for the patient but also for their caregiver since most places (appropriately) don’t want the patient alone or driving afterwards. And, as many of us know, non-cancerous polyps are frequently found which means that the colonoscopy must be repeated more often than every ten years depending on the size and number of those polyps.
One significant advantage of colonoscopy is that it can detect those polyps so they don’t progress to cancer in the first place—which means the test can prevent a colon cancer and not just detect it.
On the horizon are blood tests which will detect circulating fragments of genetic material (DNA) which come from colon cancers. These tests have been used in the treatment of folks with advanced cancers and have become more sensitive because of advancing science. Now, because of that progress, they are moving into early detection of CRC and other cancers.
There is still a lot to learn about how these tests are going to impact the early detection of CRC but suffice to say there is considerable hope they will make a genuine difference for more people—who may find them more acceptable than the current traditional methods of screening noted above. Time will tell whether they can help expand access to early detection and make the process of early detection more palatable for more consumers. The reality is that they may advance the cause of continued reduction in the burden of CRC if more people can be effectively screened with these new approaches. *
As I find myself saying frequently: imagine what we could accomplish if we did what we already know works. That sentiment clearly applies to CRC: reducing the burden of CRC for many folks is within reach today. We must figure out how to make that happen. Easy to write; hard to do.
*Personal disclosure: I am an advisor for Guardant Health, Inc., a company that is engaged in early detection of CRC using blood-based technologies.