How to Help Prevent Colon Cancer – Dr. Trible of Spotsylvania Regional Medical Center


(light music) – If I could just entitle
this prevent colon cancer, I mean, that’s just what we
need to get down to brass tacks, I’ve done this for 20 years,
forget all the trying to, or strategies to, we’re just
gonna prevent colon cancer, so that’s the goal. The reason that this is
such an important topic, is if we look at what cancers kill Americans, in men, the number one cause
of cancer death is lung cancer, in women, the number one
cause of cancer death is breast cancer. But in both men and women, it’s the second leading cause of cancer death. I have always tried to impart the wisdom that, yeah, it’s the
third most common cause of cancer death, but you’re
either a man or a woman, it’s for most of us, recognized, you either have lung as the
top and colon as the second, or breast as the top
and colon as the second, so it’s the second leading
cause of cancer death in men and women. It might be the third
overall, but it’s the second, because you’re one gender or the other. And there are a tremendous
number of new cases per year. Depending on how many
procedures I’m doing per week, almost every week, I see a
new case of colon cancer. One a week, it makes me
want to take vacation, it makes me want to leave and not, because it’s, it’s just
devastating when we find these. The vast majority are sixty-five to eighty, seventy-five, and there are folks who
have avoided skillfully through the years, having a colonoscopy. They’ve made excuses, they
have different reasons for not doing it, and they’re anemic, they’re losing weight,
their bowels have changed, they’re bleeding, and unfortunately, we can see ’em from
across the examining room, oops, when was the last time
you had your colonoscopy? Well, Dr. Trible, I never had one. Those are the ones that
really, they just get us. But, we do see folks
that we find it early, and we more importantly
than anything else, we prevent colon cancer, I mean, this is gonna sound immodest, but in a busy practice, I probably prevent 30-40 patients a week, from
ending up with colon cancer. And people are living with
the diagnosis of colon cancer, that it might have already spread, but it’s becoming more
of a chronic disease, and there’s wonderful hope that we can, we can keep this in remission, and keep people from dying of it. If you look at the mortality, about the last 15-20 years,
is when we start seeing a drop in African Americans, and
not as much as in the rest of the population, or Caucasian, but we are seeing a drop
overall in this country. And it’s because, mainly, of a test that we’re gonna
talk about, called colonoscopy, and some of the affiliated,
or associated tests. And it’s mainly from taking out these precancerous growths called polyps, which is what we do 30-40 patients a week. We’re gonna start talking,
we’re gonna talk a lot about, about different strategies
to prevent colon cancer, the heck with finding it
early and treating it, we want to prevent it. And there are treatment advances that are extending peoples’ lives. Who’s at risk? It’s 50 and older, that we
worry about for the most part. It’s an equal gender cancer, it’s essentially, you
might read one study saying it’s a little more in
men, one study saying it’s a little more in
women, it’s the same. It’s an equal opportunity cancer, from a gender standpoint, 50/50. But men and women have the same risk. And there are some differences
among certain groups, sometimes associated with economics, sometimes depending on
whether people get screened, or don’t get screened,
with increased risks in African Americans, and Alaskan natives, astronauts and Jews, and American Indians. But that’s, that’s not germane too much to our practice here in Fredericksburg. Basically, we see a lot of colon cancer, as we all do, in gastroenterology. There are some patients with a condition called ulcerative colitis,
and ulcerative colitis is a chronic inflammatory condition. One of the theories, and one
of the realities of cancer, is if you have something
that’s upsetting something, if you have the sun upsetting the skin, you’ll get skin cancer. If you have the gut upset
by ulcerative colitis, you’ll can get colon cancer
from different things. But that’s certainly a risk factor, it’s not a uncommon illness,
but it’s not something that we see all the time, either. There are some very rare syndromes, and in my 21 years in
practice in Fredericksburg, we have just a few patients,
familial adenomatous polyposis. I have six families after 21 years, that I
keep a very close eye on, with this thing called FAP, or Gardner’s, that’s out of 60,000 others. It’s not a terribly common illness. There’s a condition called
lynch family syndrome, a heredity, non-polyposis
colorectal cancer and neoplasia. We’ll test you on that afterwards, how to say that real quickly. But there are some folks with that. There are some people that can say Mom had colon cancer at age 50. Or, my brother, it showed up at age 45, that have early family histories, and prominent family histories. But the vast majority of folks that we have to wake ’em up after
the procedure and tell ’em, I’m sorry, we’ve just found something that we need to treat called colon cancer, will say, well, nobody in my
family ever had this before. Now, could it be that
there was a family link that they didn’t know about? Could it be that Dad died
in a car wreck at age 35, and passed that genetic on,
and never had a colonoscopy, and that sort of thing, sure,
that definitely happens. There are some risks for colon cancer, but
the vast majority of folks are walking around the
street and have no clue at age 50 and beyond, that they have a significant risk for colon cancer. What we’re looking for,
I’m gonna talk a lot more about colonoscopy in a
bit, what we’re looking for when we look with a lighted tube, are these little growths called polyps, and there are two types. Hyperplastic means, essentially, nothing. We can manufacture a
hyperplastic polyp just by doing little biopsies, and sending it off to the pathology lab with almost anyone. And we gastroenterologists
almost always know when it’s hyperplastic, and
when it’s the other type. The other type, adenomas polyps, are what causes 90% of colon cancer. Really, the only exceptions being things like ulcerative colitis, Crohn’s, and some of these other family issues. I’m always intrigued by,
by patients and doctors wanting to really cast
it in the best light, and I don’t blame them at all. There was a patient today, I said, “Well, you’ve got a bunch
of these adenomas polyps, “just like you had three years ago, “and the next time we’re
gonna do it is five years.” He said, “They’re benign, aren’t they?” I said, “Oh, yeah, they’re benign, “but they’re precancerous.” Meaning, if we leave
them in 10, 15, 20 years, almost everyone of them
would turn into cancer. But we never leave them in,
we always take them out. So they are benign, but if
we leave ’em in too long, that’s what’s gonna
grow into colon cancer. So if you will, normal tissue,
whether we know it or not, has obviously per square
centimeter, has millions of cells. And if there’s some cells in here that are not normal, that are predisposed towards trying to genetically
grow out of proportion and go haywire, they
can eventually stack up and form this growth called a polyp. And this is what we want to find. When they’re on a stump like
this, it’s nice to find them. It’s like chopping down a tree, you can just chop it down, and it’s gone. We want to just plain take
out these precancerous polyps, and if by misfortune, we find someone who has already developed cancer, we’d much rather find it early, than late. If we find it early, then 90% of time, people are fine. There are different stages,
but just say a low-grade stage, found it early, this has not spread, and 90% of the time,
surgery will be curative, or even endoscopy in
taking it out that way. And that’s, if we have to find a cancer, that’s the one we want to find. Unfortunately, when people have symptoms, 90% of the time it’s already spread. When people come in with
symptoms, it’s often spread, and they have lymph nodes, they have tumor in the liver, they have tumor elsewhere. And we’d much rather find
early cancer, than late cancer. How often in a 50, 51, 54-year-old
do we find colon cancers when we’re just doing routine
colonoscopy for screening? Not too often. Sometimes, maybe once a month, I might do 150, a couple hundred
colonoscopies a month, I might find one that’s a
50-year-old gentleman or lady who just came in for screening. Unfortunately, most of
the people that are, that we find with colon
cancers are 65, 75, 85, and they’ve put it off,
and never had this test. So that’s why we try
to get people screened. Unfortunately, at this point, maybe 55, maybe 60% of Americans over the age of 50 who need this, have had it done. Now, when I gave this
lecture, this is great hope, when I gave this lecture 15 years ago, I could quite honestly say
to the folks in the audience, only 15% or 20% of you have had the right, have had the test done. It’s actually going up, and as you saw in the previous graph, the
death rate from colon cancer is gradually going down,
they’re directly proportionate. The more people we can see, and
screen, and take out polyps, the more people will prevent colon cancer. So there’s slow, but steady, improvement. Does it take time, does it cost? Yes, I mean, it takes
a day out of your life to get this done. It does cost, you do have to have family or friends drive you, so
it’s a day out of their life, and they’re work situation. What are some screening guidelines? This is evolving, it’s
actually evolved recently. This slide set was from 2011, from the American Cancer
Society, and it’s even just taken another twist
in the last week, or two. The GI societies, the radiology societies, the cancer society all have parts and words to say about the screening. But what we know is, if we can detect and
remove precancerous polyps, and somehow take these out, then that’s going to affect the rate of
death from colon cancer, more than anything else. Other ways that hit at it,
to try to find these things, to try to find some blood,
there are indirect tests that do something, much
better than nothing. The freelance story years ago quoted the, gosh, it must have been,
again, I’m dating myself, it must have been 10 or 15 years ago, when we were first starting to do something called virtual colonoscopy, and we’re gonna talk
about that a bit more, which is an x-ray exam of the colon, done with a CAT scan. It’s not as good as colonoscopy, but, if you’ll do nothing
else, please do something, rather than nothing. And we have to, have to
keep our eye on the ball, and try to do that. Computed telegraphic colonoscopy,
or virtual colonoscopy, is something that is out there. I order about six a year. And there’s a unique stool
test that sounds great, to find who’s shedding the
genetically abnormal DNA from colon cancer. It sounds great. I’m amused at some of my charts from 1992, when I put in bold handwriting,
I’ve told this patient that within a few years, we
should have a genetic test, and she won’t need a
colonoscopy next time. But here we are 20 years
later, and we still don’t have a great genetic test. This genetic test is 60% accurate. It’s getting better, as we identify more of the abnormal genes, but it’s still 60%. 60% is not quite good
enough for human medicine, it’s just not something you believe in. And so, these guidelines, we have all kinds of things
that we can recommend. The flexitive, which is a
short lighted tube test, it looks at, essentially, a
third or a half of the colon. And again, it may be somewhat
sacrilegious or irreverent, I tell people, that that’s
the same as telling ladies to prevent breast cancer
by having a mammogram of the left breast. I mean, it’s a halfway test. Nobody wants to do a halfway test, we hardly every do this anymore. Colonoscopy every 10 years
for the general public is absolutely a standard
of care in our opinion. An x-ray has to, if we’re
gonna recommend barium enema or a virtual colonoscopy, we have to have a pretty good reason to
tell the insurance company to do this, because the
insurance companies wisely know that you pay now, or you pay later. They are much more eager to
have colonoscopy performed, because it prevents a $250,000 surgery, chemo, radiation
treatment of colon cancer, which sometimes doesn’t work. So it is absolutely something
that we can recommend, these x-rays, but we do it for reasons of patients being afraid of a colonoscopy, or something else. And then, these other tests,
like stool tests for blood, and a specialized stool test
for blood are out there, this one just has gotten
a little better rating, and it’s starting to become on the radar, that it might be pretty good
at screening large populations that maybe don’t have
access to gastroenterology. There are things out there that are looking, we’re looking at all of this. Why don’t we recommend
colonoscopy for everybody? We know that we can cause
a hole in the colon. The textbook, again, says one
out of a thousand patients, and again, those data are
always from university centers, because they have enough people, and enough doctors doing procedures, they can get the numbers up. And they’re mostly junior
gastroenterologists, that don’t do this very often. The real world is more like one out of 2,000, one out of 5,000, one out of 10,000. And I would encourage anyone to ask their gastroenterologist, how
many of these have you done, and how many perforations have you had? 60,000 and six, I don’t have any, any hesitancy telling
people that, it’s true. And we perforate people when we take out large polyps or small cancers. And I do that 10 times a week. Why does that out of 10,000
patients get perforated, but not the other 9,990? I don’t have a clue. So I don’t blame anybody
for being anxious about it, and want to talk about it. And then, a lot of patients
want to have something else done that’s not as obnoxious
as what we do. (chuckles) As my mother said years ago, and she was up in her 80s, and she said, “Son,” she
was in a nursing home, “my friends and I aren’t real
keen on you’re type of doctor, “we kind of, we’re not real, “they’re not our favorite doctors.” I said, “I know mother,
but we do a good job.” It’s not something that
people maybe want to kind of come flooding to see
us, and I don’t blame ’em. But it’s something we really can confess. What colonoscopy is, is a
long, flexible, lighted tube, and it’s, the technology, and again, in 20 some years has advanced,
almost every few years we get new equipment, better technology. We do use a camera, and it
has high-definition now. We can see incredible things, that we couldn’t see 20 years ago. There’s a, a little flushing,
or irrigation channel we can put water through. We have great light source,
that we can see things, otherwise, it’s pretty dark in there. And the instrument channel allows us to put in little instruments
to remove polyps, or burn lesions, or fix, or put injections and
medicines in different spots. So a colonoscopy, in my definition, what we are trying to do, is look at every square inch of the colon, look 100% from the where the appendix is, and where it joins the small
bowel, inch by inch, by inch. What I tell patients, again, a couple thousand times a day is, this is a lighted tube test. We are gonna get you very
sleepy, so you don’t have pains, or discomfort, or remember this even, because we don’t want to make
it difficult for anybody. And what I often tell
people in a joking fashion, and it’s true, we want you to come back. If you have something
bad, we don’t you to have some anxiety about
having it a second time, we don’t want you to be fearful of it. And that’s very important, so we all encourage and use sedation. And then we use that
light to get to the cecum, the end of the colon, it
takes about five minutes. But, we take 10, or 15, or
20 minutes to methodically, inch by inch, by inch,
march ourselves backwards through the lining of the colon. We actually turn the
scope backwards on itself, to look behind these
folds, around corners, suctioning abnormal debris and
particles that are in there, flushing some of the, some of the mucus and debris
that’s inside the colon. And then, that means
we can get a great look at every square inch of the colon. We probably miss one or two percent of small little growths that are on the other side of folds. But if it’s a big growth,
we’re gonna see it, and we’re gonna remove it. So colonoscopy is both a diagnostic test, we find polyps and cancer, and it’s a therapeutic test, it fixes the colon, if you will. It restores it back to
it’s pristine health, we get rid of all those little growths, and that way, we reset the clock, and we know that we’ve
bought ourself three years, five years, ten years,
before we need to look again. (light music)

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