Some of my fondest memories in my previous cancer research career was spending a week each July on a small liberal arts college campus in New Hampshire. Unlike large research and medical society meetings in metropolitan hotels and conference centers, The Gordon Research Conference on Cancer Chemotherapy was an annual retreat where students could get one-on-one time with major researchers in academia and the pharmaceutical industry, including many drug discovery scientists from the United Kingdom, Italy, and Japan.
Only one session was going at a time – a few hours each morning and again in the evening – attended by the 150 or 200 folks sharing dorms and the college cafeteria. The afternoons were left open for sports, hikes, and informal interactions that proved more valuable in my career than a decade of mentoring sessions at major medical centers where I trained.
It was there that I met a superb medicinal chemist and kind human being, Dr. Tom Burke. A Connecticut native then at the University of Kentucky School of Pharmacy, Tom patiently talked with me at length about his work on a class of chemotherapy drugs originally derived from a Chinese ornamental tree that was imported into the U.S. in the 1930s. He was only ten years older than I, but was in the most productive years of his career trying to make less toxic, more effective chemotherapy drugs.
I couldn’t make the conference in 2002, but neither could Tom. I learned that the 46-year-old chemist and teacher had been diagnosed with Stage IV colon cancer, metastatic by definition. He was dead a month later. Part of Tom’s failed treatment was the drug he was trying to improve upon.
A microscopic image of medullary carcinoma of the colon. Note that the cancer (left) meets the highly-organized normal mucosa (right) abruptly.
Credit: Ed Uthman, under a CC-BY 2.0 license.
I remember Tom every summer, and was reminded of him again earlier this year when I turned 50. Together with invitations to join AARP and solicitations to buy a burial plot and pre-pay for funeral services came my wife’s reminder to get my annual physical and referral for a screening colonoscopy. Her admonition was really driven home by the experience of my journalist friend who had her first colonoscopy and was found to have cancer. Although she needed surgery, radiation, and chemotherapy, she’ll very likely be fine in the long run.
A day-and-a-half every 10 years could save your life
I have no family history of colon cancer, but I’ve learned that neither does 85% of the 137,000 Americans who are diagnosed with colon and rectal cancer this year, 50,000 of whom will die of the disease. Good health habits certainly minimize your risk, but not to zero: my journalist friend spent most of her life as a vegetarian and riding her bike everywhere, but still developed colorectal cancer.
My colleague Tom wouldn’t have benefited from today’s screening guidelines, but if every U.S. adult 50 or older submitted to colon cancer screening, we could save 25,000 lives each year.
That’s right. If we all followed the guidelines, one of every two people who will die from colorectal cancer this year would be saved.
The screening colonoscopy procedure was introduced in 1989 and consists of a 45-minute examination of the final six feet of your digestive tract using a long, thin tube equipped with a camera and light source that is inserted through the rectum while you’re under anesthesia. If any abnormal growths are observed, they can often be removed during the process and tested for whether they are cancerous, or would’ve had the potential to become cancer. These growths are called polyps.
Why do people forgo the chance to save their lives, especially since screening colonoscopies are covered by most insurance plans? Medicaid even covers the cost of age-appropriate colonoscopies, yet a study this year of 2007 data from 46 states and the District of Columbia showed that only 6% of Medicaid recipients take advantage of this life-saving screening. In general, cancer screening rates for Medicare recipients are lower than that of those with other insurance. Moreover, those who develop cancer usually present with more advanced disease at diagnosis than the general population.
(By the way, even if colonoscopies aren’t covered, you should at least be getting a routine test for the presence of blood in the stool. It’s not 100% accurate in detecting colon cancer, but it’s better than no screening at all.)
Part of the reason might be lack of awareness, embarrassment about discussing bowel habits, or old stories about perceived unpleasantries in the preparation for the procedure. In a positive example of medical celebrity, Katie Couric, then host of The Today Show, raised awareness of colorectal cancer screening after her 42-year-old husband died of the disease. During a week-long campaign for colon cancer education, Courice had her own colonoscopy televised. National colonoscopy rates increased as a result, but were sustained for only nine months.
Are you 50 or older? Schedule your colonoscopy!
I live down in the Research Triangle Park area of North Carolina and get my medical care in the health system run by Duke University Medical Center (I also have an unpaid, adjunct faculty appointment in Duke’s Division of General Internal Medicine). To schedule my screening, I first had to visit my primary care doc for my annual physical, something I needed to do anyway.
Even though I did that a few months ago, the entire Duke system was booked solid for colonoscopies at every site in our metropolitan area through the beginning of 2015. That bodes well for decreasing colon cancer deaths, but not my own. Fortunately, I was able to get a referral to a gastroenterology private practice with some top-notch docs.
The preparation for the colonoscopy is what most people find unpleasant. In order to examine every square millimeter of your colon and rectum, the procedure requires that your digestive tract be completely devoid of any fecal matter. To do this, you drink a liquid that encourages your digestive tract to clear itself. Many types of “bowel preps” are available and some used to taste rather unpleasant. Those liquids have improved considerably and mine was surprisingly low-tech.
I only had to take a couple of tablets of a laxative called bisacodyl (generic or sold as Dulcolax; Boehringer-Ingleheim) once, and drink a liter of Gatorade twice to which Miralax or a generic powder had been added. The powder is simply a type of pharmaceutical-grade polyethylene glycol (PEG) called PEG 3350. It’s often used in small quantities as an inert carrier for drugs in liquid or tablet form. When taken in the larger dose for bowel prep, it uses the process of osmosis to pull liquid from the intestinal tract to eliminate its contents.
In a couple of visits to the bathroom over the next 12 or 18 hours, you simply let nature take its course until clear liquid comes out the other end. For me, it was no worse than having diarrhea without all of the distress that comes along with, say, having eaten improperly prepared foods. You keep a liquid diet during this time and then have no liquids for two hours prior to the procedure.
The worst part of the procedure itself was actually for my wife. Because you’re still groggy from the anesthesia after the procedure, you’re required to have someone with you for the duration of the procedure to get the post-procedural instructions then take you home afterward, about three hours from check-in to discharge. The procedure itself is about 45 minutes of that time.
For me, the procedure was pleasant. You disrobe and put on an examination gown and crawl under some blankets. The nurse starts an IV with Phenergan (promethazine), a drug with a combination of activities that produces a pleasant sedation, dampening of anxiety, and calms the gastrointestinal tract. Promethazine was originally developed as an antihistamine and was an early drug to treat psychosis and, in lower doses, motion sickness.
After being wheeled into the procedure room, you get a combination of fentanyl, a potent opioid used to treat pain, and midazolam (Versed), an antianxiety drug, to produce an anesthesia and short-term amnesia that causes one not to remember any discomfort. (For those of you who want dosing details, the totals were 25 mg promethazine/Phenergan, 150 micrograms of fentanyl, and 7 mg midazolam/Versed, and I weigh 96 kilograms.)
I learned after the procedure that the doctor found an adenomatous polyp in my rectum, one centimeter across – about the size of a marble. Polyps can be pedunculated, looking like a mushroom on a stalk, or sessile, which lie on the inner surface of the large intestine. Mine was semi-sessile. It had two parts but what would be a stalk was almost the size of the main polyp. My doctor was able to remove it and told my wife that it was likely a benign growth, meaning that it wasn’t cancerous and hadn’t grown deeply into the lining of the tissue or into the underlying muscle. However, the final determination would be performed microscopically with the report available in a day or two.
I read later that polyps are found in about half of people over 60 – less so at my age – with 6% of these going on to developing colon cancer. The problem is that you can’t tell which of this six percent will be cancerous. So, they’re removed and you’re then screened more often than every ten years.
My polyp came back as noncancerous growth called a tubular adenoma. Microscopically, the cells still looked like normal colon or rectal epithelial cells, organized into tightly-packed columns whose normal role is to protect the underlying tissue and secrete mucus to aid in elimination.
In simple language, the letter from my doctor read,
The polyp was not malignant but was that type that might have progressed to cancer if left in place. Fortunately, we removed it at an early stage before it progressed to cancer. In view of your tendency to form this type of polyp, I recommend you have another colonoscopy in three years.
Next steps for yours truly
Okay. So is there anything I can do over the next three years that would minimize my chance of having cancerous growths?
Again, my doctor:
“In addition to undergoing a repeat colonoscopy, please consider changing any health habits that might increase your risk of forming more polyps and thus, colon cancer. You may lower your risk of future polyps and colon cancer by adopting health habits such as not smoking, being physically active, and eating a diet which includes fruits and vegetables and limits red meat.”
Well, I don’t smoke. But I have suffered some exercise setbacks, with some Achilles tendon problems that have kept me away from running for long stretches this year. Perhaps some indoor bicycle machines and swimming when the weather gets nice again.
My diet, however, is in need of big changes. I’m a carnivore who loves red meat the most, eats little fruit outside of bananas and drinking the blue smoothies you see in the produce section. And – sorry, Mom – I’m still not a huge vegetable fan. So, I’ll need to work at this.
But the bottom line, as it were, is that my colonoscopy results are the best of both worlds: Yes, an abnormal growth was found. No, it wasn’t cancer. But I’m at a somewhat increased risk of more polyps and, potentially, colon cancer. But I now know that. And to prevent that, I’ll have another colonoscopy in three years instead of the normal recommendation of ten years for those without such growths.
Absolutely and completely worth it. And, overall, not a terrible burden to my insurance company.
The total charges for the procedure and polyp removal were $2,877 and my health plan paid the negotiated rate of $1,637.60. I don’t find that terribly expensive for three hours of medical care and the information I can now act upon, not to mention catching something that could become cancer and cost hundreds of thousands of dollars in medical care.
I was fortunate (?) to have met all of my deductibles earlier in the year for other surgery (to fix an underlying nose and sinus issue from running into a softball field fence at full speed 20 years ago), so I had no out-of-pocket costs except for the $23 for Dulcolax, PEG 3350, and Gatorade.
Oh, and toilet paper.