A Preventable Disease

The most important step in beating colorectal cancer is early screening.

By many measures, the story of colorectal cancer is one of success and hope. The number of cases in the United States has been steadily decreasing since the mid-1980s. In 2019, the death rate from colon and rectal cancer was less than half what it was in 1970, due in large part to screening methods that allow doctors to detect precancerous lesions and diagnose cancer at its earliest, most treatable stages.

For those diagnosed with colorectal cancer, advances in treatment are improving survival. Experimental drugs, new drug delivery methods and cutting-edge technology that helps doctors find more suspicious lesions in the colon promise to further boost survival rates and prevent more cases of the cancer altogether.

But along with the good news comes the stark reminder from the doctors who treat the disease: Colorectal cancer still kills. It’s one of the most commonly diagnosed cancers. Each year 5,000 Georgians – an average of 13 to 14 each day – are diagnosed with colorectal cancer and four to five die from it each day. And increasingly the disease is affecting younger Georgians, who are less likely to undergo screenings due to their age and may eventually be diagnosed with more advanced disease.

“We need to educate the community that being young does not prevent or stop [someone from] having colon cancer,” says Dr. Asha Nayak-Kapoor, associate professor of medicine in the Division of Hematology/Oncology at Augusta University. Why rates are rising in younger people is an interesting topic of discussion, she says. “We believe that it has a lot to do with our food. Obesity may have some role to play in it and maybe some new environmental factors. We do not know. It is a trend that we do see more cases of young-adult onset.”

The number of cancer diagnoses should be and could be much smaller if people underwent recommended screenings, says Dr. Kenneth Vega, professor and chief of the Division of Gastroenterology and Hepatology and co-director of the Digestive Health Center at the Medical College of Georgia at Augusta University.

The earlier colorectal cancer is diagnosed, the better the prognosis. “Early- stage colon cancer has a five-year survival rate of 90% versus late-stage colon cancer, [which] has a five-year survival rate of 14%,” says Dr. Arif Aziz, a gastroenterologist with the Wellstar Health System. “It’s so important to screen. Screening saves lives.”

Types of Tests and Recommendations

In addition to a colonoscopy, there are several noninvasive tests for colorectal cancer. Fecal occult blood tests and stool DNA tests look for indicators of polyps or cancerous lesions in stool samples. Although some people prefer these noninvasive tests, most doctors, including Dr. Fernando Aycinena, a colorectal surgeon with Longstreet Cancer Clinic in Gainesville, recommend having a colonoscopy – at least for people at average or higher risk of colon cancer. “A limitation of other screening tests is if they turn out to be positive, you need still need to follow up with a colonoscopy, which becomes a diagnostic rather than screening procedure,” he says. That said, the most important thing is to get screened, so a stool-sample test is better than none.

The American Cancer Society (ACS) recommends that people of average risk should have screening colonoscopies beginning at age 45, which is younger than ACS recommendations in the past. Those with risk factors for colorectal cancer – including a family history of colorectal cancer or polyps, a personal history of inflammatory bowel disease or a history of radiation to the abdomen or pelvis to treat a prior cancer – should talk with their doctors about starting earlier.

“We tell patients if you have a first-generation relative [a parent or sibling] who had colon cancer, you should either come in 10 years before the age they were diagnosed or at age 40 – whichever comes first,” says Dr. Devi Sampat, a medical oncologist and hematologist with Longstreet Cancer Clinic in Gainesville.

A colonoscopy allows doctors to accurately detect cancer and large polyps approximately 95% of the time. New artificial intelligence technology available at the Medical College of Georgia cancer center is designed to improve the accuracy even further.

“If I am looking at a screen in the procedure, now we have artificial intelligence that can look at lesions as I am looking at them in real time and tell me to investigate an area further,” says Vega. The program runs while the doctor is doing the colonoscopy and highlights areas for further investigation to make sure there is not an abnormality, says Vega.

This technology was approved recently in the U.S. and is available in the state only at the Medical College of Georgia now but will likely be available at other institutions in the near future. “It is clearly one that benefits patients by missing as few lesions as possible,” says Vega. “For example, if you did a procedure and you didn’t think you found anything, that person would come back in 10 years for screening. However, if you found something, that person would come in again sooner. By categorizing them correctly with this tool, it will help us maximize the benefits of colonoscopy.”

Why People Pass on Procedures

For screenings to be effective at combatting cancer, people have to get them. And statistics show that among Georgians with Affordable Care Act-compliant plans – which cover the cost of routine colonoscopy screenings without a copay or deductible – three-quarters get recommended colonoscopies. Among the uninsured and underinsured, only about one-third do. In 2020, about 15% of Georgians lacked health insurance, according to the Kaiser Family Foundation.

There are other reasons, too. For many, colonoscopy makes them anxious, from the preparation stage – taking strong laxatives to clean out the colon – to the sedation required for the procedure and the eventual findings. Embarrassment and fear over a highly personal and invasive procedure is understandable, says Vega, who tries to allay his patients’ anxieties with humor.

COVID-19 affected screening rates, too. Some people skipped appointments out of fear of catching the virus, and then hospitals, overwhelmed with COVID cases, postponed elective screening procedures. Those delays could have dire consequences, Aziz says. “A study out of Italy shows that delays in screening during the pandemic could lead to a 12% increase in colon cancer death over the next five years. That’s why it’s important for people who delayed it for whatever reason to come in and get their screening colonoscopies done.”

Even for those whose insurance covers colonoscopy the procedure is not without costs, notably lost work time, says Vega. Both the patient and a driver or caregiver must take the day off for the procedure, and the patient may have to take a day off for the prep, too.

Many people don’t seek screening simply because they are not aware of its importance. They may not have screenings because they aren’t having symptoms, when in fact any symptoms – blood in the stool, bloating, abdominal pain – often don’t appear until the cancer is advanced.

Issues of access and awareness can be even more acute in underserved communities, including among Black, Hispanic and rural populations, which historically have had lower screening rates than White populations. For example, people who don’t have a primary care provider they see regularly may miss an important method of communicating why and when to get screened. Lack of Spanish-language messages – ads, brochures or even bilingual healthcare providers – can be a barrier, too. And people in these groups may be more likely to be uninsured, which presents another barrier to getting screened.

“I think we need to do more, bring more awareness in the community that this is a disease that can strike anyone. It can affect anyone at any time,” says Nayak-Kapoor.

Offering Support

Indeed, several programs seek to increase the numbers of people who receive recommended screenings. At Wellstar, colon cancer navigators, who are members of Wellstar’s nursing staff, contact people to help them through the process, says Aziz. “So if the patient is having questions about colonoscopy, they will answer them, they will try to allay anxiety, they will help them with understanding the prep and they will even help them get the appointment or the colonoscopy,” he says. Since its inception in April 2019 the Navigator Program at Wellstar has helped increase colon cancer screening by 23%, a significant improvement, says Aziz.

At the Albany-based Phoebe Putney Health System, a program in partnership with the Cancer Coalition of South Georgia, a division of Horizons Community Solutions, helps uninsured and underinsured patients access screenings for colorectal and other cancers.

For patients who are 45 and older and have insurance that covers colonoscopy, Phoebe Putney typically offers a colonoscopy up front, says Dr. Franklin Goldwire, a gastroenterologist with Phoebe Putney. But for those without insurance that covers colonoscopy, the program identifies people at highest risk and offers them a fecal test. If the test comes back positive, the program schedules a colonoscopy at no cost to the patient. Typically, the program identifies high-risk patients through their primary care manager, he says.

A number of health systems throughout the state offer open-access colonoscopies, which means patients can schedule a colonoscopy directly, without the time and cost of getting a referral from a primary care physician.

Yet experts say more is needed, not the least of which is the willingness of people to have their recommended screenings and follow through – particularly as colo- rectal cancer is one of only a few types of cancer that are actually preventable, says Goldwire. “I just want to encourage people to be aggressive and involved in their healthcare and get all of the screenings they need.”

Advances in Colon Cancer Care

Treatment for colorectal cancer has traditionally consisted of surgery, radiation and chemotherapy. Although the fundamentals have not changed, advances in these treatments have increased precision to save more lives with less pain, shorter recovery and fewer side effects.

Surgery

Removing the malignant lesions or affected portion of the colon may be the only treatment needed for early-stage colon cancer. “The principles of surgery haven’t changed a whole lot over the years. What has changed is the technology to achieve the goal,” says Dr. Fernando Aycinena, a colorectal surgeon with The Longstreet Cancer Clinic in Gainesville. Many surgeons, including Aycinena, perform bowel surgery through small incisions with the robotic da Vinci Surgical System.

“Whereas patients once spent five to seven days [in the hospital] after surgery, most now go home the following day,” says Aycinena. Improvements in anesthesia and post-surgery exercise and nutrition also minimize the impact and speed healing.

Radiation

Although it’s not generally used to treat most colon cancers, radiation often precedes surgery for cancers of the rectum, and may be given alone or with chemotherapy, says Dr. Geoffrey Weidner, a radiation oncologist with Northeast Georgia Health System.

Advances in radiation that have increased its precision and lowered the risks include intensity-modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT), says Weidner. IMRT delivers precise radiation doses to the tumor. IGRT uses imaging during the treatment to improve precision and accuracy. The physician does a low-dose CAT scan before each treatment that helps focus the radiation and determine dosage amount.

Targeted Therapy

While chemotherapy drugs are still an important part of colorectal cancer treatment, more targeted options are available to some patients, depending on their tumors. “We send every cancer tissue to what is called next-generation sequencing, which is RNA or DNA testing of the tumor tissue that helps us know what genomic changes are happening in the tumor that can help us treat the patient with certain targeted treatment or even immunotherapy,” says Dr. Asha Nayak-Kapoor, associate professor of medicine in the Division of Hematology/Oncology at Augusta University. These treatments do less damage than chemotherapy does to the body’s healthy cells. Immunotherapy treatments use the body’s own immune system to fight cancer.

The Future

New drugs in development now will likely improve treatment of colorectal cancer. New ways to deliver drugs could minimize doses needed and therefore the risk of side effects.

At Georgia State University, for example, researchers are working on a more effective way to treat ulcerative colitis (UC) – a form of inflammatory bowel disease that has been shown to increase the risk of colorectal cancer six-fold – with the goal of both treating bowel inflammation and preventing cancer’s development. Right now, the drugs that treat UC suppress the immune system and carry a risk of side effects, including serious infection.

A new technology called nanotechnology uses incredibly tiny particles (equivalent to about 1/100,000 the thickness of a sheet of paper) to deliver microdoses of medication directly to the site of inflammation without damaging cells in the rest of the body.

Georgia State researchers, led by Didier Merlin, a Distinguished University Professor in the university’s Institute for Biomedical Sciences, have done experiments that show this delivery approach worked in mice, but Merlin estimates human studies of such drugs are about five years away.