When it comes to discussing our intestines, renowned author John Updike summed up our sentiments perfectly: "Talk about intimacy! I'd almost rather not." But with almost 150,000 new cases of colorectal cancer last year alone, we can no longer afford to avoid the conversation.
In honor of Colon Cancer Awareness Month, the News-Letter spoke to Hopkins surgeons, oncologists and pathologists about the current state of colon cancer care, cutting-edge research in the field and what the public - not just the over-50 crowd - needs to know about prevention and treatment.
First, the basics: Colon cancer can occur anywhere in the colon (large intestine), while rectal cancer is found in the last several inches of the large intestine. Referred to collectively as colorectal cancer, the disease is diagnosed via a lower gastrointestinal series (an x-ray used in combination with an enema containing contrast material) or, more commonly, a colonoscopy.
Colonoscopies are useful after patients present symptoms (??diarrhea, blood in stool, anemia, weight loss, etc.), but doctors also recommend that patients over the age of 50 undergo a preventative colonoscopy every 10 years.
The difficult part of colonoscopies is not the procedure itself, which is done under anesthesia and usually lasts less than an hour, but the preparation. Depending on the doctor, patients are required to follow a liquid diet (broth, juice, tea) for one to three days before the procedure. Patients must also take a number of laxatives to clear the colon of any material.
In short: A colonoscopy is no one's idea of a good time. Many patients miss opportunities to find colon cancer early because they opt out of preventative tests. Patients also lose the chance to stop cancer in its tracks - during colonoscopies, doctors remove benign and precancerous polyps that can develop into cancer if left in the colon.
One of the biggest frustrations for doctors like Nita Ahuja, a surgical oncologist at Hopkins, is this lack of screening. "Most people still don't undergo screening for colorectal cancers," Ahuja said. "Only 50 percent ever get a screening test, so cancers are often found at later stages." In fact, in a survey done by the American Cancer Society, 38 percent of people over age 50 could name a judge on the television show American Idol, but only 34 percent knew they were at risk for colon cancer.
One goal of modern colon cancer care is increasing the use of preventative tests, both by raising awareness of current tests and discovering less invasive ways to check for cancer. Researchers are beginning to test for biomarkers - molecules that are present in a certain cell type, in this instance, cancer - in order to detect malignant tumors. Some of these biomarkers are found in blood and others in stool.
Doctors also need to better understand how specific genes correlate with an increase in colon cancer risk. Chris Iacobuzio-Donahue, an anatomic pathologist at Hopkins, is working to determine if an abnormal expression of the insulin-like growth factor 2 (IGF2) gene may be a reliable marker for increased cancer risk. "This data may form the basis for a diagnostic test to be performed on patients coming for routine colonoscopies," Donahue said.
Beyond improving initial diagnostic procedures, Donahue and other pathologists are also changing the way they test colon cancer tumors. "We are currently in a transition ... from relying solely on morphology and tumor staging methods to using molecular data of the tumor." This will allow doctors to make better immediate treatment decisions after they biopsy malignant tissues.
The Hopkins Colon Cancer Center is working on the other half of the equation: spreading awareness of current diagnostic tests. Michael Choti, a metastatic colon cancer surgeon who heads the center, has a message for older patients: "Don't wait for symptoms." Choti also stresses that, while colon cancer is less common in younger people, doctors often wrongly disregard cancer symptoms in young patients - sometimes with disastrous results.
In a July 2007 issue, The New York Times covered one of Choti's patients - a 35-year-old woman who noticed a lump under her ribs after giving birth to her first child. Her first doctors told her it was a bruise and sent her home. But soon, the patient was back - this time severely ill. After testing, doctors quickly found the cause of her symptoms: stage IV colon cancer that had already spread to her liver. Her first doctor gave her six months to live. When she consulted other physicians, they wanted her to undergo chemotherapy but not to have surgery.
The patient, instead, sought more aggressive care. Eventually she found her way to Hopkins, where Choti offered to operate. After an eight-hour surgery, in which Choti removed 70 percent of the patient's liver and 12 to 18 inches of her colon, the five tumors - one the size of a tangerine - were out.
For Choti and other doctors who treat late stage colon cancer, discovering more aggressive methods of treatment and spreading awareness of these treatments is of the utmost importance. "We're looking at designing new surgical techniques with computer assistance," Choti said. "We're also doing more and more laparoscopic surgery." Laparoscopy, a minimally invasive procedure performed through small incisions in the abdomen, often helps to speed up patient recovery time.
But while a number of aggressive treatments exist, many colon cancer patients are unaware of their options. "The most frustrating challenge is that not all patients are managed properly," Choti said. "They need to seek more aggressive treatment ... it's very underutilized."
Choti's patient with stage IV colon cancer is an exception to the rule; most patients need help navigating the system, and here, again, is where programs like the center come in. The center makes it clear that there "no two cancers and no two people are identical," and that every patient's therapy should be carefully tailored to the severity of his or her disease. In addition, care should be managed in a multidisciplinary team, with surgeons, oncologists, gastroenterologists and pathologists all working towards common goals.
Modern colon cancer care also needs to address the non-physical side effects of illness. Caroline Saunders, a clinical social worker at Hopkins, understands that colon cancer patients don't just need outstanding medical care, but emotional and financial counseling as well. "Social work can assist patients through counseling and resource guidance from the time they are newly diagnosed to survivorship," Saunders said.
Though colorectal cancer mortality in the U.S. has steadily decreased since 1985, there is still work to be done by both doctors and the public. While physicians work to develop less invasive diagnostic tests and more aggressive treatment options for every stage of colon cancer, we have an obligation to spread awareness.
"You can tell your relatives that screening is very critical," Choti said. "You can get excited about seeing advances in this area." Discussing our intestines may not make the best dinner table conversation, but we have a lot to lose if we continue to keep our mouths shut.
