Mark Pochapin, President of the American College of Gastroenterology, on the latest developments in colorectal cancer research
It was devastating to hear about actor Chadwick Boseman’s death from colon cancer at the age of 43. And it hit particularly close to home for me, as my late husband Jay died of the same disease when he was 42 — more than twenty years ago.
One of his doctors was Mark Pochapin, who is now President of the American College of Gastroenterology. He answers my questions on the latest developments in colorectal cancer research and offers advice on how you can protect yourself and your loved ones from the second leading cancer killer in the U.S.
Katie Couric: Mark, Chadwick Boseman’s death is such a tragedy. More and more young people are being diagnosed with this disease. Can you tell us the latest statistics?
Dr. Mark Pochapin: According to the most recent 2020 colon cancer statistics, the incidence of new colorectal cancer for young adults less than age 50 continues to increase by about 2 percent per year. This is in contrast to a greater than 3 percent decrease per year for people 65 and older. Although the incidence of new colorectal cancer was decreasing for people ages 50 to 64, this reversed slightly and is increasing by 1 percent per year since 2016.
Do scientists know why this is happening?
The short answer is no, and this question remains one of the most frustrating parts of understanding this disease. We know that about 1 in 5 of younger patients with colorectal cancer have a genetic reason that increases their risk, although only half of these patients actually have the family history that matches the genetic mutation. For all patients with colon cancer — about 5 to 10 percent have a genetic cause.
This is why we especially need to genetically test all young patients with colorectal cancer to protect their families. Other factors that have been hypothesized include diets rich in sugar, fat, red meat and/or alcohol, obesity, decreased physical activity and exercise, and changes in the gut bacteria known as the microbiome from antibiotic use. That being said, nothing has surfaced as a single likely cause and the answer will probably be more related to a combination of factors that need to be identified.
One of the symptoms is rectal bleeding, or blood in your stool. Sometimes younger people ignore this sign. And even doctors may not take it seriously. What should people do if they see either A. Blood in their toilet bowl or B. Darker than usual stools? (Sorry everyone, but this information is potentially lifesaving.)
This is a very important question. We all need to take ownership of our health and not deny that symptoms exist, which so many of us are very good at doing. Blood in the stool or a change in bowel habits in either color, size, shape or caliber, need to be evaluated by a medical professional. People should not panic, as there are many causes of rectal bleeding that are not serious, such as hemorrhoids.
However, we know that in young adults diagnosed with colorectal cancer, cancer tends to be located towards to end of the colon near the rectum and may result in the passage of blood from the rectum. Unfortunately, younger patients often go months longer to get diagnosed with colorectal cancer because either they ignore their symptoms or the healthcare professionals caring for them do not initially consider colorectal cancer as a possible cause. We all need to take this more seriously and do better.
Chadwick fought the disease for four years. He was initially diagnosed with stage 3. Have the treatments for this disease improved when it’s not diagnosed early?
We have come a long way with treatments and even when the disease is stage 4 with liver involvement, there remains hope for a cure.
I don’t know the specifics of Chadwick’s condition, but I do know he was a fabulous actor and played outstanding roles when he must have been in the throes of treatment. The fact that none of us knew he was sick, and the incredible acting he was able to achieve while fighting colorectal cancer, is a tribute to Chadwick and his medical team. However, we must do better. Since this disease can be prevented in many cases, knowing your family history and screening starting at age 45 to 50 is essential.
Unfortunately, we still have no way of predicting or screening for young patients with colorectal cancer without a family history. This is something you and I discussed over 20 years ago when Jay so tragically died at age 42. As I said, the medical profession must do better to figure this out.
Do you know why Black populations may be more susceptible to this disease? I know scientists have been looking into this.
The reasons are not known, but the problem is complex and probably a combination of many things. Unfortunately, disparities in health care likely play a significant role.
Among 5 major racial/ethnic groups, non-Hispanic Black populations had the highest rates of colorectal cancer — about 20 percent higher than non-Hispanic white people. Even worse, from 2013 to 2017, colorectal cancer death rates in Black people were almost 40 percent higher than those in non-Hispanic white people. Factors such as lower socioeconomic status, decreased access to health care including screening and follow-up, other medical conditions, diet, and obesity, may all be contributing to these trends.
We also see significant differences geographically. Colorectal cancer incidence and mortality are lowest in the west, and highest in Appalachia, parts of the south and midwest. The geographic differences are generally the same between racial/ethnic groups, suggesting the socioeconomic factors and access to quality healthcare are the main reasons for the disparities seen.
Colon cancer can often be cured if detected early. Can you remind us of the screening guidelines?
This is critically important. Colorectal cancer is one of the few cancers that can be prevented with screening. But the time to screen is when you are well. If you have any symptoms such as rectal bleeding, change in bowel habits, or abdominal pain, that is no longer considered screening and you need to be evaluated by a healthcare professional. In addition, if there is any family history of colorectal cancer or other cancers, you should talk to your doctor about screening early or seeing a genetic counselor for possible genetic testing. The American Cancer Society has recommended that all people at normal risk start screening at age 45.
People have two main choices that are quite different: colonoscopies and fecal immunochemical testing. A Colonoscopy is done by a gastroenterologist, requires a bowel clean out the night before (known as the prep), and under sedation uses a scope to look in the colon and find and remove colon polyps, the precursors to cancer. By removing the polyps, doctors are able to prevent the cancer. If the colonoscopy is normal, the next colonoscopy screening exam would not need to be done for 10 years if no polyps are found. In contrast, FIT testing needs to be done at home every year if this is the screen modality used. It requires taking a small stool sample after a bowel movement and sending it by mail for analysis to see if there is any microscopic blood. If the FIT test is positive, then a colonoscopy must be done soon afterwards.
FIT testing is primarily a cancer detection test and is really looking to diagnose early cancer. Another test, most commonly known by the trade name Cologuard, is a combination of the FIT test and stool DNA. It is also done at home by collecting a larger stool sample in a collection container that had been mailed to the patient’s home and then sending it in a box to the lab. Like FIT, a positive Cologuard test requires a colonoscopy soon after to further evaluate. Cologuard testing detects more cancer and some polyps, but it also has more false-positive tests than FIT alone.
A false positive means that the Cologuard test is positive, but the colonoscopy is then normal. As we have always said about the different screening tests: The best test is the one that gets done. The most important take away message is to talk to your doctor about colorectal cancer screening.
What can the average person do to protect their health?
Curate a healthy lifestyle! A healthy diet is rich in fruits and vegetables. Sugar, fat, red meat, and alcohol should be consumed in moderation. People can eat what they like. The key is balance and moderation.
Another important factor is trying to watch the caloric intake and keep fit with exercise. This does not mean you must join a gym. Walking and using the stairs are wonderful forms of exercise that are free and readily available.
Specifically for colon cancer, people must know their family history for colon cancer and polyps and family clustering of other cancers, such as uterine, ovarian, stomach, pancreas, urinary tract, and breast cancer. For people with a family history of cancer, they should speak to their health care professionals about genetic testing, which is less expensive than it had been even just a few years ago. Finally, in this time of Covid-19, people must still address their medical needs. Now with increased testing and a better understanding of how to prevent the spread of the virus, seeking medical attention is safe and important. Too many people have been putting their routine medical care on hold for months now. Please don’t ignore your health because of this pandemic.
This interview has been edited and condensed.
This originally appeared on Medium.