Frank Salinas remembers his first colonoscopy to check for colon cancer.
“It was 20 years ago,” he said.
He was in his mid-40s, healthy, active and fit (he does mini-triathlons), absolutely no symptoms. As the years went by, getting subsequent, regular screenings didn’t feel like a high priority. So, he never went back. “And I would have continued to overlook it,” he said.
A couple of things changed his mind.
In those intervening years, Salinas began a relationship with City of Hope, first as a patient — he had a successful bone marrow transplant in 2009 to correct a blood disorder known as polycythemia — and later as an employee handling customer relationship management software platforms.
About a year ago, Salinas heard about a company-wide screening event run by gastroenterologist Trilokesh Kidambi, M.D., assistant clinical professor in the Division of Gastroenterology, Department of Medicine, and director of the Colon Cancer Screening Program. Salinas filled out an application, and within minutes of hitting “send,” his phone was ringing. It was Kidambi.
“We didn’t know each other,” said Salinas. “And he just starts saying, ‘You’re overdue! You need to do this, Frank!’ He just jumped on it.
“I was very impressed.”
Equally impressive, Salinas recalls, was his family’s reaction. His sister, a nurse, urged him to get screened as soon as possible. So did his wife Lisa, who kept asking him, “Well? Have you signed up yet?”
It’s estimated that barely a third of all people who should go in for a colonoscopy actually do so. Kidambi and his colleagues warn how dangerous that is. In blunt terms, delay and neglect can be deadly. The key to stopping colorectal cancer is catching it early, often before full-blown cancer has developed. Colonoscopies can do that by spotting precancerous polyps that can be easily removed.
Nevertheless, people don’t go, enabling colorectal cancer to remain the second deadliest cancer in the U.S., claiming more than 50,000 lives each year.
And the casualties are getting younger. Over the last decade or so, while the onset rate for people over 65 has declined, those under 50 are seeing a 2% climb year after year.
People hesitate to get screened for a variety of reasons, but a big factor, many say, is the procedure itself, especially the preparation required beforehand. The bowel must be emptied, an unpleasant task accomplished in the “old days” by drinking large quantities of special prescription laxatives. These days, a series of pills (commercially known as SuTab) or lower volume liquid preparations can do the job, but of course the end result is still unsettling. “It’s terrible, but it’s worth it,” said Kidambi.
There are innovations on the horizon that may someday make things easier: so-called “liquid biopsies” that detect cancer cells in the bloodstream, and colonoscopy tools that eliminate the need for the prep by clearing the bowel step by step during the screening itself. Kidambi says that’s still a long way off. What’s here now, he says, is technology, like artificial intelligence and high-definition imaging, that help catch more polyps and anomalies than ever before, doing an even better job of keeping cancer at bay.
Confusion may also play a role. Patients, and very often their doctors, don’t always have clarity on the necessity of screening. The uncertainty grew after the New England Journal of Medicine published the results of a years-long study comparing colon cancer rates among people invited to get screened to patients who received no such invitation. The “invited” group showed only a slightly lower risk over time.
“I got many questions about that study from colleagues, patients, family and friends,” said Kidambi. He points out that “invited” doesn’t mean the patient actually did get screened. Comparing patients who went ahead and had colonoscopies to those who didn’t, Kidambi says the screened group showed a much lower risk – about 30% lower.
Ideas about who should get screened and at what age they should begin are also evolving. For a long time, the medical community felt that people of average risk — having no family members with the disease — should get screened every 10 years, starting at age 50.
But then the American Cancer Society, seeing the rise in colon cancer among younger people, lowered that age to 45. “It was super provocative,” said Kidambi, “and many didn’t follow the new guidelines.”
He thinks they will now. The influential U.S. Preventive Services Task Force recently recommended the same thing — start at 45 — giving the guidelines more credibility and increasing the likelihood that insurance will cover the procedure for younger patients.
That same task force may also be on the verge of greenlighting another procedure that will help take colon cancer detection to the next level: genetic screening for Lynch syndrome.
Colorectal cancer isn’t usually hereditary, but scientists continue to discover more and more genetic markers and anomalies that point to an elevated risk of developing the disease.
“We definitely have at least 22 genes that implicate colon cancer and polyposis syndrome, a condition that produces a large number of polyps,” said Heather Hampel, M.S., City of Hope’s resident expert in genetic screening for colon cancer and associate director of the Center for Precision Medicine. Hampel says a big target to watch out for is inherited Lynch syndrome, a no-symptom, frequently under-detected condition that dramatically raises the risk of colon and other cancers.
Hampel wants to see more people sign up for genetic screening, but it is not yet the standard of care everywhere. Many institutions tend to stress family history first before examining a person’s DNA. But at City of Hope, a research project known as INSPIRE — Implementing Next-generation Sequencing for Precision Intervention and Risk Evaluation — offers genetic screening to any patient, whether diagnosed with cancer or not. The goal is twofold: to benefit more people earlier and to collect data that will help demonstrate that such screening has value. “We’re trying to prove that it will affect outcomes,” she said. So far, some 15,000 patients have taken advantage of the program.
Both types of screenings can work together. “If you have relatives who’ve had colon cancer,” advised Hampel, indicating a higher-than-average risk, “get started with colonoscopy screening when you’re 40. And if those relatives were young when they developed the disease, you should come in for genetic screening.” People with Lynch syndrome may need to start even earlier, as young as age 25.
As for Salinas, his colonoscopy came just in time. During the procedure, Kidambi was able to find and remove four precancerous polyps. However, a large, advanced precancerous polyp was detected near his rectum — the type that in a short time could have morphed into a rectal cancer. It was too large to be removed during colonoscopy.
Salinas followed up with a specialized endoscopic procedure performed by James Lin, M.D., chief of the Division of Gastroenterology, to remove the polyp without the need for traditional surgery, avoiding what could have resulted in an ostomy bag and weeks of recovery had he waited longer. Although it took several hours, his procedure was minor, and he went home the same day. He knows how lucky he is.
“I’m very thankful,” he said, and he added a final message:
“Do the prudent thing. The preventive thing. Get yourself checked while you still can. It’ll save you a world of pain.”