Five things you should know about prevention and early detection of colon and rectal cancer.

Flexible sigmoidoscopy demonstration by Dr. Noorali Bharwani.
Flexible sigmoidoscopy demonstration by Dr. Noorali Bharwani.

Generally speaking, nearly half of Canadians will get some kind of cancer during their lifetime, according to Canadian Cancer Statistics 2017. Cancer is the leading cause of death in Canada, responsible for one in four deaths.

Today, we will talk about colon and rectal cancer – also known as colorectal cancer.

1. How common is colorectal cancer in Canada?

Colorectal cancer is one of the most common cancers worldwide and the second-most common cancer in Canada. Both men and women are equally at risk. The cancer is most common among people aged 50 and older but can occur in patients as young as teenagers. The average age at the time of diagnosis for men is 68 and for women is 72.

2. Who is at high risk for colorectal cancer?

Over 75 per cent of colorectal cancers happen to people with no known risk factors, which is why regular screening is so important. There are many risk factors. Most common ones are: previous history of colorectal cancer (CRC) and pre-malignant polyps, family history of CRC, genetic predisposition like Lynch syndrome (also called hereditary non-polyposis colorectal cancer, or HNPCC).

3. Signs and symptoms of colorectal cancer include:

A persistent change in your bowel habits, including diarrhea or constipation or a change in the consistency of your stool. Rectal bleeding or blood in your stool. Persistent abdominal discomfort, such as cramps, gas or pain. A feeling that your bowel doesn’t empty completely.

4. Who should be screened for colorectal cancer and how often?

Screening program is meant for individuals who have no bowel symptoms or any risk factors. The idea is to pick up cancer in an early stage.

There are many screening programs for early detection of colorectal cancer. They vary slightly in details. Overall, the summary is as follows:

  • Asymptomatic people should be screened with a fecal immunochemical test (FIT) every 2 years.
  • Abnormal FIT results should be followed up with colonoscopy.
  • People ages 50 to 74 without a family history of colorectal cancer who choose to be screened with flexible sigmoidoscopy should be screened every 10 years.

There are two types of tests to check for blood in the stool – FOBT and FIT.

The FOBT can detect blood from any part of the gastrointestinal (GI) tract, while the FIT is more reliable in cases of bleeding from the lower part of the GI tract. The Canadian Task Force on Preventive Health Care published guidelines in 2016 that state people who do not show symptoms and don’t have a strong family history of colorectal cancer start getting screened at age 50.

Not all patients with positive FOBT will have colorectal cancer. No test is one hundred per cent accurate. Overall, about 12 per cent of patients with a positive FOBT have colorectal cancer. If you do an FOBT every two years, you can reduce your risk of dying from bowel cancer by up to a third.

5. Who needs a screening colonoscopy?

Colonoscopy is considered the gold standard for colon investigation. Indeed, if anything is found on fecal occult blood or by sigmoidoscopy, patients are referred for colonoscopy. It is the test advised for higher risk patients with a family history of colorectal cancer.

New guidelines from the Canadian Association of Gastroenterology urge people with a history of colorectal cancer in their immediate family to start screening earlier and get more frequent checks for the disease. People whose parents, children or siblings have been diagnosed with colorectal cancer are encouraged to get screened between ages 40 and 50, or 10 years earlier than the age at which their relative was diagnosed, whichever comes first.

The whole premise for doing these tests is to pick up pre-malignant polyps and cancer in early stages. Cancer picked up early has 92 per cent five-year survival. If it is in the late stage then the five-year survival is around 10 per cent. Talk to your doctor and get your test done.

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Acute Coronary Syndrome

Lake Louise. (Dr. Noorali Bharwani)
Lake Louise. (Dr. Noorali Bharwani)

Acute coronary syndrome is a medical emergency.

Acute coronary syndrome is a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart. Part of the heart muscle is unable to function properly or dies. It is critical to make an early diagnosis.

The problem is, not all chest pain patients get investigated because the presentation of symptoms can be short term, intermittent or not very clear. Just like not all patients with headache get a CT scan of the head. Because not every person with a headache has a brain tumour. That is why many brain tumours are diagnosed late.

“Diagnosing a patient presenting with chest discomfort or pain remains a challenge for physicians despite advances in diagnostic testing, clinical practice guidelines, and enhanced understanding of acute coronary syndrome (ACS),” says the Canadian Medical Protective Association (CMPA) in their newsletter (December 2019).

CMPA suggests appropriate triage and testing, as guided by symptoms and patient risk factors. This may help improve the timely diagnosis of ACS. Basically, no chest pain should be ignored irrespective of age or sex of the patient.

What is acute coronary syndrome?

Acute Coronary Syndrome is a name given to three types of coronary artery diseases that are associated with sudden rupture of plaque inside the coronary artery. One such condition is a heart attack (myocardial infarction) — when cell death results in damaged or destroyed heart tissue. Angina and heart attacks are types of acute coronary syndrome.

Acute coronary syndrome often causes severe chest pain or discomfort. It is a medical emergency that requires prompt diagnosis and care. The goals of treatment include improving blood flow to the heart, treating complications and preventing future problems.

Chest pain or discomfort is the most common symptom. However, in some patients’ signs and symptoms may vary significantly depending on patient’s age, sex and other medical conditions.

If you are a woman, older adult or have diabetes then you are more likely to have signs and symptoms without chest pain or discomfort. That is one of the reasons why a correct diagnosis is missed.

CMPA says, “Consistent with the medical literature, risk factors for women also displayed gender-specific characteristics, such as menopause and pregnancy, and women frequently presented with atypical chest pain.”

The signs and symptoms of ACS usually begin abruptly. They include: Chest pain (angina) or discomfort, often described as aching, pressure, tightness or burning. Pain spreading from the chest to the shoulders, arms, upper abdomen, back, neck or jaw.

Early diagnosis is important. When someone is rushed to the emergency room with chest pain, testing must be performed to determine whether or not a person’s signs and symptoms are due to a heart attack or to another cause. The doctor will order a blood test to see if there is evidence that heart cells are dying and order ECG to check for the heart’s electrical activity.

Initially, if the tests are normal then serial testing (ECG and cardiac enzymes) should be done to check for any changes. Mistakes occur if there is failure to consider cardiac risk factors in the diagnosis of unexplained chest discomfort or pain. Especially in female patients.

In conclusion, managing acute coronary syndrome is a relatively common and challenging task, says CMPA. Patient’s risk factors should be considered along with appropriate serial blood testing in the emergency department. This can contribute to safer patient care, says CMPA.

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Obesity projections for 2020 are grim.

The Colosseum amphitheater located in the centre of Rome, Italy. (Dr. Noorali Bharwani)
The Colosseum amphitheater located in the centre of Rome, Italy. (Dr. Noorali Bharwani)

Obesity is generally caused by eating too much and moving too little. Fat and sugar are high in calories. They are your big enemies. Add to that lack of exercise and physical activity. All that leads to surplus energy that will be stored by the body as fat.

Here are the facts.

In 2020, 83 per cent of men and 72 per cent of women will be overweight or obese.

Currently, 72 per cent of men and 63 per cent of women are overweight or obese (people who are overweight have a BMI of 25 to 29, people who are obese have a BMI of 30 or greater).

More than 50 per cent of these individuals will suffer from diabetes. or pre-diabetic conditions. These projections were presented by Northwestern Medicine researchers at the American Heart Association (AHA) Scientific Sessions recently in Orlando.

The AHA has set a target to help North Americans improve their overall heart health by 20 per cent in 2020. To achieve this target, we have to make a drastic change in out eating habits and increase our physical activities.

More people would need to improve health behaviors related to diet, physical activity, body weight and smoking, and health factors, related to glucose, cholesterol and blood pressure.

Believe it or not, less than five per cent of Americans currently are considered to have ideal cardiovascular health. Can you believe that – only five per cent!

The modest six percent improvement in cardiovascular health that is projected for 2020 means better cholesterol and blood pressure numbers for Americans and fewer smokers.

Achieving a healthy weight through diet and physical activity is the best way most Americans can improve their cardiovascular health. Add to that not smoking is the number one preventable cause of preventable death.

Obesity is a chronic and often progressive disease, similar to diabetes or high blood pressure. Many organizations including Obesity Canada, the Canadian Medical Association, the American Medical Association, and the World Health Organization now consider obesity to be a chronic disease.

It is estimated that one in 10 premature deaths among Canadian adults age 20 to 64 is directly attributable to obesity.

It is no secret that most methods of treating obesity have failed. Some are good for a short duration but most people revert to their old habits. Habits are hard to get rid off. Habits that have been ingrained in your system since childhood.

Experts agree there is no single solution to the problem of obesity. We should help people make better choices. People are addicted to sweet and high-fat foods that are inexpensive and easily available.

Can you think of a law that will make us exercise more, eat less and eat healthy?

Finally, a question to think about. Is BMI the best way to measure ideal weight?

A study published in the Frontiers in Public Health (July 24, 2017) by Philip B. Maffetone and colleagues say using BMI to measure obesity likely underestimates the problem. They propose measuring a person’s waist instead of their weight to assess health risks. Abdominal fat or obesity has more severe health effects than fat in other parts of the body.

Ideally, all should aim to keep their waist measurement less than half that of their height.

If you want to lose weight then 75 per cent of your effort should be spent on eating less and eating right. Twenty-five per cent of your effort should be spent on physical exercise. Have a wonderful healthy and happy 2020.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

New year is a good time to control the silent killer.

Sunrise at Haleakala Volcano summit in Maui, Hawaii. (Dr. Noorali Bharwani)
Sunrise at Haleakala Volcano summit in Maui, Hawaii. (Dr. Noorali Bharwani)

In the new year, you can wish for many things and make many resolutions. But don’t forget to take care of the silent killer – your blood pressure.

The lifetime risk for developing hypertension (high blood pressure) among adults aged 55 to 65 years is 90 per cent. Our New Year’s resolution should be to keep our blood pressure under control.

More about that later. First, I have a question for you: when is the best time to take your blood pressure pill?

Currently, there are no guidelines on when to take your blood pressure pills – is it better to take it in the morning or at bedtime?

The answer is in an article recently published in the British Medical Journal (BMJ 23 October 2019) titled “Taking antihypertensives at bedtime nearly halves cardiovascular deaths when compared with morning dosing.”

A study of nearly 20,000 hypertensive patients in primary care has shown taking pills for high blood pressure at bedtime is associated with improved blood pressure controls. Besides, the risk of dying from cardiovascular causes is reduced by half when compared with morning dosing.

The Hygia Chronotherapy Trial randomly assigned 19,084 hypertensive patients (median age 60.5 years) to take their entire daily dose of one or more antihypertensives at bedtime or on waking in the morning. The patients were followed up with ambulatory blood pressure monitoring, for a median follow-up period of 6.3 years.

The results show these patients have better controlled blood pressure and, most importantly, a significantly decreased risk of death or illness from heart and blood vessel problems.

The researchers found there was enough evidence from this study to recommend patients consider taking their blood pressure medication at bedtime.

It should be noted that this recommendation does not apply to medicines that need to be taken more than once a day or to blood pressure medicines that are prescribed for other problems, such as angina or heart failure.

Do not change your medication schedule without consult your doctor.

What is considered to be high blood pressure?

Blood pressure that is consistently more than 140/90 mmHg is considered high, but if you have diabetes or chronic kidney disease, 130/80 mmHg is high, says Health Canada website.

High blood pressure significantly increases risk for stroke, ischemic heart disease, peripheral vascular disease and heart failure.

Some facts about high blood pressure (hypertension):

  1. Hypertension affects more than one in five people.
  2. Approximately 17 per cent of individuals with hypertension are not aware of their condition, the true prevalence of hypertension is likely higher.
  3. Hypertension is the most common reason to visit a doctor.
  4. Hypertension is the number one reason for taking medication.
  5. The lifetime risk for developing hypertension among adults aged 55 to 65 years with normal blood pressure is 90 per cent.
  6. It is estimated that almost 30 per cent of hypertension can be attributed to excess dietary sodium. Reduction in daily sodium intake to recommended levels could result in one million fewer Canadians with hypertension.
  7. Smoking, being overweight or obese, lack of physical activity, too much salt, stress, genetics and family history can induce hypertension.

That is it for this year. Let me wish you all Merry Christmas, Season’s Greetings, Happy Healthy Safe and Sober New Year! Remember what Earl Wilson (American Athlete) said, “One way to get high blood pressure is to go mountain climbing over molehills.” Talk to you next year.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!