Tag: flexible sigmoidoscopy

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Are we doing too many colonoscopies? The new guidelines are here.

Dr. Noorali Bharwani demonstrating flexible sigmoidoscopy.
Dr. Noorali Bharwani demonstrating flexible sigmoidoscopy.

First, let us face the facts. Colorectal cancer is the third most commonly diagnosed cancer in Canada. It is the second leading cause of cancer death in men and the third in women. The lifetime probabilities of dying from colorectal cancer among men and women are three to four per cent.

What’s the best way to prevent colon and rectal cancer?

We have been doing colonoscopies just over 50 years. The technology is changing almost every year. The service is now available almost everywhere. There are more doctors doing colonoscopy. And people are getting the procedure done more often. The indications of doing the procedure are increasing everyday. The saying goes, “If you haven’t had a colonoscopy then you need one. If have had one then you need another one!” Is that the way to go?

Last time the guidelines for colonoscopy were updated was 2001. Now, in 2016, we have new guidelines from the Canadian Task Force on Preventive Health Care. The new guidelines state there is not enough evidence to justify colonoscopies as routine screening for colorectal cancer. Instead, patients should undergo fecal occult blood testing every two years, or flexible sigmoidoscopy every 10 years. Flexible sigmoidoscopy is a procedure in which a scope is inserted in the lower portion of the colon and rectum rather than the entire tract. I used to provide that service in my office.

It is sad to note that currently no provincial screening program includes flexible sigmoidoscopy.

It is important to remember that the guidelines apply to adults aged 50 to 74, who are asymptomatic and at low risk for colorectal cancer, meaning they have no prior history of the disease, no family history, no symptoms such as blood in the stool, or genetic predisposition. If they have any of these risk factors then they need a colonoscopy – full examination of the colon and rectum.

The task force hopes that ultimately, most Canadians will likely be screened using fecal occult blood tests, which look for microscopic specks of blood in the stool that could be a sign of cancer. If that is positive then a colonoscopy is indicated. If a flexible sigmoidoscopy (a 60-cm scope which examines the rectum and left colon) is positive for any abnormal findings then the person needs a colonoscopy.

To spread this message, we have to educate the public about the risk of the disease and the safety and importance of screening. Adults 75 and over should not be ignored. If they are in good health then they should discuss with their doctor and get into the screening program.

Colonoscopy is a great test but because waiting lists are long and the potential for side effects such as bleeding or intestinal perforation are greater than they are for other tests, the guidelines recommend against using colonoscopies as a routine screening tool in asymptomatic low-risk adult.

The old guidelines (2001) recommended annual or biennial faecal occult blood test (FOBT) and flexible sigmoidoscopy every five years in asymptomatic people older than 50 years. The guideline did not recommend whether these screening modalities should be used alone or in combination or whether to include or exclude colonoscopy as an initial screening test for colorectal cancer. And provincial screening programs do not include flexible sigmoidoscopy as one of their screening options. This should change.

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Had Your Butt Checked Out Lately?

There are more jokes and humorous videos on the internet about colonoscopy than about mammography or cervical cancer screening. The reason is quite obvious. Most people do not like the idea of people inserting long tubes and cameras in the rear end of our anatomy. That is where the problem lies. Out of fear and embarrassment, we ignore that area and by the time we pick up cancer it is too late.

Alberta Cancer Board, Canadian Cancer Society and Alberta Health Services have been very aggressive in promoting the Alberta Colorectal Cancer Screening Program. You must have read about it in the newspapers, heard about it on the radio and seen the news on TV. The question is: what have you done about it? Are you ready for it?

The program aims to save lives by improving the prevention and early detection of colorectal cancer in Albertans between the ages of 50 and 74. The sad part is only 10 to 20 per cent of Canadians come forward to have some kind of screening test done for their colon. More women would go for mammography and cervical cancer screening than colorectal screening. And men are worse when it comes to screening for colorectal and prostate cancer.

Men and women are almost equally at risk of getting colorectal cancer. There is a less than three minutes video on YouTube (http://www.youtube.com/realmenscreen) titled: “Had your butt checked out lately? – The Canadian Cancer Society asked men this question.” It is humorous and educational. Check it out!

Colorectal cancer is the fourth most common cancer. The average lifetime risk of developing colorectal cancer is six per cent. It is the second leading cause of cancer death in Canada. It is expected that colorectal cancer screening will decrease both, incidence and mortality.

Most people are scared as soon as they hear the word colonoscopy. It is important to remember that colonoscopy is not the only test for screening although it is the best test and is considered as gold standard against which other screening tests are compared. In certain circumstances (high risk patients) you do not have a choice but go through a colonoscopy for diagnosis, prevention and treatment of certain conditions.

You are at a high risk of getting colorectal cancer if you have a family history of colorectal cancer or polyps, have a personal history of ulcerative colitis or Crohn’s colitis
and have had polyps or previous history of colorectal cancer.

If you have symptoms like rectal bleeding then you don’t have a choice – you need a test. Depending on your age, the test may be a flexible sigmoidoscopy in the office or colonoscopy at the hospital. For example, six per cent of the patients who say they are bleeding from hemorrhoids have colon or rectal cancer.

Every individual is at risk of developing colorectal cancer. If you have no symptoms, have no family history of colorectal cancer and you are 50 years or older then you do not have to go through colonoscopy. You have a choice of doing stool tests for occult blood yearly or bi-annually, flexible sigmoidoscopy in an office every five years or combine stool test and flexible sigmoidoscopy every five years.

Every test for screening has advantages and disadvantages. None of them are full proof. And they vary from very invasive (colonoscopy) to least invasive (stool test). If you fall into high risk category then colonoscopy is the way to go. If you are asymptomatic person with an average risk then you have a choice of tests mentioned earlier.

So don’t be scared, talk to your doctor and have your butt checked out!

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Colorectal Cancer Screening Program

Last week, every physician in Alberta received an envelope from Alberta Cancer Board containing Alberta’s first clinical practice guidelines for colorectal cancer screening. There isn’t much new in the protocol they advocate. This protocol has been used before and followed by many physicians in Alberta and around the world. What is new is that the protocol has now been formally accepted and promoted by various health organizations in Alberta.

Number one cancer killer in Alberta is lung cancer. What is the second leading cause of cancer death in Alberta? Of course, colon and rectal cancer. In 2004, 650 Albertans died of this disease. In Canada, 8,700 people died of colorectal cancer in 2007.

How many people over the age of 50 get screened for colorectal cancer each year? Less than 15 per cent. That is not good. Alberta Cancer Board hopes that this number will improve in the next few years.

Asymptomatic men and women who are 50 years or older, with no family history of colorectal cancer, are considered to have average risk for colorectal cancer and one of the following options is available for screening:
-Stool tests, also known as fecal occult blood tests (FOBT), yearly or bi-annually or
-Flexible sigmoidoscopy (60 cm. scope) every five years – checks rectum and left side of the colon. This is an office procedure. It picks up 50 to 70 per cent of advanced polyps and cancer or
-Combine fecal occult blood tests with flexible sigmoidoscopy every five years or
-Barium enema every five years (not used very often for screening) or
-Colonoscopy every 10 years

It is quite reasonable to choose any one of the above methods. This is better than no screening. Each method has advantages and disadvantages which your doctor will discuss with you.

It is of interest to note that Alberta Medical Association’s TOP (Toward Optimized Practice) program has launched Health Screen in Act10n (meaning 10 screening maneuvers) program to enhance screening practices among Alberta doctors.

The TOP pamphlet says that the campaign asks physicians to use a checklist of health markers when seeing patients for periodic health examinations to make sure that they have covered areas of importance which would improve the quality of their practice and enhance patient’s health in preventing disease.

Ten markers or maneuvers were selected were on the basis of best practice evidence available from various sources. These are: patient’s smoking behavior, blood pressure, tetanus/diphtheria vaccination status, PAP test, clinical breast examination, fasting glucose, lipids, mammography, colorectal cancer screening and bone density.

It would not be a bad idea for you to make a list of these markers and see where you stand. Even better would be to take the list with you when you see your doctor next time and see how you are doing. Human memory can be short or deceptive when it comes to remembering dates. Your doctor should be able to help you update your checklist.

It is not easy to stay healthy. It requires time, perseverance and sacrifice. Good luck.

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Screening for Colorectal Cancer

Dear Dr. B: What is the best screening tool for early detection of colorectal polyps and cancer? What are the guidelines for screening?

Answer: This subject is gaining more importance each day. In the month of March I was at Peter Lougheed Centre, Calgary to attend a seminar on Update on Colon Cancer and Endoscopy organized by the University of Calgary’s Division of Gastroenterology. One of the topics for discussion was on colon cancer screening guidelines.

Colorectal cancer is the fourth most common cancer. It is the second leading cause of cancer death in Canada. In 2004, 19,100 new cases of colorectal cancers were diagnosed in Canada and 8300 deaths were reported.

Screening for colorectal cancer is recommended to pick up polyps and cancer at an early stage when they can be treated effectively. Currently we do not know what the best test is for screening purposes. A variety of tests are now available, each with advantages and disadvantages.

Every individual is at risk of developing colorectal cancer. The average lifetime risk of developing colorectal cancer is six per cent. If you have any of the following risk factors then the risk increases:
-Family history of colorectal cancer or polyps
-Ulcerative colitis or Crohn’s colitis
-Presence of polyps or previous history of colorectal cancer

What is the approach to an individual with average risk of colorectal cancer?

For asymptomatic men and women who are 50 years or older with no family history of colorectal cancer are considered to have average risk and the following options are available for screening:
-Fecal occult blood tests yearly or bi-annually
-Flexible sigmoidoscopy every five years
-Fecal occult blood tests plus flexible sigmoidoscopy every five years
-Barium enema every five years
-Colonoscopy every 10 years

What is the approach to an individual with above average risk of colorectal cancer?

For asymptomatic men and women age 50 or over with a positive family history of colorectal cancer the lifetime risk of developing colorectal cancer is anywhere from 15 per cent to 80 per cent depending on how many first degree relatives had colon cancer and at what age.
-If two or more first degree relatives have had colon cancer and if one of them is under the age of 60 then colonoscopy is advised at the age of 40 or 10 years earlier than the affected first degree relative and then every five years
-If only one first degree relative has colorectal cancer and is 60 years old or older then the individual is considered to have average risk and the screening starts at age 40
-If there is a hereditary history of polyps then genetic testing and colonoscopy is advised.

Fecal occult blood tests are done by patients and stool samples are taken to a lab to detect traces of blood not visible to naked eye. If positive then the patient needs a colonoscopy in the hospital. If negative then the test is repeated yearly or every two years. If done annually death rate from colorectal cancer is reduced by 30 to 45 per cent. The test can be combined with a short scope (flexible sigmoidoscopy) which is an office procedure. We do flexible sigmoidoscopy in our office on a regular basis. This can be repeated every five years.

Barium enema and colonoscopy are done in the hospital. If abnormality is found on a barium enema then colonoscopy is required. If colonoscopy is normal then it should be repeated every ten years for an average risk person. If less than one centimeter adenomatous polyp is found then the scope should be repeated in five years. If the polyp is bigger than one centimeter then it should be repeated after three years.

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