Colorectal cancer's silent spread and how to prevent it

Providence Health Team

Colon cancer increasingly affects those under age 50
Most people diagnosed with colon cancer don’t have any symptoms
Screening and early diagnosis are critical to survivorship

March is National Colorectal Cancer Awareness Month, and now is the ideal time to learn about the latest insights on prevention and advancements in the treatment of this disease that claims the lives of more than 50,000 people in the U.S. each year. We spoke with colorectal surgeons Amanda Hayman, MD, MPH, and Jeffrey Manchio, MD, both affiliated with Providence St. Vincent Medical Center and Providence Portland Medical Center, and Amy Myers, APRN, director of the Digestive Health service line at Providence Alaska Medical Center in Anchorage, to better understand who is at risk, what the symptoms are, and how screenings and advanced surgical techniques are helping to prevent colon and rectal cancer from progressing to the later stages.

What is the medical reality behind the need to raise awareness of colorectal cancer in the United States?

Dr. Hayman: Many people may not realize that colon cancer is the second most common cancer in America. The American Cancer Society estimated that 95,520 new cases of colon cancer and 39,910 cases of rectal cancer would be diagnosed in the U.S. in 2017. It occurs in all ages, and especially in those over 50. However, we are seeing more and more patients in our clinics who are fully symptomatic in their 40s and 30s, and even in their 20s.

You mentioned younger people, people under age 50, are being diagnosed with colon cancer or rectal cancer. Do we know when the trend started? Do we know why it is occurring?

Dr. Manchio: The National Cancer Institute’s publications show that since the 1950s, the rate of colon cancer, and particularly rectal cancer, in patients under age 50 is going up at an alarming rate and we don’t exactly understand the reason why. Before 1950, roughly one out of every 12 newly diagnosed rectal cancers occurred in someone under age 50. Now, in the decades since 1950, it’s more like one in three, so it’s a staggering change, and we don’t know why this is the case. It’s probably the result of multiple factors including environmental exposures, dietary habits, and other external and internal influences.

For some cancers, like skin cancer, people can check their bodies for signs or symptoms that would prompt them to see their doctor. For colon or rectal cancer, are there specific symptoms someone should look for or pay attention to?

Dr. Hayman: Most people who are diagnosed with colon cancer don’t have any symptoms at all. This makes it very challenging because you don’t know if or when you should be screened. Symptoms may include rectal bleeding, a change in your bowel habits, or unexplained weight loss. But many people don’t necessarily pay attention to their bowel habits or realize they may be losing weight, so my recommendation is that any rectal bleeding that is unexplained is justification for a call to your doctor.

What are the age recommendations for colorectal cancer screening?

Dr. Hayman: If you don’t have any family history of colon cancer, screenings typically start at age 50. This drops to age 45 for African Americans. Studies show 80 percent of people who get colorectal cancer have no family history, and that’s something I think that is really important to emphasize. Everyone is at some level of risk, especially if you are age 50 and over.

Amy Myers: Even though the average risk for most is between the ages of 50-75, there are certain populations that have been found to have a higher risk. For example, the Alaska Native population should be screened starting at age 40. One important area we tend to miss is when an immediate family member has been diagnosed with colorectal cancer or has had a pre-cancerous polyp. It is recommended that a person start being screened 10 years prior to when the family member was diagnosed. This seems to be one factor related to colorectal cancer in patients under the age of 50.

In terms of screening, what is the standard or best screening for an accurate diagnosis?

Dr. Hayman: I tell my patients that colonoscopies are the best screening we have right now to find colon cancer at an early stage. For average Americans, most insurance plans will pay for a screening colonoscopy at age 50 even if you are not symptomatic. And again, for African Americans the screening recommendation is age 45. There are other types of screenings available if you choose not to have a colonoscopy. You can perform a fecal occult blood test or fecal immunochemical test at home using a kit provided by your doctor, but these tests may not find polyps. Other types of tests include sigmoidoscopy, a stool DNA test, and a CT colonography.

Amy Myers: Colorectal cancer is the only cancer that is preventable and one of the easiest to treat if caught in early stages. The best test is the test that gets done.

If a person waits until they have the pain or other symptoms, such as rectal bleeding, to see their doctor, does that usually mean that the cancer, if any, will be found at a later stage?

Dr. Manchio: Yes, absolutely. If one waits until symptoms are present there is going to be a much greater likelihood that it will be an advanced-stage cancer. If a patient’s cancer is at an advanced stage, the likelihood of achieving cure goes down significantly. Cancers first start as polyps which rarely produce any symptom, hence the reason for recommending colonoscopy for screening in patient’s without any symptoms. This allows polyps to be removed simply via colonoscopy before they have become a cancer thus avoiding surgery altogether. If a patient waits until symptoms are present and a cancer is found at the time of colonoscopy, then an operation will be necessary to remove that portion of the colon and its associated lymph nodes. If the cancer is found to have spread beyond the colon, the patient will then typically need chemotherapy thereafter. So colonoscopy both finds and removes polyps before they can become a cancer and finds cancers at an early stage when they are highly curable by surgery alone. This is why routine screening colonoscopy has been shown to both reduce the likelihood of ever getting a cancer by two-thirds and reduces the chance of dying from colon if detected by two-thirds as well. That is one of the most staggering impacts that any modern day preventative medicine approach could possibly tout relative to its impact on a given disease process.

What is the current survival rate for colon and rectal cancer if it’s caught early, as compared to if it is not caught early?

Dr. Hayman: Survival rates are linked to the stage of the cancer: the earlier the stage, the likelier we are to be able to cure the cancer or keep it from coming back. For people with stage one colon cancer, we can expect up to 90 percent of them to survive for at least five years. However, if the cancer has advanced to the patient’s lymph nodes, then that survival rate drops to less than 50 percent. This is why we work so hard to raise awareness and try to get people in for screenings so that, if cancer is eventually diagnosed, it is more likely to be diagnosed at an earlier stage when it is smaller in size and scope.

What are the trends or advancements in terms of procedures and techniques to treat colorectal cancer that you feel have made a big impact on patient outcomes?

Dr. Manchio: There have been dramatic changes in surgical treatment for colorectal cancer. Many more of our colorectal surgeries are performed with a minimally invasive approach compared to even just 10 years ago. In our own practice in Oregon, over 90 percent of our surgeries are done either laparoscopically or robotically. The technological advances, combined with the enhanced recovery pathway that myself and other Providence St. Joseph Health surgeons have been implementing, has resulted in an average length of hospital stay of less than three days. In my opinion, patients facing elective colorectal surgery should demand a minimally invasive approach to their surgery or at least have a good explanation provided as to why this is not an option in their particular case. The data clearly shows that there are far fewer complications, less postoperative pain and quicker recovery for those undergoing a minimally invasive colectomy.

What are the components of the enhanced recovery pathway, and how do they help colon cancer patients get home sooner after surgery?

Dr. Manchio: The enhanced recovery after surgery protocol is an integrated approach to the patient’s preoperative, intraoperative and postoperative care. It has been around for well over a decade, and it involves many clinical components, all of which have very high levels of evidence that show reduced risk of complications, shortened length of stay and an improved overall patient experience.

The protocol starts preoperatively, when we first meet the patient and talk with them about things like the risks of smoking and diabetes, the risks of complications such as infection or wound healing problems, and then some newer elements such as their nutritional profile. We want to be sure patients are nutritionally optimized, because many patients going into cancer surgery have lost a lot of weight in a short period of time. So we’ll look at lab tests prior to surgery to determine if we need to make some improvements for proper nourishment before their procedure.

Then, intraoperatively, the anesthesiologist gives the patient a form of nerve block during the procedure. It is injected directly into the nerves of the abdominal wall or, in some instances, into the spinal canal so that when the patient wakes up in recovery, they wake up with far less pain and they require far less narcotics for pain control. Fewer narcotics mean less issues with nausea and constipation. This allows the patient to start eating the same day of surgery. Postoperatively, we work with patients to get them up and walking around the same day of surgery and multiple times a day starting the day after surgery.

All of these elements, along with many others, are factored into the patient’s overall recovery, which drives down their length of stay in the hospital. In fact, we’re able to discharge between 15 and 20 percent of our surgical patients the day after their surgery by following this enhanced recovery pathway. Providence St. Joseph Health has invested a great deal of time and resources into this and has dedicated nurses whose sole responsibility is to help implement this process. As a result, we’re seeing significant improvements in patient outcomes and their quality of life after they go home from the hospital.

Do you think outreach efforts, such as Colorectal Cancer Awareness Month, have had a positive impact in terms of getting more men and women in for appropriate screenings?

Dr. Manchio: There is no question that public awareness and alleviating fears and misconceptions about colorectal cancer is having a profound impact on encouraging early preventative screenings. I think things like supporting National Colorectal Cancer Awareness Month play a key role in encouraging people to pay attention to their bodies and being proactive.

Dr. Hayman: Greater awareness among the public is the first step toward increased prevention, and colorectal cancer is one of the most preventable cancers if it’s caught early. Something on the order of six of 10 deaths from colorectal cancer could be averted if everyone age 50 and up were regularly screened, according to the Department of Health and Human Services.

Amy Myers: Education is key to getting the right people screened at the right time.

Get screened and schedule preventive visits. Remember, early detection is the key to minimizing your risk of colorectal cancer. Find a doctor near you using our provider directory.

For more information on colorectal cancer and additional cancer resources throughout the Providence St. Joseph Health network, visit:

AK: Providence Cancer Center

OR: Providence Cancer Institute, Portland and surrounding communities

CA: Gastrointestinal Oncology Center, Providence Saint John’s Health Center and the John Wayne Cancer Clinics; Colorectal Cancer Program, St. Joseph Hospital, Orange

WA: Providence Regional Cancer System; Swedish Cancer Institute; Kadlec Oncology Program; Pacific Medical Centers

MT: Montana Cancer Center at Providence St. Patrick Hospital and Providence St. Joseph Medical Center