Commentary – March 2012
Tex Med. 2012;108(3):55.
By Craig Johnson, MD, and Harry Sarles Jr., MD
In 2001, the Texas Society for Gastroenterology and Endoscopy (TSGE) teamed up with Texas legislators, the governor, and ultimately the citizens of Texas to enact a colorectal cancer (CRC) screening bill, making Texas the second state in the nation to pass this kind of legislation. Texans now have covered access to colon cancer screening. Multiple states have passed similar legislation.
Colon cancer is the second leading cause of cancer death (56,000 deaths per year) and the third most common cause of cancer (147,000 new cases per year) in the United States. Colon cancer affects men and women equally. CRC can be prevented, not just detected, with appropriate screening by colonoscopy. Based on national data, 45 percent of Americans are taking advantage of available screening. This utilization should be 100 percent.
The American College of Gastroenterology (ACG) screening guidelines recommend colonoscopy as the preferred CRC prevention strategy. Screening should begin at age 50 for the average risk patient. CRC incidence and mortality rates are highest in African-American men and women. Compared with white patients, African-Americans have decreased survival. For these reasons, African-Americans should begin screening at age 45.
Survival can only improve with the use of high-quality colonoscopy. Pristine bowel preparation is essential, and the 2009 ACG guidelines recommend split dosing of the preparation as the gold standard. Colonoscopy should be performed by well-trained highly skilled physicians.
Colonoscopy is the only strategy that provides prevention because of adenoma removal. Other detection tests include fecal imunohistochemical tests and CT colography.
"Doctor, how can I prevent polyps?" This is one of the most commonly asked questions after a colonoscopy. The polyp-to-cancer sequence is well established, but only 30 percent of all polyps removed are from patients with a positive family history. The answer lies in the genes. This year, patients can expect to pay about $1,000 to have their genome mapped. (Most insurance plans do not cover it.) Then they will know if they have one of many polyp/cancer markers.
Other good news includes the use of the common aspirin in doses between 81 mg and the adult size (325 mg), depending upon the patient's risk stratification. Data suggest this daily dose reduces polyp formation. It reduces the risk of recurrence in colon cancer survivors by more than 35 percent.
Other less predictable ways to decrease polyp/cancer risk include a low-fat diet and high dietary calcium.
Lastly, what about alcohol? The Wall Street Journal summarized the two faces of alcohol in a Nov. 1, 2011, article. The risk for colon cancer increases 52 percent in people who have more than two drinks per day. A drink is considered to be 4 to 5 ounces of wine, 12 ounces of beer, or 1.5 ounces of 80-proof liquor.
March is designated as Colorectal Cancer Awareness Month. TSGE recommends all physicians in Texas talk to their patients about appropriate screening for CRC. For more information, click here.
Dr. Johnson and Dr. Sarles are past presidents of the Texas Society for Gastroenterology and Endoscopy. Dr. Johnson practices in Houston. Dr. Sarles practices in Rockwall.
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