Ask Us Anything About… Colorectal Cancer

Scott Gilbert – From Penn State Health, this is Ask Us Anything About Colorectal Cancer. I’m Scott Gilbert. The second leading cause of cancer deaths in the US is also often easy to catch early. Even before it’s cancer. Well, as March is national colorectal cancer awareness month, it’s a good time to learn more about the risk factors and screening methods involved. In fact, there are some new guidelines we want to make you aware of and here to talk about all of that is Dr. Hadassah Consuegra. She’s a colorectal surgeon at Penn State Health Holy Spirit Medical Center. Dr. Consuegra, thank you. Great to have you with us today. What can we do to reduce our risk of getting colorectal cancer in the first place? Can you talk a bit about the connection with lifestyle?

Dr. Hadassah Consuegra – Yeah, that’s a huge, important aspect of preventing colorectal cancer, right? Obviously, we’re going to get into screening but what — what can we do to prevent it before it even becomes a cancer. So overall, healthy lifestyle is the most important thing. When we talk about that we’re not just talking about activity, but also diet. So making sure you get your fresh fruits and veggies, your fiber, anything with fiber is super great for your colon. Avoiding those red meats. Decreasing the consumption of alcohol, tobacco. All of those things are going to help decrease your overall lifetime risk of getting colorectal cancer. On top of that, those things are going to help you decrease your risk of obesity, but also adding in the physical activity to again, stay active and help decrease those risks.

Scott Gilbert – So there’s some of the factors we can control. On the other side of things, we’ve got things like family history, genetics, race. How important is it to screen these patients early? And what is the connection with those factors?

Dr. Hadassah Consuegra – Yeah, so it’s really important to screen those patients specifically on top of obviously, our average risk patients. When it comes to family history, genetic history, race, we typically change the guidelines, which I’m sure we’ll talk about later and decreasing the age when we start screening patients as well as increase the frequency with which we screen those patients.

Scott Gilbert – You’re watching Ask Us Anything About Colorectal Cancer from Penn State Health. Dr. Hadassah Consuegra. She’s a colorectal surgeon at Penn State Health Holy Spirit Medical Center. She’s here to answer my questions, but also your questions. And we hope that you’ll add those to the comment field below this Facebook post. Even if you’re watching this interview after the fact and not live, we can still get you some answers. And if you’d prefer not to ask your question publicly, you’d prefer for it to be anonymous, you can send it as a private message to the Milton S. Hershey Medical Center Facebook page, and we’ll de identify when we ask it of Dr. Consuegra. So you know, one of the things that sets colorectal cancer apart from many other cancer types is the ability to catch it before it’s cancer, you know, that would seem to suggest that screening is everything, isn’t it?

Dr. Hadassah Consuegra – Screening is the absolute most important thing. No matter how healthy you are, which obviously we continue to emphasize, screening is the best, most proactive way to take care of your health and be on top of that so that you can prevent this. Right?

Scott Gilbert – So who should be screened and when? I mean, this is an important question, because your answer to this is going to be different than it might have been a year or two ago, guidelines have changed, right?

Dr. Hadassah Consuegra – Yeah. So for years now, there’s been a specific group of patients that we’ve screened at a younger age, specifically African Americans. We recommended screening at the age of 45. In the last several years, American Cancer Society has actually changed the recommendations from 50 to actually 45 as well, for all patients. I should say all patients of average risk. Again, starting at age 45, is going to help catch those cancers even sooner as the incidence of cancer in patients younger and younger are being diagnosed more frequently.

Scott Gilbert – And you mentioned race. What about family history? Probably another factor that involves an earlier screening, right?

Dr. Hadassah Consuegra – Absolutely. So when we talk about screening, we kind of lump patients into average risk and then high risk patients. So high risk patients definitely get screened at different intervals as well as younger age. So when we talk about specifically family history, we’re actually recommending to screen patients starting at the age of 40 or 10 years before the youngest family member was diagnosed. And we talk about family members, we’re specifically talking about first degree relatives.

Scott Gilbert – So mother, father, brother, sister, those patients. And as you note as the — the guidelines for screening become younger, it’s because we’re seeing more incidents, a rising incidence in younger people. Do we know why that’s the case?

Dr. Hadassah Consuegra – We don’t know exactly. We want to obviously attribute it to a lot of the risk factors that we talked about earlier. Again, those healthy lifestyle and whatnot. We are kind of attributing it to that, however, I think there’s a lot of risk factors that we haven’t yet established yet. So there’s still a lot more research to be done. Overall, the most important thing is because we are seeing it, we definitely want to make sure that primary care physicians are aware of that and patients so that again, advocate for yourself to get a screening that much sooner.

Scott Gilbert – And we’ll talk about the various types of screenings shortly. But once somebody is screened, how often will they need subsequent screenings after that? Is it frequent?

Dr. Hadassah Consuegra – So it’s actually not that frequent, depending on what we find during your colonoscopy. So it’s every 10 years for an average risk patient, again, that really is variable for each patient. So if we find polyp, or we find numerous polyps, or depending on the pathology of those polyps, that can definitely change your frequency. And actually, we would suggest, again, maybe a little bit sooner rather than the 10 years. So it’s actually not that frequent, again, depending on what we find. So it’s very individual basis.

Scott Gilbert – And speaking of those screening methods, let’s get into those now. We often hear about colonoscopy, that’s the gold standard, isn’t it?

Dr. Hadassah Consuegra – Absolutely. Colonoscopy is hands down the best test that you can do for this. The reason being is — and I’m sure we’ll talk about that in a second — is this test allows us to not only see what we need to look for, but it allows us to intervene, right. So if we — when we do the colonoscopy, we’re able to insert the colonoscopy through the anus and work all the way around to the beginning of the colon on the right side, and even see the distal part of the small bowel. By doing that, again, we’re looking for any abnormalities including polyps, and during this procedure, we’re actually able to take care of that. And that means we can either take a bite of it and send it to pathology, or we can even hopefully, remove it completely, and you won’t have that polyp anymore.

Scott Gilbert – Yeah, and talk a bit about — a bit more about what a polyp is, if you could, because it’s not always cancer, right? In fact, it often isn’t.

Dr. Hadassah Consuegra – Absolutely and that’s the key again, with screening is that these polyps are just colon tissue that has kind of multiplied and created this various types of polyps, it can be one that looks kind of like a lump, it can be flat. But by removing these — these polyps before they become cancer, we’re again preventing a patient from having cancer down the road. And that’s the key is that once we are removing these polyps, we’re able to look at the specific types of polyps to determine is this one that’s more high risk that we maybe need to change the frequency so that again, we’re intervening before something happens.

Scott Gilbert – This is Ask Us Anything About Colorectal Cancer from Penn State Health. We’re talking today with Dr. Hadassah Consuegra. She’s a colorectal surgeon at Penn State Health Holy Spirit Medical Center in Camp Hill. We welcome your questions for her, so add those to the comment field here. Or you can send them if you prefer as a private message to our Facebook page and we’ll de identify them before we ask them. So we’re talking about colonoscopy here. And some people might say, yeah, I get that it’s the best but oh that prep, they fear that prep. What’s your advice for them on — on kind of weathering that stage of things.

Dr. Hadassah Consuegra – The prep, I will say is everyone’s big complaint. The colonoscopy is the — the breeze in the park you get a really — get nice nap, you’re not having to deal with that part. The prep is the hardest part for people to deal with. That being said, the preps that we do nowadays are so much better than the preps we used to do several years ago, there’s so many different alternatives. Each person, each physician is going to have their own preference on the specific type of bowl prep you use. But if you stick through it, it’s a day. You know, it can change your life. So I would say just stick with it and it’s worth it.

Scott Gilbert – Right, beats the alternative. Right?

Dr. Hadassah Consuegra – Absolutely. So we talked about colonoscopy. I’ve also heard of sigmoidoscopy, what exactly is that and how does it compare?

Scott Gilbert – Yeah, so a colonoscope is a long flexible tube, right, that we’re able to snake through the colon. The flexible sigmoidoscope is similar to it, and that it’s just a little bit shorter. So while it gives us the same view, it only actually shows us about half of the colon. The benefit of it is again, it’s a little bit shorter procedure, but really honestly, you know, you still kind of have to go through the bowl prepping, you’re not able to visualize the whole colon. So to me, obviously, again, that kind of emphasizes why the colonoscope or colonoscopy is the gold standard.

Scott Gilbert – And if you’re going to go through the bowel prep you might as well get the colonoscopy it sounds like.

Dr. Hadassah Consuegra – Yeah, exactly.

Scott Gilbert – Because it’s more thorough, it inspects more of —

Dr. Hadassah Consuegra – Absolutely.

Scott Gilbert – Everything that’s down there.

Dr. Hadassah Consuegra – Yeah, there’s a chance of missing tumors on the right side of your body, so.

Scott Gilbert – What about stool DNA tests? We see these advertised. Things like Cologuard. How do they stack up compared to the other methods?

Dr. Hadassah Consuegra – Yeah, the benefit with the Cologuard test is that you kind of get to do it from the comfort of your own home, right. You don’t have to do the bowel prep. You don’t have to go in, you know, have a procedure. That being said, it definitely — you have to weigh the pros and cons, right. So what it does is it specifically looks for DNA in your stool, that is correlating with again colon cancers or large polyps, and again, it looks for those — that DNA within the stool. If it finds DNA in the stool that’s consistent with a cancer or polyp it only kind of gives us a yes or no answer, if you will. So, regardless, you still have to undergo a colonoscopy then once it says it is positive for us to be able to actually locate, is there a tumor? Is there a polyp? Can we take care of it via a colonoscopy? The other kind of downside with that is there are some false positives and false negatives, right. So there’s a chance that we could miss something and there’s a chance that you have a positive and you go — undergo a colonoscopy anyways, and you may not find anything. So it’s definitely important to, again, have a conversation with your primary care physician about this. The other downside is not everyone can do it, right. So there are certain contraindications or patients that may not qualify for a Cologuard. Specifically, we’re talking about patients who have a family history of colon cancer, they have a genetic or familial disease related to colon cancer. They themselves have had colon cancer, or they have polyps in the past or if they have rectal bleeding. So that would not allow you to have the Cologuard.

Scott Gilbert – We’ve talked quite a bit about the familial connection. And Kathy has a question related to that here. She’s asking my maternal grandfather has colon cancer, my mom passed away at 62 from colon cancer, Kathy, we’re sorry to hear that. My uncle, she says, her brother had cancerous polyps removed, she said she had her first colonoscopy at 40. And it was clean, but she says I have to go every five years, would I be considered high risk? And should I go earlier or more frequently than every five years?

Dr. Hadassah Consuegra – That’s a great question. So you are considered high risk in the sense of your family history. That being said, in a high risk patient, as long as their colonoscopy is clear, we do recommend every five years. So that can change. You know, if your colonoscopy showed something, we may decrease that — or increase the frequency. So have you come back sooner. But if your colonoscopy was clear during your first one, then you can go ahead and wait the five years. Obviously, I always emphasize to my patients, if you notice a change in your bowel movements or any blood in your stool or anything like that, that would be important to let your physician know sooner so that you’re not waiting the five years.

Scott Gilbert – Thank you, Kathy, great question. And we welcome all of your questions for Dr. Consuegra, just add them in the comment field below this Facebook post. Our next question comes from Daniel. Daniel saying he had a colonoscopy, I’m sorry, colonectomy about five years ago, should I be concerned about recurrence.

Dr. Hadassah Consuegra – So when we talk about colectomy, again, it would be important to know specifically why you have the colectomy, what type of tumor you had, how invasive or aggressive it was. But typically, when we talk about cancer surveillance, or again, monitoring patients after they’ve already had a history of colon cancer, we typically follow them out several years, a lot of times, again, five years, even sometimes farther, depending on the type of tumor again. So that would be a conversation with your family physician or your surgeon that did your surgery, that they can review all of that and make sure that you’re continuing on the surveillance pathway.

Scott Gilbert – Yeah. And it seems like some of these questions point to the fact that there are some very unique — everybody’s got a unique situation, right.

Dr. Hadassah Consuegra – Absolutely.

Scott Gilbert – And so it’s really hard to — to give advice that really applies to everybody. But you know, I think — again, I think these are really great questions that point to just how everybody’s coming at this with different risk factors and different circumstances.

Dr. Hadassah Consuegra – Absolutely.

Scott Gilbert – We welcome your questions for Dr. Consuegra, drop them in the comment field below this Facebook post. And again, you’re welcome to send them as a private message to our Facebook page, if you prefer to ask your question anonymously. So I was wondering about symptoms. Let’s say somebody hasn’t gotten a screening, or are there some concerning symptoms people should watch for? Does it typically present in the same way in everybody or not so much?

Dr. Hadassah Consuegra – That’s an important question to ask. And even more important to emphasize why we talk about screening, right? So probably the most common symptom is no symptom, which is why we try to do screening so that we can catch them before patients do have symptoms, right. When we talk about symptoms that patients do have, though, some of the questions we ask are if you’ve noticed blood in your stools if you’ve had a change in your bowel movements. So not only the consistency but also you know the size, the quality. Sometimes you can have bright red blood versus you know, even darker, darker stools. Abdominal pain, which can be vague but again, something to keep in mind, abdominal bloating or dissension, weight loss, and those are kind of some of the more common but also vague symptoms. When we talk about it getting farther along, they’ve usually become more symptomatic. So as the tumor progresses, as it becomes larger, patients can actually have bowel blockages or when the tumor gets so big that it won’t allow stool to pass. And that’s obviously a much more concerning symptom. Sometimes it can get so big that it actually pokes a hole in the colon wall or has a perforation, if you will. So it’s super important again, to emphasize even more the importance of screening to catch it before you do become symptomatic.

Scott Gilbert – All right, we have a comment now from Arletta, she’s just sharing some of her experience. She says she did the home DNA test for three years. The last one was flagged, colonoscopy found stage 3a cancer, surgery and six months of chemo, but it’s almost a year now since the last chemo treatment. Colonoscopy in the fall found polyps but they were non cancerous. Agree colonoscopies are easy. The prep is the worst part. So you know, here’s a real success story of somebody who went through — you know, she did the home DNA test. It got flagged, and then she followed up, which seems like a very key step here.

Dr. Hadassah Consuegra – Absolutely. And I think something to also pay attention to is that she’s had three tests, right. And it wasn’t till the third one that it became positive. So it’s important to also realize that each test has its fallibility. So we want to make sure and again, emphasize the importance of colonoscopies, because the false negative rate is much lower than a Cologuard test. Because you’re able to, again, visualize something, but that’s great. That’s an awesome success story.

Scott Gilbert – In addition to her comment Arlette has a question that is, for your opinion, on the age to first get a colonoscopy, do you feel that 50 is too old? I see a number of cancer patients in my support group who are in their 30s or younger. And I know Dr. Consuegra, you did talk about how we’re — you know that those guidelines have dropped a little bit, but 30 sounds really young for colon cancer?

Dr. Hadassah Consuegra – Absolutely. In those patients, you always have to question whether there’s some type of genetic or familial trait in the younger population, but absolutely, we do see patients who are even younger than 45. But again, typically, there’s not always but often some other underlying process that’s happening as well. So I do think 50’s too old, hence, I would definitely emphasize again, screening at age 45, unless you definitely have one of those family histories or disorders that would preclude you from getting it that late.

Scott Gilbert – As I mentioned, it’s national colorectal cancer awareness month. We use that term. But in fact, the term colorectal cancer lumps together two different types of cancer, colon cancer, and rectal cancer. And when it comes to treatment, each is managed differently. Can you walk us through that a bit?

Dr. Hadassah Consuegra – Yeah, so the first step in diagnosis and management and treatment is obviously getting a piece of that specimen for pathology to say you do or you don’t have cancer. Once you do that, then you start working out the patient. And in that sense, colon and rectal cancer is the same type of similar start of the workup, right? So when we first diagnose someone, we go ahead and stage them. When we talk about staging, we’re not only looking at the tumor itself, but we’re also looking to make sure has it spread elsewhere. So the first thing we do is look for spread elsewhere. And we order CT scans of not only the abdomen, but as well as the chest, because that’s the most common places for colon cancer to spread. And again, that’s the same thing for rectal. Once again, we decide okay, there’s no spread elsewhere, then we have to determine whether we go ahead with surgery or, again, an alternative like chemotherapy. Most often we attempt surgery in these patients, as long as they’re not spread elsewhere. There’s other factors that we look at, like local spread of the disease, as far as you know, is it real bulky tumor has it invaded other organs. Sometimes in those situations, we’re talking about chemotherapy first to try to hopefully decrease the size of the tumor before undergoing surgery. But all of that, again, as you’ve said before, is kind of on a patient basis. As far as rectal cancer. I know we mentioned the CT scans. One of the things we do in addition to the CT scans is actually an MRI. The nice thing about the MRI is it actually allows us to see how much has the tumor invaded locally in the pelvis and is there any lymph nodes that have been involved? More often than not rectal cancer is treated first with chemotherapy and actually radiation as well. And then you know, depending on how that goes, we talk about surgery. So it’s very important to kind of distinguish them.

Scott Gilbert – And chemotherapy and radiation again used not to — as a curative necessarily but rather to shrink it make it more manageable so a surgeon can handle it?

Dr. Hadassah Consuegra – There is some literature to suggest that sometimes chemotherapy and radiation alone can be curative, obviously with close observation, but oftentimes yes, it does lead to surgical resection.

Scott Gilbert – As a physician, I have to ask, do you see a disconnect between the fact that colorectal cancer can be detected in the pre cancerous stage right, here we talked about polyps, yet it’s also the second leading cause of cancer deaths. I mean, I don’t want to put words in your mouth. But that — that seems — that must frustrate you to some extent.

Dr. Hadassah Consuegra – It does. And I think the big problem is people are just so hesitant to do it, right? You got to have somebody that’s kind of in your court and pushing you in a way sometimes. Everyone hears just the horror stories of bowl preps and whatnot, or they know someone that had a bad experience. And I think it’s just so important to continue to emphasize that you got to get screened early. But you’re right, it is frustrating that we’re waiting till these tumors become bigger. You know, we can catch this sooner, and we can — we can treat people before it even becomes a problem. So, it goes back to just emphasizing screening, screening, screening.

Scott Gilbert – Yep, indeed. And I know we’ll add some information in the comment field of this Facebook post. So you can learn how you can get in touch with Dr. Consuegra and her office. But I want to thank you very much for taking the time today to talk with us Dr. Consuegra.

Dr. Hadassah Consuegra – Absolutely.

Scott Gilbert – There are a lot of folks here who — on the feed that I think have found this to be useful, including I want to thank Joyce for her kind comment here. She says thank you, Dr. Consuegra for all your useful and important information. And it has been just that, so I appreciate that. And also some really great questions from Joyce, from Arlette, from others, from Daniel, Kathy, so thank you for the great questions. Thank you for watching Ask Us Anything About Colorectal Cancer from Penn State Health.