Ask the Expert: Colorectal Cancer

The Expert: 

Dr. Fola May, M.D, Ph.D, M.Phil 

When should people start screening for colorectal cancer? How often should you get screened? 

Screening for colorectal cancer actually depends on what your level of risk is, so if you’re an individual who doesn’t have a medical condition that predisposes you to colorectal cancer and if you have no one in your family who’s had this condition, you actually will start screening at age 45. And depending on the test, you will get screened every 10 years. If you pick a colonoscopy, um, some of the less invasive tests that you can do at home – the stool kits – you need to do that every one to three years. Now, if you do have a family history of colorectal cancer — so if you have a mother, a father, a brother or a sister who’s had this disease —we actually are going to start screening you earlier. So, we’ll start screening you at age 40, or 10 years before the earliest family member was diagnosed. So, for example, if you had a father that was diagnosed with colorectal cancer at age 35, we’ll start screening you at age 25.

What are the different methods for screening? 

One of the best things about the technologies we have for screening in cancer is that for colorectal cancer in particular, there are many different ways to get screened. So, for some cancers, there’s just one option. For colorectal cancer, there’s many that you can choose from. We have a governing body in medicine called the United States Preventive Service Task Force, and they actually recommend one of seven different strategies. So, as long as you pick any one of these seven, we think that you are getting a high-quality screening test. The most invasive strategy is the colonoscopy. This is when we do a medical procedure in a hospital or clinic. We clean the colon with the laxative so that we can actually look at the lining of the colon for early signs of colorectal cancer, and the least invasive tests are the stool-based tests. These are wonderful because you can do them at home, and it just requires you to deposit a small stool sample into a Bio Safe container and send that off to a laboratory. So, you can get screened with colonoscopy, you can use one of these stool-based tests, there’s also a CT scan that’s available for screening, um, and a few other options as well.

What type of provider does colorectal screening? 

Generally, most people will get a recommendation to start their colorectal cancer screening from their primary care doctor. This is because the primary care doctor in medicine really organizes everything from preventive health to chronic disease management, so your PCP is the one that will get a family history of cancer from you, will understand your other risk factors and tell you when to start screening for colorectal cancer — whether that’s age 45 or or earlier. Now, if you choose colonoscopy as your method for screening, you will then be referred to a gastroenterologist. I’m a gastroenterologist. We perform screening colonoscopies in hospitals and clinic with the assistance sometimes of an anesthesiologist to put you to sleep for the procedure.

How do I find a provider? 

For people who are already connected to healthcare system, it’s pretty easy to find a provider who can give you screening for colorectal cancer. You just talk to your primary care physician. He or she will take care of either referring you to a gastroenterologist or ordering a stool-based kit that you can do at home. Sometimes people will see their obstetrician-gynecologists or their OB gyne as their primary care provider, and these physicians as well can recommend screening. Now if you happen to be in a situation where you don’t have a health facility that you consider home base, you can look at other resources. So, you can look for local clinics or hospitals to see if you can find a primary care provider through those networks. 

I know as well that Fight Colorectal Cancer or Fight CRC has a patient-provider portal on their website. If you google “Fight CRC patient-provider finder,” that also will point you in the direction of a gastroenterologist who can perform your screening colonoscopy.

How do you think healthcare providers can help with fear and/or anxiety around colorectal cancer screening? 

I think the most unfortunate thing about colorectal cancer screening is the lack of awareness and the misinformation. So, colorectal cancer is the second most common cause of cancer-related deaths in the United States. Unfortunately, it’s very common in women and in men, but it doesn’t have to be, because we think that we can prevent about 90% of cases with screening, so it’s really important that people understand that this is a common disease, that it’s a deadly disease, but that there’s something that we can do about it. Unfortunately, in the media, there’s been, um, a lot of jokes about colonoscopy being an uncomfortable procedure, particularly because it is involving an instrument that’s being put in an intimate area. What I like to remind people, however, is that we are bringing you into a safe hospital or a clinic setting. We’re giving you medications to put you to sleep for the procedure — sometimes completely to sleep with the assistance of an anesthesiologist — so you’re not going to feel the colonoscopy at all. You’re not going to feel pain, you’re not going to be uncomfortable during the procedure. In fact, most of my patients wake up and they look at me and say, “Doc when are you going to get started?” And I tell them we’re already done with the procedure. So really, the most challenging thing for some people is the day before the colonoscopy, when they have to do the laxative, which is the cleanser to clear out the colon of all the food and all the stool in there, and that can be a little hard for people. You’re on a clear liquid diet, and you’re taking this laxative, you’re on the toilet a lot, but once you get through that day and you come in for the procedure itself, it’s pretty easy from there. And then I’ll also mention for these stool-based tests, those you can do in the comfort of your own home, so if you’re not so keen on going in and having a colonoscopy with a gastroenterologist, just remember you still have other options. You can do these very simple stool-based tests once a year in the comfort of your own home.

What are the next steps if a colorectal cancer screening test is positive? 

For most people, you’ll get screened for colorectal cancer at age 45, and that screening test will be normal and you will be off the hook for a while. So if you get screened with a colonoscopy and it’s normal, you don’t need to do anything for 10 years. If you get screened with a stool-based kit and it’s normal, then you don’t need to repeat that test for one or three years. So you you get some protection for some time. Now, if the test is abnormal, we have to follow a different pathway. If the colonoscopy is abnormal, sometimes we bring people back as frequently as every three years, depending on the findings. If the stool test is abnormal, then those people actually need to have a colonoscopy to find out why the stool test is abnormal, and this is very important because those stool tests become a two-step process in which the 7 to 10% of people who have an abnormal result will still need that colonoscopy to figure out if there’s a polyp or a growth that’s making that stool test abnormal.

Anything else people should know about colorectal cancer or screening? 

What I always like to highlight to my friends and my female patients, also the women in my family, is that colorectal cancer can affect women too. There’s this misunderstanding that colorectal cancer is the disease of men, and that’s not true. Women, unfortunately, are getting this disease or dying of it, and it’s unnecessary in many cases because we can prevent this disease with screening. So I encourage all the women out there, that in addition to the screening that they’re doing for breast cancer, for cervical cancer, the skin checks that you’re doing for skin cancer, make sure that you also include colorectal cancer in the list of diseases that you’re working to prevent.

Where can patients go to find more resources or information about colorectal cancer?

So I always recommend that people talk to their primary care provider or trusted providers first, and also there are a lot of great resources for information on the internet. I, in particular, like the resources that are provided by Fight Colorectal Cancer or Fight CRC. On their website, they have information about what colorectal cancer is, what screening is, the different methods for screening. They also have resources on the different types of colorectal polyps. And if you are in the situation where you or a family member are diagnosed with colorectal cancer, they have incredible resources for patients and for families, so I always tell people to start there.