Last week, a colleague, who is a colorectal cancer (CRC) survivor, reminded me that it’s CRC Awareness Month and I should write about it. He was diagnosed incidentally with early CRC during a work-up for other medical problems more than five years ago and successfully underwent surgery followed by chemotherapy.
With God’s grace, there is no trace of cancer recurrence with his semi-annual check-ups. By all medical parameters, he’s considered cured from his cancer.
CRC is one type of cancer that if diagnosed early enough, could be curable by surgery, with some requiring chemotherapy and radiation. We’ve seen cases who remain cancer-free decades after they were diagnosed and treated for CRC.
Some very early cases of CRC may not need chemotherapy or radiation anymore after surgery. But vigilance in monitoring for recurrence is important no matter what the stage of the CRC.
The goal of CRC Awareness Month is to make the public conscious about early diagnosis. This is attained by being conscious of the symptoms of CRC—and if one is considered high-risk due to a strong family history of CRC—or previous diagnosis of colon polyps, then one should undergo regular screening even in the absence of symptoms.
Symptoms
Because many are diagnosed when they’re in the advanced stage already, CRC remains one of the leading killer cancers in the country and worldwide. There is no question that every physician would like the incidence of this cancer to be dramatically reduced. We suggest that all physicians make an effort this month to advise their patients about early detection of CRC, regardless of what their medical problems are.
Patients with CRC may have non-specific symptoms like loss of appetite and reduction in weight, nausea, anemia, tiredness or easy fatigability and vague abdominal discomfort.
More specific symptoms that may warrant a work-up for CRC include: a change in bowel habits like alternating diarrhea and constipation, or feeling that the bowel does not empty completely; bright red or very dark blood in the stool; loss in caliber of stools that look narrower or thinner; abdominal pains, bloating or fullness and colicky cramps; noticeable weight loss.
If one experiences any or several of above symptoms, it warrants a discussion with one’s family physician. CRC patients are getting younger and younger. When I was a newly practicing physician, we’d only consider CRC if one is middle age or older. In the last 10 years, we’re occasionally seeing CRC cases in their 30s or even late 20s. So, age is no longer an absolute criterion when deciding who to screen or work up for CRC.
Environmental factors including diet, pollution and the excessive stress of modern living may be playing important contributory roles. Before, we emphasized the dominant role of genes or familial factors. Now, we call it epigenetic factors, brought about by environmental triggers that can lead to the development of CRC.
Although several screening tests for CRC have been recommended, in our clinical practice, we find colonoscopy and determination of occult colonic bleeding with the fecal (stool) immunochemical test or FIT as the most practical and useful.
What FIT tests for
The FIT tests for occult or unseen blood in the stool, which can be an early sign of CRC. Grossly, no blood could be seen but the test could detect human blood coming from the lower intestines. Medicines and food do not interfere with the test, although we still advise our patients to avoid uncooked meat or fish for two days prior to the test as this may contain blood which may still affect the result. This is not a standard requirement though.
With the FIT, one does not have to collect and bring a stool sample to the lab, which is most inconvenient and some feel squeamish doing it. One is provided the test kit with detailed instructions on how to collect a small amount of sample by using the brush in the kit and apply it to a test card. The card is sent back to the lab.
The FIT is considered to be more accurate and yields fewer false positive results than other tests determining occult bleeding.
A normal result indicates that the test did not detect any blood in the stool, but it must be noted that some CRCs may not always bleed. It’s best to repeat the test a few times to confirm that there is really no blood in one’s stool.
On the other hand, if the FIT is positive, your doctor may opt to do a colonoscopy, which is a procedure in which the gastroenterologist or gut specialist inserts a long, hose-like instrument into the entire length of the colon. It has a camera at its tip which can visualize any abnormality inside the colon. It’s like being in one of those deep-sea reconnoitering vehicles exploring the cavernous recesses of the deep seas.
Digestive endoscopy, of which colonoscopy is party of, has revolutionized the diagnosis and treatment of various gastrointestinal tract (GIT) disorders, especially cancers. The GIT used to be called the “temple of surprises” with many hidden problems in its inner recesses which could not be detected early with traditional diagnostic modalities.
With the advent of modern endoscopic techniques, early detection of GIT disorders is now possible. Therapeutic or curative interventions could also be done with the procedure.
A frequent finding during colonoscopy are polyps, which are tiny outpouchings in the gut’s inner lining that are known to be precursors of cancer. In the polyp stage, they’re benign or noncancerous, but after several years, they can become cancerous. Hence, colonoscopy can be lifesaving for many.
Lives saved
We’re happy for the thousands of lives saved by the timely diagnosis of colonic polyps or the CRC itself, wherein early surgical resection is curative.
I wish modern digestive endoscopy was already available decades ago. They probably would have saved my two older brothers from CRC.
Manoy Greg, my eldest brother and one of the most brilliant lawyers our country ever had, succumbed to this disease three years and three months after diagnosis. He underwent extensive surgeries here and in the United States.
For a while, he was in remission. We thought the cancer had been licked for good. But after over a year of remission, it came back, with a vengeance. It would not respond even to potent anticancer therapies. He breathed his last at age 59.
Francis, my other brother, who came back to the Philippines after staying almost 25 years in Canada, also died of CRC at age 57, less than six months after diagnosis and even after 11th-hour efforts to save his life.
Gastrointestinal cancer seems to be the Achilles heel in our family. Another brother, Mario, died of liver cancer at age 67.
I’m fortunate to have been a beneficiary of digestive endoscopy when I first underwent colonoscopy around 12 years ago at Manila Doctors Hospital.
Noted gastroenterologist Dr. Choy Nolasco performed it on me, with Dr. Mon Pesigan and Dr. Ariel La Rosa giving the intravenous sedation.
Dr. Nolasco expertly removed three polyps from my colon, one of which was quite big already and almost ripe to become cancerous tissue in a few years.
Life-changing moment
It was a life-changing moment for me. Still partly in dream state due to the anesthesia, I cried like a child when Dr. Nolasco informed me of the findings and that all the polyps have been successfully resected. I could see the faint figures of my brothers, smiling and giving me a thumbs-up sign. I was saved with early diagnosis, and I wish the same for the millions worldwide who are at risk to develop CRC.
So, if possible, colonoscopy to screen for CRC is indicated in the average-risk patient, beginning at the age of 50 years and every 10 years thereafter, regardless of gender.
For those with a family history of CRC, Dr. Jun Ruiz, gastroenterologist at The Medical City who’s also very passionate about and active in CRC awareness campaigns, recommends it to be done earlier, beginning at age 40, or 10 years earlier than the age at diagnosis of the youngest relative diagnosed to have CRC, whichever comes first.
Family history of CRC is a major risk factor, and first-degree relatives of CRC patients have up to threefold increased risk of dying from CRC. The risk decreases past the age of 60.
Those with a first-degree relative diagnosed with CRC at or more than age 60 are advised to undergo routine CRC screening, just like an average-risk individual beginning at age 50.
Patients younger than 60, or those with two first-degree relatives with CRC like in my case, should have a colonoscopy every five years.
If a colonoscopy could not be done due to financial constraints or other reasons, then screening with the FIT is the next best alternative; but if it’s positive, there is no choice but to proceed with a colonoscopy.
So, if you’re past 50, have yourself checked to rule out colon cancer. It might turn out to be one of the best decisions you’ve ever made. INQ