Screeing for colorectal cancer saves lives — but, unfortunately, Novant Health surgeon Dr. Joseph Payne says that opportunity is missed by a large portion of the population. Sadly, that included his father, who passed away from the disease.
Payne also says that non-invasive diagnostic testing like Cologuard doesn’t always detect cancerous polyps with the same degree of accuracy as a colonoscopy does; however, the company that produces Cologuard testing kits claims they could be a substitute for those at average risk.
Rachel Keith: If you have symptoms of colorectal cancer, it's not too late, necessarily, but the reason why we’re discussing this is that it can oftentimes be prevented through a colonoscopy.
Dr. Joseph Payne: Correct, the media is full of articles about colon cancer, and almost all of them focus on symptoms, and we would like to never have symptoms. You don't have to worry about winning the war if you prevent the war to start with.
RK: And you're saying now, or the doctors or medical practices are saying, that 45 is probably a good age to start to get a colonoscopy that screens for this cancer.
JP: That's correct for years, the recommended starting age for colon cancer screening was 50. Then it shifted to African Americans at 45 and everyone else at 50. And then in the last few years, with the increased incidence of colorectal cancer, not just in Black people younger than 50, but in everyone younger than 50. The recommendation has changed to 45, and I'll emphasize that it's just for people at average risk. If you have a family history or long-standing inflammatory bowel disease or other reasons, then you should probably start even earlier.
RK: Why do you think it shifted to earlier? Were you seeing more cases? Or what was the research telling you in your practice?
JP: Absolutely, we're seeing more cases, and this probably started in the 1980s. When I was a fellow at the Cleveland Clinic Foundation, we were actually starting to look at younger people with colorectal cancer. But in the last three decades, it's come close to doubling each decade. So it used to be that of the people who have colon cancer, one in 10 of them were under the age of 50. Now it's more like one out of five.
RK: And do we know why? Is it environmental?
JP: So far, we don't really know. There are several leads. We thought it might correlate with increased obesity, but the statistics haven't really borne that out. Clearly, there are environmental issues. I mean, our food contains all kinds of preservatives and microplastics, and we just don't look after our bodies.
There's also a bacterial toxin implicated, called Colibactin; hopefully, that will have something to do with it, because it might give us some direct prevention. But there are many theories, and we just don't know.
In addition to the increase in younger people getting colon cancer, there is also an increase in the cancer moving to the left side. And I guess in layman's terms, that means more downstream. Earlier in my career, younger people had a predominance of colon cancer on the right side of the body, near where the appendix lives. And for some reason, in that same interval of time, it switched more towards the lower end of the bowel, down into the rectum, which has even more consequences than if it's in the more proximal or upstream colon.
RK: Say you come in because you're doing your due diligence; 'I'm 45. I'm going to start this.’ And maybe you do see something; their chances of survival are pretty good, is my understanding.
JP: So, completely true. Early-stage colorectal cancer is highly curable. Late-stage colon cancer is highly incurable, so there is definitely value in making the diagnosis early. What we really want to do, however, is prevent it altogether in the average-risk population, meaning those who don't have inflammatory bowel disease or other problems. There's this thing called the adenocarcinoma sequence. And in plain English, that means that there are benign growths called adenomatous polyps that, for whatever reason, form in the colon and then, over a period of years, get into a bad mood and become colon cancers. So if we can find all of the adenomatous polyps and remove those, we don't completely remove the risk of getting colon cancer, but we're very close to it.
So prevention, here is the goal, not necessarily early detection of colon cancer, and that's one of the reasons that I'm bothered by Cologuard, we can't get through an evening meal if you watch TV while you eat without seeing the big box for [it] right there in the middle of your dinner. And while Cologuard is pretty good for detecting early colon cancer, it is pretty terrible for detecting the premalignant lesions that we would like to find. So while it's a lot better than nothing, it is nowhere near the equivalent of a colonoscopy, and the company doesn't really market it that way.
They chop up their statistics so that if you do Cologuard every three years, you have a comparable life saved to colonoscopy. But what they're including in those statistics is that many people don't follow through with a colonoscopy. So if we could get everyone screened with a colonoscopy, Cologuard would be nowhere near as effective, and that's lost on the population.
RK: That's where you send off a fecal sample, right?
JP: That's correct. It works by looking for blood in the stool, which, of course, we've had fecal blood tests for years and years. And the current Cologuard test looks for 11 tumor antigens in stool. So, unless you have an advanced enough lesion that's shedding tumor antigens, it won't show up. And we want to get it before then there's also a fairly high false positive rate with Cologuard, which does two things, it creates an awful lot of anxiety for patients, and the other thing that it does is it changes your colonoscopy from a screening colonoscopy, which Medicare and most insurance companies cover completely, to a diagnostic colonoscopy, which frequently insurance does not cover as well.
WHQR reached out to Cologuard about their diagnostic testing. Exact Sciences, which makes the testing kits, sent information from Dr. Travelle Ellis, its senior medical officer. The company mainly claims that a Cologuard test is a “noninvasive option for screening for people aged 45+ at average risk of colorectal cancer. Anyone with symptoms of colorectal cancer or at high risk needs to get a colonoscopy.” This is in contrast to Payne’s medical advice that most people, starting at 45, should have the procedure every 10 years. The company also said that the need for screening exceeds surgeons' capacity to perform colonoscopies.
As for the insurance coverage on a positive test from a Cologuard, they write, as of 2023, “A follow-up colonoscopy after a positive Cologuard test should not come with added cost for most people on most health plans.”
With regard to Cologuard Plus, which is the company’s newest screening test, the company responded, “Based on [a] clinical study, the Cologuard Plus test detects 43% of advanced adenomas and 73% of high-grade dysplasia, a type of precancerous growth that is likely to advance to cancer.”
As for the false positive rate, for Cologuard Plus, “Modeling data estimates that out of 10 people who receive a positive test result, seven would have a clinically actionable finding on colonoscopy.”
RK: And how do you convince people? Because, yeah, sending off a fecal sample is way easier than going through that colonoscopy prep, and that's tough, right?
JP: Well, I think you do what we just did, which is try to explain the difference between the two procedures. And historically, when I would get pushback, I would, because people don't want to do the bowel prep, my response would be, would you rather prep for a colonoscopy or prep for surgery four or five years from now, and most people see the value in that, right?
RK: And I think people are sold on this preventative care because, for the most part, it's covered by insurance. Why did the insurance companies decide that this was worth their while?
JP: There was a lot of pressure from organizations that foster colon cancer screening. There were some colorectal surgeons who started organizations like the Colon Cancer Alliance, Stop Colon Cancer Now, et cetera, back years ago, that heavily lobbied Congress to cover it. And then, of course, there's the realization that it's valuable, and most insurance companies emphasize the bottom line. And they realized, ‘Hey, maybe we'd rather pay for a colonoscopy rather than having to pay for colon cancer treatment.’ So it's in their best interests to prevent the disease rather than treat it.
RK: And it's been in the consciousness, in the news, there have been famous celebrities like Chadwick Boseman and James Van Der Beek, who filmed here in Wilmington, that they eventually succumbed to their colon cancer because it was too late when they caught it, is that right?
JP: And it's younger people who get missed more than older people, because younger people, both themselves and their physicians, will go, ‘Oh, it's just IBS or okay, you probably got bleeding hemorrhoids or whatever,’ and just push it off. And I think the primary care physicians are realizing, along with us more and more, that, ‘hey, this needs to be checked out.’ But younger people tend to be a lot more resistant to early medical care than older people, and with tragic consequences sometimes.
RK: And when someone gets a colonoscopy at 45, they're doing what doctors recommend. Is it every 10 years that you keep checking? Or what does that look like?
JP: It's every 10 years if there aren't other risk factors, or if you didn't find adenomatous polyps on the initial colonoscopy. For the average-risk population, the recommendation is a colonoscopy every 10 years, starting at age 45.
RK: If you do find the polyps, do you see more that they don't come back once you pull them out, it's probably not probable that they'd come back?
JP: There is a risk of them coming back. So if someone has adenomatous polyps on exam, they don't get the next colonoscopy at the 10-year point, depending on the characteristics, number, or size of the polyps. They might be followed up in 2, 5, or 7 years, depending on what you find, but not for 10 years in the face of any significant adenomas. There are recommendations now that if there are tiny polyps, you can probably still go that long. But in practice, most of us aren't willing to do that.
RK: With preventative care, I mean, people want to know about lifestyle things. Is there anything, as a doctor, that you would say would help reduce your risk through diet or exercise?
JP: I mean, there are long, long lists of things that help reduce the risk of colon cancer. Probably the biggest part is the proper selection of your parents, which, of course, we don't get to do. But low meat diets, high vegetable diets, high prebiotic diets, which are essentially eating fresh fruits and veggies and fiber that the healthy bacteria in your gut prefer, staying fit, even smoking, have a risk for colon cancer, as does everything. But most of the things that reduce your risk are the same sorts of things that also just improve your lifestyle in general and are better for your heart and blood pressure, etc. So there are a lot of reasons to try to stay healthy, other than just prevention of colon cancer, but the single biggest thing you can do to try to reduce your risk of getting colon cancer is proper screening. Just get out and do it. The information is there. We know it saves lives, and it's just a shame to throw away 20 or 30 years of your life because you didn't want to do a bowel prep.
There is also a trend, based on statistics on how long people live in this country, that after age 75, people stop having colonoscopies. And I don't subscribe to that. I think if you're a sickly 75 to 80 and you have other health issues that are more risky to you than the likelihood of developing colon cancer, that makes a lot of sense. If you're 80 years old and hiking the Appalachian Trail, the likelihood that you'll be alive and well at 95 is high.
And on a very personal note, my father was working full-time at age 85 and died of colorectal cancer at 89, so a colonoscopy in his early 80s would have saved his life. So, [it’s a] classic case of no shoes for the shoemaker's father. I could never talk him into getting a colonoscopy, and sadly enough, it took his life. And it's just heartbreaking to watch that.
Just having a first-degree relative or two second-degree relatives who have colorectal cancer increases your risk. But people have taken this to mean, ‘Oh, I don't have any family history. I'm safe.’ Not true. Still, the majority of people, younger and older, who develop colorectal cancer have no one in the family with it, so just because you feel fine and you don't have a family history does not mean you don't need to have appropriate screening.
RK: Do you really look at national statistics versus state versus local? How does that look? Do we know if there are higher incidences locally, or is it just based on national numbers?
JP: I mean, we look at national numbers, and we look at local numbers. The mortality rate changes probably more than the incidence rate, because there are states that have more poverty, less access to care, where colon cancer deaths are higher per population. But looking at the United States as a whole, there are about 150,000 cases of colorectal cancer a year, and about a third of those don't survive, which means two-thirds of them are cured. But again, the early stage cancers are highly curable, and we've made a dent, especially in older people, through screening, but we're still not reaching the younger people, but they're still probably depends what you read, but 40% - 50% of people that are eligible for colonoscopies aren't getting them at the proper times, and frequently with tragic consequences.
RK: And you mentioned earlier that there were different recommendations for the Black population a while back. Is that the poverty issue, or do we know?
JP: Again, hard to say, it probably reflects some level of access to care. Again, the death rate was a little disproportionate to the incidence rate; it was being found at later stages, but it may be that it's just a little more aggressive disease in the African American population, or it may just be that it's not caught as early, and it's a little hard to filter out all of that. But the White population has unfortunately caught up, and now it's 45 for everybody.
Another thing I hear is that sometimes people express a fear of the colonoscopy procedure itself because they think it's dangerous. The thing people always worry about is that everybody has a story about someone who had a perforation. And yes, that does happen.
They always quote one in 2,000. I don't think it's even that common, because in my 36 years here, I've only had to operate on a handful of people who had a colonoscopic perforation, and that's out of the tens of thousands of colonoscopies that have been done here. Of course, other surgeons were taking care of those, too, but it's less than one in 2,000, whereas the risk of getting colon cancer unscreened is one in 20. So it's not hard to do that math.
