Colorectal Cancer

March has again been designated as National Colorectal Cancer Awareness month. This is important, as an estimated 112 340 cases of colon and 42 420 cases of rectal cancer are expected to occur in 2007.1 Colorectal cancer is the third most common cancer in both men and women; however, colorectal cancer incidence rates have been decreasing for the last two decades, from 66.3 cases per 100 000 in 1985 to 49.5 in 2003. From 1998 to 2003 the rate decreased 2.1% per year, mostly due to increased screening. An estimated 52 180 deaths from colon and rectal cancer are expected to occur in 2007, accounting for almost 10% of all cancer deaths. Mortality rates from colorectal cancer have declined in both men and women over the past two decades, which reflects declining incidence rates and improvements in early detection and treatment.

As physicians, we know that colorectal cancer fulfills the criteria for a disease for which screening is appropriate. Unfortunately, screening rates are not adequate to eliminate this important cancer. Even physicians and their families are not uniformly screened. Several factors may explain this failure.

Colonoscopy is the gold standard screening method for colorectal cancer. A major issue with the procedure has been the required bowel preparation. We currently have several methods to clean the colon prior to a colonoscopy:2 (1) the “traditional” lavage prep (Golytely, NuLightly, TriLyte, etc), (2) a low volume lavage prep (Halflightly, Miralax, etc), and (3) sodium phosphate in small-volume liquid or tablet form. Each of these methods has some advantages and limitations, but we can usually select an acceptable method. Additional information on colonoscopy and bowel preparations is available on the Ochsner Web site (www.ochsner.org/CRS).

Economics are often an issue. This is especially true with the newer catastrophic or high deductible health plans as well as copay issues. In this cost-conscious environment, we must critically analyze our recommendations. Screening has been shown to be cheaper than treating colorectal cancer if compliance rates are high and the cost of screening tests is reasonable.3 In perspective, the health advantages of screening should certainly outweigh the equivalent of several months of cable television. Current recommendations for screening for colorectal cancer range from annual fecal occult blood testing (FOBT) with flexible sigmoidoscopy at 3–5 year intervals to colonoscopy at 10-year intervals starting at age 50 for average-risk individuals. These screening methods have all shown reduced mortality.4–6 As colonoscopy views the entire colon and can treat polyps, it is the preferred method. This has been realized by Medicare, which began reimbursement for screening colonoscopy as of July 1, 2001. A newer option, being evaluated at Ochsner, is computed tomographic colography. Studies have shown reasonable accuracy in detecting “significant” lesions, but a bowel preparation is still currently required, availability of the test is limited, and reimbursement issues have not been resolved. Currently this option is best for patients with coagulation issues or a technical inability to have a complete colonoscopy.

On a national and local level, multiple efforts are underway to expand colorectal screening. Television programs, radio spots, print articles and local lectures contribute, but physician encouragement of screening must become a daily component of our patient care. We also need to lead by example and ensure that each of us, as well as our family members at risk, gets screened. Progress is occurring, but each of us needs to continue and increase our efforts to expand screening until it becomes universal. Remember, the recommendation and example of a trusted physician remains a major determinant of patient action.

Additional information is available from any of our colon and rectal surgeons or gastroenterologists and the Ochsner website (www.ochsner.org). Open access colonoscopies can be scheduled by calling one of the Ochsner endoscopy scheduling nurses at (504) 842-4060. We even have some Saturday scheduling to minimize the impact on the patient's daily schedule.

• Academic Division of Ochsner Clinic Foundation