Dr. Indran Krishnan and Georgia Governor Nathan Deal

Indran Krishnan, MD, FRCP (London), FRCP(C), FACP, FACG is fighting colorectal cancer on many fronts. As a gastroenterologist, he personally screens people every week. As an associate professor at Emory University, he trains the next generation of physicians. As an advocate, he serves on Fight Colorectal Cancer’s Board of Directors, and was a founding member of the Georgia Colon Cancer Coalition. In the first 4 months of 2012, Indran stepped up his efforts by:

• Meeting with Georgia Governor Nathan Deal and members of the Georgia legislature to introduce them to Fight Colorectal Cancer and spread the word about screening;
• Attending this year’s Call-on Congress, our annual advocacy training and lobby day;

• Participating in a CVS Caremark webinar to speak about colorectal cancer awareness and the role of pharmacists as advocates for early detection and prevention of colorectal cancer;
• Providing the keynote speech at a “Closing Out March, Colorectal Cancer Awareness Month” ceremony sponsored by Given Imaging; and
• Answering questions about screening via Talk About Health. We thought you might enjoy reading Indran’s responses:

1. At the time of colon cancer screening what questions should a patient ask a physician?
2. Would you share what colon cancer screening is and what it entails?
3. How is it determined if someone is at high risk for colon cancer?
4. If my primary care physician suspects colon cancer, what are the next steps?
5. Is there any link between IBS (irritable bowel syndrome) and colon cancer?
6. Are there any new promising treatments or medications for men with IBS (irritable bowel syndrome)?
7. How do you decide what colon cancer screening option should be used for a particular patient?
8. If polyps are found during a colonoscopy, should I be worried? What are the next steps?

A Colon Polyp Snared and Gone

We thought it was true . . . and now research comes along with evidence.

Colonoscopy reduces death from colorectal cancer.

In a follow-up analysis from the National Polyp Study, people who had adenomas — the risky kind of polyps — removed during the study were much less likely to die from colon or rectal cancer than  the general US population.  In fact, removing adenomas cut the death rate from colorectal cancer in half.

We knew that colonoscopies find and remove precancerous polyps and reduce the number of new colorectal cancers, but this is the first study to actually link colonoscopy to cutting back death from colorectal cancer.

There was good news in the study for people who didn’t have adenomas too. They had a very low risk of colorectal cancer death. Only one person out of nearly 800 with no adenomas found at the initial exam  died of colorectal cancer.

Between 1980 and 1990, the National Polyp Study (NPS) enrolled patients  who were having a colonoscopy to rule out colorectal cancer due to symptoms or positive finding on another test.  All polyps were removed during the exam. Patients with adenomas had another colonoscopy 1 or 3 years later and again at 6 years. Patients with no polyps or only benign hyperplastic ones had no further testing.

For this long-term follow-up study, Ann Zauber, PhD, and her team used the National Death Index to find those patients in the NPS who died from colorectal cancer. The researchers used the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registry to figure out how many colorectal cancers could be expected in a group of people with the same age, race, and sex of the NPS participants.

Comparing  2602 NPS adenoma patients to what was expected in the general population there were:

• Overall, 12 deaths in the NPS group compared to an expected 25.4.
• In less than 10 years 4 NPS deaths compared to an expected 9.1.
• For more than 10 years 8 NPS deaths compared to 16.3

In the follow-up study, 2602 patients had adenomas found during their initial colonoscopy, another 773 didn’t.

About a third of the people in the control group did have polyps. But they were the safer hyperplastic type. Only one person in that group of 773 died of colorectal cancer. She died about 8 years after her initial colonoscopy.

Ann Zauber PhD and her team concluded,

These findings support the hypothesis that colonoscopic removal of adenomatous polyps prevents death from colorectal cancer.

Dr. Zauber also wrote,

A demonstrated reduction in mortality with colonoscopic polypectomy is a critical prerequisite for continued recommendations of screening colonoscopy in clinical practice while we wait for the results of randomized, controlled trials of screening colonoscopy.

SOURCE: Zauber et al, New England Journal of Medicine, February 23, 2012.

 What This Means for Patients

Advocates can confidently say that colonoscopy saves lives. Not only does it prevent colorectal cancer from ever happening, it cuts deaths in half.

However, deaths were not zero. Patients who have had adenomas removed during a colonoscopy need to remain aware of the symptoms of colorectal cancer and have them evaluated with another colonoscopy if they occur.

It is also important to remember that the National Polyp Study involved high quality colonoscopies. The gastroenterologists who performed them were experts and all cases included in the study reached the top of the colon.

Research has found aspirin or resistant starch doesn’t help people with Lynch syndrome avoid new polyps.  While almost all people had seen a cancer-related ad, very few actually got a prescription for the advertised drug. People who followed a low-fat, high-fiber diet most carefully had fewer new polyps.

A Johns Hopkins team has developed SUDS — a device for cleaning ER equipment that wipes out dangerous bacteria and keeps it from returning for several days.  The Caring Connection will help you find advance directive forms and instructions for your state.

Research Reports

• People with Lynch syndrome don’t benefit from either aspirin or resistant starch (Novelose) even when aspirin is given at a high dose of 600 mg a day.  Over four years, Lynch patients on aspirin, Novelose, or a combination of the two had no fewer polyps than clinical trial participants on placebo.  Serious adverse events, gastric bleeding, strokes, and heart attacks, weren’t any different between the two groups either.  Dr. John Burn and the CAPP2 team report their results in the New England Journal of Medicine, December 11, 2008.
• Almost 9 out of 10 patients in treatment asked about cancer-related advertising directed at consumers had seen ads, mostly on television.  A majority of surveyed patients felt that the ads made them “aware of treatments they did not know about“, presented information “in a balanced manner“, and helped them have “better discussions” with their doctor.  One in ten felt that the ads reduced their confidence in their doctor’s judgment.  Of those who were aware of ads, 1 in 5 discussed an advertised medicine with their doctor, but of those only 20 percent actually received a prescription for the drug. Gregory A. Abel and the team at Harvard Medical School report the results of the survey in an early online edition of the Journal of Clinical Oncology August 3, 2009.
• People prone to colorectal polyps who were “super-compliers” in following a recommended low-fat, high-fiber diet with high amounts of fruits and vegetables had 35 percent fewer new polyps than people who were not on the diet at all.  However, most trial participants didn’t report that level of compliance.  Of 1,900 people in the trial, only 210 consistently reported success in following all three diet recommendations:  low fat, high fiber, and high fruit/vegetable intake.  Dr. Leah B. Sansbury and her team from the Polyp Prevention Trial Study Group reported their results in the American Journal of Epidemiology online July 30, 2009.

Other Headlines

• A team at Johns Hopkins has developed a device, similar to a shower cubicle, that can clean and decontaminate hard-to-clean emergency room equipment from electrocardigram machines to  cell phones.  SUDS or  the Self-cleaning Unit for the Decontamination of Small instruments beats manual scrubbing for removing bacteria and keeping it away for at least two days.  Two days after manual cleaning, 1 in 4 devices had new bacterial growth, but SUDS-cleaned devices were bacteria-free even in heavy ER settings.  Treatment inside the 7 foot high SUDS machine didn’t appear to damage electronics, and its use can replace expensive  and wasteful disposables.  Development and testing of the SUDS device is described in Annals of Surgical Innovation and Research, online July 30, 2009.
• Caring Connections, a program of the National Hospice and Palliative Care Organization, provides free advance directives and instructions for each state that can be downloaded and filled out.  The packets include information about the HIPAA Privacy Rule and the specific forms and information you’ll need for your own state.  Depending on the state, advance directives allow you to appoint an advocate or proxy to make health care decisions if you are unable to speak for yourself and to specify what health care you do or do not want if you are critically ill.