Search for tag: "colonoscopy"

So you just had your Pap smear or your mammogram and it wasn't that bad was it? Or your colonoscopy. Okay, it really was that bad, but you didn't remember it. Are you wondering when you can stop doing these tests?

I asked a woman I know, who is in the health and fitness business, when she thought she could stop doing her cancer screening, you know, Paps, mammos, colonoscopy. She said, "Never," with a smile. She never wanted to stop her cancer screening, "It isn't all that bad, and it makes me feel safe," she said. I replied that cancer screening decisions about when and how often is a cost, risk, benefit analysis, and there are some data to inform that decision. She said, "You go with your brain, I go with my heart."

Well, let's go with the brain for a little while, okay? Let's start with Pap smears. The recommendations about Pap smears have been changing as we know more about what mostly causes cervical cancer -- the HPV virus -- and how fast it grows, usually not too fast. Cervical cancer does not increase with age for a lot of reasons. Sexual activity and the number of partners doesn't increase with age. Well, usually. And the cervix in postmenopausal women may not be as receptive to the virus. So there are good reasons to say that when you get to 65, if you've had normal Pap smears for the past 10 years, that means you actually have been having Pap smears in the past 10 years, and you haven't had an abnormal Pap in 20 years, you can stop testing. There's some pretty solid numbers to back this up, and the U.S. Preventive Services Task Force makes that recommendation.

Okay. How about colonoscopy? Well, colon cancer does not decrease with age. But if you don't have any family history of colon cancer and if your previous colonoscopies, that assumes that you've had some, have not shown any polyps or precancerous lesions, you can stop at 75. That's the recommendation of the U.S. Preventive Services Task Force and the American College of Physicians.

Lastly, mammography. Breast cancer does not decrease with age. It increases with age. The aggressiveness of breast cancer is less in older women than it is in younger women. But women still will get treated, which can be aggressive in and of itself. The U.S. Preventive Services Task Force said there's not enough evidence to recommend for or against mammograms at age 75 and older. But about a quarter of deaths from breast cancer each year are attributed to a diagnosis made in women after the age of 74. Women as they get older are less likely to get mammograms. About three-quarters of women 50 to 74 have had a mammogram in the past two years, but only 40% of women over 85. Of course, many women over 85 are in poor health, and mammography is just not on the list of things to do. And clinicians are less likely to recommend mammography if a woman is in poor health. The American Cancer Society suggests women should continue mammograms as long as their overall health is good and they have a life expectancy of at least 10 more years.

Well, how long am I going to live? I went online and Googled, "How long will I live?" There are lots of calculators because insurance companies and pension plans really want to know. Well, I tried a life expectancy calculator that was developed by the University of Pennsylvania and has been mentioned in the mainstream media. It asks sex not gender, age, height, weight, alcohol, smoking, diabetes, marriage status, whether I exercised, ate my veggies. I didn't fudge my weight or height. This calculator said I was going to live till 93 and I had a 75% chance of living to 85.

Another life expectancy calculator from confused.com asked me just a few questions, not my height or weight,or smoking, or alcohol, or diabetes. It did ask my relationship status, and options included happy relationship and married, but these were mutually exclusive. You could only pick one. Well, this one had my life expectancy of 97. And the calculator from Northwest Mutual, a well-respected life insurance company, cranked me out at 98.

Well, I really don't want to hang around the planet all that long. But I really hope that my savings will take me up there, and I'm going to have to have mammograms for a while yet.

Thanks for joining us for the "Seven Domains of Women's Health" on The Scope.

Interviewer: It used to be 50. Now it's 45 and there's a good reason for that. Huntsman Cancer Institute and University of Utah Health says more lives can be saved if men and women who are at average risk of colorectal cancer get screened at 45 instead of 50 years old. Dr. Priyanka Kanth is from Huntsman Cancer Institute. Why the change? What happened?

Dr. Kanth: Over the years since mid-'90s to early 2000, we have noticed an increased risk, increase incidence, and mortality. Actually both. So increased cases and people dying from colorectal cancer. And that was the main reason people started looking into it, researchers started looking into it and came up with this studies, modeling studies. And that's why this recommendation was changed.

Interviewer: Yeah. And the reason that's so important is because unlike other disease that perhaps might show symptoms, and then you would go get treatment. That's not how colorectal cancer presents. It really is screening is the best way to save lives.

Dr. Kanth: Absolutely. You're very right about it. So most of the early onset cancers or any colorectal cancer, early stages do not produce symptoms. Polyp usually starts with a polyp, which is a little bump in the colon and it changes into colon cancer. These polyps do not produce symptoms and they grow slowly, and you will never know you have one. So that's the biggest problem with colorectal cancer. And by the time you have symptoms, it's fairly late. So screening is the best strategy to prevent this cancer.

Interviewer: And this new research has just really shown that people between 45 and 49 because catching it early is the best defense that a lot of good can be done by having it at 45.

Dr. Kanth: Absolutely. Absolutely. There are certain research which has shown that there was a drastic increase even between age 49 and 50. So one study showed that there was an increase of almost 46% between age 49 and 50. So if we decrease it from 50 to 45, we are really hoping to capture that colon cancer patient. And this would be very, very beneficial between that age group.

The other thing I would like to say that this is also an incentive, an added benefit to increase screening from age 50 to 55, 50 to 54. But traditionally, it has been on the lower side if you do it from 50 to 75. There's slightly decreased screening rates in screening uptake between age 50 to 55. So this will help patients who are thinking about it at age 50, but did not get it till age 55. Now they're like, "Oh, you have to get it done at 45, let's get it one at by age 48." Something like that. So this will be very helpful at that point.

Interviewer: Is there a perception that colorectal cancer is an older person's disease?

Dr. Kanth: Yes. I think a lot of us, a lot of our patients in general public we think cancer is an old person's disease, especially colorectal cancer. That's not the case anymore. This is still true. Most colorectal cancer will still be diagnosed when you're older, but there has been a rise in patients who are younger than age 50. Some of it is because of genetic causes, but the rise has been in the average risk. So this perception should be changed. We should consider 45 as new 50 to start screening now.

Interviewer: And really that number, age 45 is the most important number. It's not do I have a family history? It's not do I have symptoms? It's not am I a man or a woman and think I'm less likely to get it. Really as soon as anyone hits that age of average risk of 45, that's the trigger you should go get it checked.

Dr. Kanth: Absolutely. Very correct. So 50 was . . . the same recommendation was for anyone, any gender, male, female. Any person who hits 50, you should get a colonoscopy. Now that has changed to 45. So it doesn't matter if you have symptoms, you should get it checked, especially if you don't have family history. If you have family history, that's a different story. If you don't have family history or average risk, please go get checked at age 45.

Interviewer: How is this going to impact those that do have an increased risk? Not an average risk, an increased risk? Does that also drop their age that they should go in down or do we know?

Dr. Kanth: So, at this point, if you have a family history, we usually start screening early. Most of the time we start screening at age 40. Or if somebody had colon cancer, I'd say whatever age, 10 years before they had colon cancer. So that may not change so much. It's possible we can look at the data and that may change again, but at this point, this recommendation is only for average risk. So family history is a different cohort of patients. That is still a very good point for primary care physician for all of us to ask that history from patients, "Do you have a family history of colon cancer?" Because your risk might be very different from the average risk.

Interviewer: So have that conversation if you're above average risk with your physician, your provider is whether or not you should get it earlier.

Dr. Kanth: Absolutely. Yes.

Interviewer: All right. And for the recommendation, is a colonoscopy okay? The home stool test, is that impacted by this age going down to 45?

Dr. Kanth: The best screening is the one that gets done. So that's another message which has to be delivered by providers. Colonoscopy is not the only screening test. Colonoscopy is gold standard because you can see the polyps you can remove it before it turn into cancer. But there are other very, very good stool tests which can detect colon cancer easily. They are non-invasive, you stay at home, you don't have any logistics around it. And those are good tests to be done. So that's a big message which everyone should know that colonoscopy is not the only way to detect cancer. There are other very good stool tests, which everyone should consider. If you're declining colonoscopy for any reason, do go for a stool test.

Interviewer: So if it's a stool test or if it's the colonoscopy, it doesn't matter. Average risk needs to be 45 now.

Dr. Kanth: Absolutely.

Interviewer: All right. And also, I understand with the new recommendation that Medicare, Medicaid, and also your commercial insurance will cover either one of those screenings starting at 45.

Dr. Kanth: That is correct. And that's what we believe after the new recommendation which has been endorsed by pretty much all the societies that all these should be now covered under preventive care just that how we had it at age 50. Even now, some insurances are already covering at age 45, but that was more sporadic. So now we expect this to be 100% covered.

Interviewer: Colonoscopy has reduced deaths from colorectal cancer up to 70% but yet some people still don't have them done. Can they help you overcome some of the common barriers that people face to getting a colonoscopy next on The Scope.

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Interviewer: Dr. Kathleen Boynton is a gastroenterologist at University of Utah Health and colonoscopy is one of these instances where it's a really good tool for prevention but a lot of people still choose not to use it. What are the reasons and how can we overcome some of those barriers? Dr. Boynton, I guess there's five of them so let's just start with number one.

Dr. Boynton: I think it's probably fair to say that perhaps what we need to be doing as a medical establishment is doing a better job of informing patients about why we emphasize colonoscopy screening. We know that colonoscopy, as you mentioned, is effective at cancer prevention in up to 70%. In other words, your reduction and the likelihood of getting colon cancer is decreased by 70%.

Interviewer: Yeah, it's one of the most deadly cancers but yet, one of the most preventable but only if you get the colonoscopy.

Dr. Boynton: Right, right. And it's a tricky thing because most people assume that cancer causes symptoms but not necessarily and that's why we do screening. We recognize that for both breast and colon cancer for instance, you don't have symptoms. When you get symptoms is generally when the disease is advanced and your window for cure is gone. So when studies are done to look at how is colon cancer affected by getting a colonoscopy, we see that the decrease and likelihood is substantial.

Interviewer: So sometimes it can be a little overwhelming. As a patient, it feels like there's all these screenings and tests we have to take which is not necessarily always the case. However, colonoscopy is one of those that really we know is really effective at preventing a disease. So that's the first thing is a lot of people don't realize the importance. Number two, this is a common one I hear, the preparation is tough. You have to drink all sorts of stuff and it takes a day of preparation. Explain that a little bit.

Dr. Boynton: Yeah, well, I do not mean to sound as though I'm making the experience a trite one. I think it is a very difficult prep but in my mind, it's worth the investment. As difficult as it is, I think it's worth it to go through that experience for that reduction and risk. And keep in mind, the risk reduction, let's say it's 70% risk reduction, if I tell you you don't have to come back for 10 years, I'm telling you you have a 70% decline in your likelihood of colon cancer for the next 10 years. That's pretty profound.

Interviewer: Yeah, for a 12-hour, 24-hour investment of your time. Who wouldn't do that, right? The return on investment on that is really good. So the preparation can be tough for some people but the return on investment is really, really high and it's probably not as bad as a lot of people . . .

Dr. Boynton: Yeah, we get the gamut of experiences but I think it's fair to say we generally have a couple of patients everyday who say it's not nearly as bad as I thought it was going to be.

Interviewer: All right, number three, one of the barriers to people choosing to get a colonoscopy is just the fear of the unknown, like there's a lot of scary things involved with this, least of which is, "If I have cancer, I don't know that I want to know that I have it." So what about pain? I would imagine a lot of people fear that they don't know if it's painful or not.

Dr. Boynton: Yes, yes. My answer if patients ask me about the likelihood of pain, I generally say, "The possibility that's going to happen is very low that you're going to experience any discomfort at all." In very unusual circumstances if somebody has a complication related to the pain medication, we may back off, but that's decidedly an exception to the rule. Generally, it's painless to go through this.

Interviewer: And back to the main point. One of the biggest fears is, you know, that diagnosis can be kind of scary. Maybe I'd rather not know. Do you run in to that a lot?

Dr. Boynton: Yeah, and I can sympathize with that. I don't want to go to the dentist because I'm afraid I'm going to have something wrong.

Interviewer: Yeah, like a cavity which . . .

Dr. Boynton: Yes.

Interviewer: This is something quite a bit, a lot worse, right?

Dr. Boynton: Much. Very much so. But in this case, again, I get back to the idea of why we do this exam. Generally, when I find it on a scope, it's a curable lesion and many times, we can remove it at that time.

Interviewer: Don't even have to come back.

Dr. Boynton: Right. Even if it's an early cancer, we can take it out.

Interviewer: Reason number four, it can be a bit of an invasive experience and some people are afraid of that.

Dr. Boynton: Yes, yes.

Interviewer: What do you say to that?

Dr. Boynton: I think that is also in a sense related to that whole fear of the unknown. We've taken in breast cancer and colon cancer, we're kind of screening in very personal areas of the body and I think for a lot of patients, just this idea, this concept in their mind of what we're about to do, much less with people you've never met before, is pretty daunting. At the same time, I can say with great assurance that, at least here, we are very aware of how complicated this is and very sympathetic with how invasive this seems. We're investigating a very private area of the body, how is this going to happen in a way that's not awkward or embarrassing? So the link that we've provided on our website is actually a reenactment of going through the prep and the colonoscopy, and hopefully it serves to reassure people that we are very aware of the hesitations people have about this.

Interviewer: And then finally, the cost. There can be some confusion sometimes as to what the insurance might cover, what it might not cover for those without insurance, how they pay for it so . . .

Dr. Boynton: Right. So the university will investigate this issue on their own as well as you can call your insurance company and find out what your limitations are. We are very happy to work with people that have certain limitations provided by their insurance. Generally, screening is covered on insurance.

Interviewer: And they're getting . . . even if you might have to pay a little bit more, as far as all the tests that are out there in the world, this is really one that could make a difference in the quality of your life, not only just the longevity but the quality of it.

Dr. Boynton: Yes. The co-pay for a colonoscopy is much less than the co-pay for colon cancer.

Interviewer: Right, right. So we covered, I think, a lot of barriers and of course, if people have any other personal barriers, what should they do at that point?

Dr. Boynton: When we call to schedule patients, we have a dedicated call team that schedules only these. They can leave a message with the call center that's scheduling individuals and let them know what their concerns are and we do get that message and we're very happy to work with anyone if it makes their experience easier.

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Interviewer: Figuring out the best colorectal cancer treatment option for you. That's next on The Scope.

Announcer: Medical news and research from University of Utah Physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Courtney Scaife is a surgeon that specializes in gastrointestinal oncology and is also an expert in colorectal cancer treatments at Huntsman Cancer Institute. I was doing a little bit of research on colorectal cancer treatment options and I've got to tell you, Dr. Scaife, it's overwhelming. There are a lot of different options. I can't even imagine somebody's who has just been diagnosed that's trying to parse through all these different options on their own what they're facing. Help me make sense of that.

Dr. Scaife: There's no question that the information available on the Internet, on public institutional venues and so on is overwhelming. Doing research, investigating your diagnosis before you see your doctor is useful, but if you haven't had your diagnosis narrowed down exactly what is your diagnosis and what is your stage, that information can be very, very overwhelming. To some extent, knowledge is power, but when it becomes overwhelming, it's helpful to wait until you meet with your physicians and get your diagnosis and your staging narrowed. But that information can be whittled down into a package that's more tolerable.

Interviewer: Yeah, I think I scrolled through six, seven pages of a bunch of words that made no sense to me. After you get your diagnosis you said the two key things are your stage . . .

Dr. Scaife: Correct.

Interviewer: . . . and what's the other one?

Dr. Scaife: Your stage and your diagnosis. Colorectal cancer is a term that we group together. Colorectal cancer, it is one disease, but the distinction is the anatomy or where the tumor is located in the body. Because of the anatomy of the rectum, which is the farthest down or the lowest part of your colon, the anatomy of that is a little bit different than the colon so we treat rectal cancer, which is a sub-type of colon cancer, just a little bit differently.

The first thing we decide is does someone have rectal cancer or do they have colon cancer. Then, we decide what stage is it or what is the preliminary staging that helps us look at the treatment plan from there.

Interviewer: Help me walk through some of this process when you do have a patient in your office. They would go through some tests. You would determine the stages. You would determine the type of cancer. What do you do at that point to determine the treatment option that's best for them?

Dr. Scaife: Well, the most common scenario is that someone's had a colonoscopy. Either they had symptoms or they're in their routine surveillance, which should be everyone at the age of 50 and then every five to 10 years after that. If something was found, a concerning polyp, a precancerous high-grade dysplastic polyp is what it's called, or a cancer, then the next thing we do is stage that.

We do the staging by getting a CT scan of the chest, the abdomen and the lower abdomen that we call the pelvis. If we are sure that there is no evidence that, that cancer in the colon has tried to spread to other organs, specifically the lungs and the liver, the most common, that would make it a stage IV if it has spread to other organs. If it has not it's a stage I, II, or III.

That stage is determined by are any of the lymph nodes involved, which would be a stage III, or how thick has the tumor tried to go through the wall of the colon, which would distinguish a stage I, II or an advanced stage III. Those things we often don't know until after a surgery.

If you have rectal cancer, we do further studies to try to help to find those stages first. If you have colon cancer, surgery is the first treatment and that stage is determined at surgery. Already, you can see that the distinction between colon cancer and rectal cancer starts making those decision trees very different. Interviewer: What are some common questions that patients ask in that consultation with you after you've determined the type of cancer and the stage?

Dr. Scaife: The most common question is, "When can we get this taken care of?" Obviously, as soon as possible. We'll do everything we can to do that as soon as possible. The next most common question is, "Will I need chemotherapy?" We don't know the answer to that until after we've decided if it's rectal cancer, most commonly. We often do use chemotherapy. If it's advanced stage II or stage III colon cancer, then it will get chemotherapy after surgery, but surgery would be first.

The third most common question is, "Will I need a colostomy? Will I need a bag to poop in?" Unless it's a low rectal cancer or a really worrisome, very, very large left-sided or more distal in the colon, colon cancer, it's really uncommon to need to have a colostomy bag.

Interviewer: Are there often, after that point, different ways that you can approach the treatment that the patient might have to make the decision, "I would rather do treatment A or treatment B?"

Dr. Scaife: Yes and no. Most commonly, that comes if we have a clinical trial. An important point is that a clinical trial is only ever available if we think that the investigative arm is most likely to be a better option than the standard of care.

Some patients are very scared of trials, but we can't write a trial and IRB wouldn't approve a trial if we didn't that the trial arm is probably actually better than what is the standard of care. If a clinical trial is available, then we give patients the option do they want to be involved in the trial or not.

Otherwise, for colon cancer, really surgery is the first option. Then decisions of do they want chemotherapy after the surgery if they're a stage II or a stage III. In rectal cancer, decisions about do you want only chemotherapy before surgery. We do chemotherapy and radiation often before surgery in rectal cancer. Do they want chemotherapy only? Do they want chemotherapy and radiation before surgery? Do they want a short course of radiation or a longer course of radiation? All of those decisions are decisions that patients participate in but based on the advice of the medical oncologist, radiation oncologist, and surgical oncologist.

Interviewer: What tends to be done most often, it sounds like, is surgery.

Dr. Scaife: Correct. Again, for rectal cancer, it's very common to get chemotherapy and radiation before surgery, but the treatment for either colon or rectal cancer is surgery.

Interviewer: What are some of the other considerations that a patient should keep in mind as they're going through this conversation, as they're sorting through what options they might have? What would you want them to keep in mind?

Dr. Scaife: Definitely the most important thing to do in getting ready for a treatment for colon cancer surgery and possibly chemotherapy is really to just be healthy. There's a big push across the country. The University of Utah and Huntsman Cancer Institute have a huge push right now to really emphasize pretreatment health.

Minimize or stop, ideally, your smoking. Control your diabetes really well. Control your other medical problems, your high blood pressure. Try to exercise three or four times a week at least 30 minutes those three or four days a week. Try to eat a well-rounded, healthy diet. There's no special diet that can prevent or cure rectal or colon cancer, but just a well-rounded, healthy diet really strengthens a patient to get through surgery and other treatments that are necessary.

Interviewer: That's kind of nice. Somebody could take control of those things right away before they know anything else about their cancer.

Dr. Scaife: That's exactly right. There's actually data now that shows that people that exercise before and after colon cancer surgery decrease their risk of recurrence.

Interviewer: Do people that tend to have colorectal cancer have time to get in shape before the surgery? Are we talking about they would have three or four weeks that they could stop their smoking? Is it a slow-moving cancer that they're allowed that luxury?

Dr. Scaife: Yes and no. The answer is yes, there usually are two to three weeks. It is a very slow moving cancer. Two to three weeks, five to six weeks won't make a difference in the outcome of the cancer. Sometimes even longer.

But the other side to the answer of your question is that even just two days is beneficial. For a smoker, just not smoking for two days before an operation makes a really, really big difference. For a person who's relatively sedentary to just go out for a 30-minute walk three days a week for just the two days before your operation can already make a difference.

Interviewer: It sounds like wait until you find out the type of cancer and the stage before you start freaking yourself out with all the options. Let your physician or your cancer team help narrow those down for you. It sounds like surgery is going to be kind of the first thing and then some other decisions will have to be made after that point and get out and exercise right now in preparation for any treatment that you might get. Is there anything else that you would tell a patient at this point as they're leaving your office because I imagine it's an emotional scary time for them?

Dr. Scaife: After the diagnosis has been made and you're leaving your doctor's office, as you said, this information is overwhelming from the beginning. But now that you know is it colon or rectal cancer and you know what stage it is, I, II, III or IV, now you can start to find out specific information.

Asking your doctor what questions to ask, where to get the information. One of the most valuable resources is the Cancer Learning Center at Huntsman Cancer Institute. It's one of the biggest, I think it is the biggest, patient cancer centered library in the country. They have librarians trained to teach people how to get the resources in their diagnosis, in their family situation and in their social network and their questions that they have. The librarians can help them get educational materials appropriate for their diagnosis.

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Dr. Miller: Rectal bleeding. Could that be a hemorrhoid or what is that? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller for Scope Radio, and I'm here with Dr. Molly Gross. She's an Assistant Professor in the Department of Surgery, and she's also a colorectal specialist.

Tell me a little bit about rectal bleeding. If someone comes in and says, "Look, I had some blood that I saw on my stool or in the toilet bowl." Is that usually due to a hemorrhoid, or what should they think?

Dr. Gross: Everyone has hemorrhoids, and often it could be due to hemorrhoidal disease, bleeding from internal hemorrhoids. However, there are other things that can cause bleeding such as a fissure which is a skin tear in the skin by the anus.

Dr. Miller: Is that painful?

Dr. Gross: Yeah. That kind of bleeding usually is associated with pain with the bowel movement. People describe pooping a knife out sideways.

Dr. Miller: Now sometimes hemorrhoids can be painful and sometimes not. What's the difference there? Is there a problem with recognizing what's painful and what isn't in terms of hemorrhoids?

Dr. Gross: Internal hemorrhoids which are up inside usually aren't painful, and they just bleed. External hemorrhoids which is on the outside of the anus, those hurt when they have problems and when the blood vessels inside clot off or thrombose.

Dr. Miller: Is there a simple way to take care of those hemorrhoids, or does one always need to see a surgeon about that?

Dr. Gross: Rectal bleeding can also be concerning because it could represent cancer or a polyp which should be seen by a professional. Hemorrhoids, if you know that you don't have a cancer, and you just have hemorrhoids, the patient can first start to do some things at home to help with those.

Dr. Miller: And what might those things be?

Dr. Gross: The important thing is to have good formed bowel movements. I say have a bowel movement looking like a greased banana. So how do you get that greased banana? Fiber, fiber and fiber.

Dr. Miller: And so what is the best source of fiber? Should people purchase fiber at the store like Metamucil, or do they just up their diet in terms of vegetables and fruits?

Dr. Gross: It's really hard for the average person to eat enough fiber in the day. You'd be having to eat lettuce all day long to get 30 grams of fiber. So I recommend starting Metamucil, Citrucel, or the generic, Fibercon, Konsyl, any of these options. Start with one tablespoon once a day.

Dr. Miller: And then move up to maybe twice or three times a day depending on how it goes?

Dr. Gross: Correct.

Dr. Miller: Okay.

Dr. Gross: Also, the other thing is to not strain on the toilet. Don't bring your phone.

Dr. Miller: Don't sit and read the newspaper, if people are still reading newspapers.

Dr. Gross: Or your phone.

Dr. Miller: Or your iPad.

Dr. Gross: Yeah.

Dr. Miller: And then the other thing about that is what about over-the-counter remedies, Preparation H? Do those things actually work?

Dr. Gross: They can't hurt, but really what needs to happen is to have a better bowel movement and not strain. As long as you're having those troubles, you will continue to have some bleeding. But I also want to stress the importance of being seen by a health care professional to rule out other causes of bleeding like rectal cancer.

Dr. Miller: And so how would one determine if they had those more rare and serious causes of bleeding?

Dr. Gross: A colonoscopy is the best way to rule out other causes of bleeding.

Dr. Miller: So one must not necessarily assume that it's just due to a hemorrhoid. They actually need to see a physician or a health care provide that could actually send you to have a colonoscopy or a sigmoidoscopy to sort out the cause of the bleeding. Now, does everyone that has rectal bleeding need a colonoscopy to rule out the serious nature of bleeding?

Dr. Gross: Not everyone. However, if the bleeding continues despite treatment of the hemorrhoids, or the patient has a family history of colon and rectal cancer, or if they're above 50, they definitely need a colonoscopy.

Dr. Miller: What else would you say for patients that have painful hemorrhoids? Should they use a donut that you can purchase at the pharmacy? Does that work? Does that make any sense?

Dr. Gross: No, donuts really don't work. People who have painful hemorrhoids, like external thrombosed hemorrhoids, if they have a blood clot in them sometimes they get better just from lancing it in the first 24 to 72 hours after the clot has formed. Otherwise, we often recommend sitz baths, so that's filling your bathtub with a little bit of warm water and sitting in it.

Dr. Miller: That sounds like a home remedy. Does that really work?

Dr. Gross: It does work.

Dr. Miller: And if they do that what, once, twice, three times a day?

Dr. Gross: Once or twice a day and after bowel movements.

Dr. Miller: Now, there's something that I understand is called laparoscopic banding. Do you do that?

Dr. Gross: Rubber band ligation is a management, an office procedure to treat internal hemorrhoids that are bleeding. That is simple and easy to do in the office at the time of our initial consultation if we see large hemorrhoids that are causing some problems. Those are for internal hemorrhoids only.

Dr. Miller: Now, if I remember what you said, internal hemorrhoids are not necessarily painful, so banding them would not be painful either.

Dr. Gross: Correct. Banding shouldn't be painful. If it is painful, that can be concerning. Usually patients say it feels like they're sitting on a cue ball for a couple days. There's some pressure but no pain.

Dr. Miller: So the bottom line is if you have rectal bleeding it could be due to a hemorrhoid, but you have to assume that there are other things and perhaps some rare things that are very serious, and you need to have that checked out by a health professional, and certainly bleeding that's persistent needs to be looked at.

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updated: May 7, 2019
originally published: January 6, 2016

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Host: It's been generally thought that a colonoscopy was 100% effective at preventing colorectal cancer, but new research has shown that's not necessarily the case. N. Jewel Samadder is the lead author of a recent study. He's at Huntsman Cancer Institute. What did you learn in this study?

Dr. Samadder: Yes, for a long time physicians were under the impression that colonoscopy was 100% or nearly 100% protective from colorectal cancer, however, our data clearly shows that though colonoscopy is excellent, it can capture 94% of all colorectal cancer.

Host: That's still pretty good.

Dr. Samadder: Exactly, it's pretty good, but it's not perfect. We just need to be aware that it's not perfect. We need to figure out why this small number, 6% of all colon cancers, are being missed at colonoscopy, and what can we do to capture them.

Host: So what did you discover as far as why?

Dr. Samadder: We found a number of predictors that were associated with the missed colon cancers at colonoscopy. This included patients being of an older age, over age 65, having a family history of colorectal cancer in a close relative, or having a polyp, which is a precursor of colon cancer, found at the prior colonoscopy. These are some features that physicians can use to decide the risk that their patient may have for missed or interval colon cancer at colonoscopy. Hopefully that will allow them to spend more time examining the colon in these high risk patients and reduce the risk of missed cancers.

Host: So if you don't have those risk factors you're probably still going to be really good. If you do have those risk factors the physician actually can spend more time and overcome them?

Dr. Samadder: We think so. We think that, obviously, every physician should spend as much time as he or she needs to examine the colon and do a good job of reducing the risk of colon cancer in their patients, however, with patients who have these risk factors the physician can spend additional time in the colon. Some studies have suggested that the amount of time required to examine the colon should be at least six minutes, and some have suggested nine minutes or more. Physicians could elect to use a longer time on the withdrawal to examine the colon. They could also make sure that the bowel preparation is adequate so that they can look behind folds throughout the colon without stool impairing their vision.

Host: For patients it's really important that they communicate any of these risk factors to their physician so that they can have the information to do a more thorough job.

Dr. Samadder: They need to have an open discussion talking about their family history of colorectal cancer as well as the results of polyps, these precursors to colon cancer, that were found at a prior colonoscopy.

Host: This was a really significant study of a wide base of population if I understand correctly as well, so these results are very accurate.

Dr. Samadder: Yes, the data here which is derived in Utah is broadly applicable to the rest of the United States since the data was generated from both a very large academic medical center and a large managed care organization that together account for over 85% of all patient care in the State of Utah. It's broadly applicable throughout the United States. We hope that it will inform patients and physicians of the strength of colonoscopy in preventing colon cancer, but also the challenges that lie with colon cancer screening that not all cancers are detected at colonoscopy. Hopefully it will drive further research as to understanding the causes of these missed cancers, what we can do to better understand the limitations of colonoscopy and improve polyp detection and polyp removal to make colonoscopy maximally useful.

Host: What's the takeaway message that you would want to have our audience leave this discussion with?

Dr. Samadder: I think the take home message is that colonoscopy is extremely effective at reducing colorectal cancer, however, like any test it is not perfect. Up to 6% of colon cancers can be missed at colonoscopy, and it's important for patients and physicians to discuss some of the risk factors that we've found that can increase your chance of having a missed cancer including older age, having a family history of colorectal cancer and a prior colonoscopy with polyps or advanced polyps found.

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