Editor’s Note Polyp boy

The last thing I heard before slipping into a Versed®-induced stupor was my gastroenterologist graciously inviting me to watch the TV monitor as his colonoscope went window-shopping past my intestinal mucosa.

Minutes, hours or days later, I stumbled into consciousness again to see GI Joe holding snapshots of a handful of barely visible white mounds. “Benign-appearing polyps,” he said, brightly. “I took them out and you’ll be fine.” My daughter Jennifer, the COO of our burgeoning CME enterprise, snickered, “I feel a CCU editor’s note coming on here.” Yeah, me too.

Gradually over the next few hours, the enormity of the moment dawned on me. I wasn’t a man whose doctor ordered a “routine” PSA as part of incidental blood work and now had to decide whether to have his prostate removed because two percent of one core biopsy had Gleason 6 in it. I wasn’t a woman who had religiously gone for her yearly mammograms only to be diagnosed with a 1.2- centimeter infiltrating tumor that would require chemotherapy. I was a person who just had a bunch of potentially premalignant lesions snipped off painlessly. Not that there’s anything wrong with waiting 10 more years and maybe having my sigmoid removed and a course of adjuvant chemo, but this sure seemed a whole lot easier.

Aside from being very thought provoking, this experience led me to again consider the role of the medical oncologist in the cancer control process. As a result, I’ve created the following not-so-simple but brief CME pre-test. The answers are, of course, open for discussion:

Should every medical oncologist be actively involved in education and advocacy related to colorectal cancer prevention, screening and diagnosis?

A. No

B. Yes

Answer A: No

Justification: This is a pragmatic and serious question — not a platitude or non sequitur. Our time is precious. The potential for clinical revenue is diminishing. Urologists are out there pushing PSAs, radiologists and surgeons pretty much have breast screening under control and the GI guys are talking about colonoscopy. Let’s focus our attention on what we do best — providing research-based, compassionate care to people with cancer.

Answer B: Yes

Justification: We are the only docs who see the bottom line and can put this in perspective. Many or most patients with metastatic breast or prostate cancer had screening done but will still die of the disease. When was the last time you saw someone die of colorectal cancer who had followed screening guidelines for a while? It does happen, of course, but how often?

How many more patients are out there like the one discussed by Dr George Fisher in this program — a young postpartum woman who was diagnosed with T3 rectal cancer and liver metastases after months of symptomatic treatment for “hemorrhoids”? Additional related issues for oncologists to consider are clinical trials of chemoprevention and lifestyle and dietary alterations. The known biology of colonic carcinogenesis and the potential for chemoprevention of colorectal cancer are at least as promising as with any solid tumor.

My role is not to provide the answers but to stoke the debate. Meanwhile I will treasure the snapshots of that gang of tiny baby rascals who someday might have made my life miserable but now are stuck in formalin.

— Neil Love, MD
NLove@ResearchToPractice.net

Select Publications

Asano TK, McLeod RS. Nonsteroidal anti-inflammatory drugs and aspirin for the prevention of colorectal adenomas and cancer: A systematic review. Dis Colon Rectum 2004;47(5):665-73. Abstract

Bast RC Jr et al. 2000 update of recommendations for the use of tumor markers in breast and colorectal cancer: Clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001;19(6):1865-78. Abstract

Key TJ et al. Diet, nutrition and the prevention of cancer. Public Health Nutr 2004;7(1A):187-200. Abstract

Lieberman DA, Atkin W. Review article: Balancing the ideal versus the practical — considerations of colorectal cancer prevention and screening. Aliment Pharmacol Ther 2004;19(Suppl 1)71-6. Abstract

Lindblom A et al. Colorectal cancer as a complex disease: Defining at-risk subjects in the general population — a preventive strategy. Expert Rev Anticancer Ther 2004;4(3):377-85. Abstract Not Available.

O’Malley AS et al. Patient and provider barriers to colorectal cancer screening in the primary care safetynet. Prev Med 2004;39(1):56-63. Abstract Not Available.

Rozen P. Cancer of the gastrointestinal tract: Early detection or early prevention? Eur J Cancer Prev 2004;13(1):71-5. Abstract

Seeff LC et al. Patterns and predictors of colorectal cancer test use in the adult U.S. population. Cancer 2004;100(10):2093-103. Abstract

Smith RA et al. American Cancer Society guidelines for the early detection of cancer, 2004. CA Cancer J Clin 2004;54(1):41-52. Abstract

U.S. Preventive Services Task Force. Screening for colorectal cancer: Recommendation and rationale. Ann Intern Med 2002;137(2):129-31. Abstract

Winawer S et al. Colorectal cancer screening and surveillance: Clinical guidelines and rationale — update based on new evidence. Gastroenterology 2003;124(2):544-60. Abstract

Young GP et al. Choice of fecal occult blood tests for colorectal cancer screening: Recommendations based on performance characteristics in population studies: A WHO (World Health Organization) and OMED (World Organization for Digestive Endoscopy) report. Am J Gastroenterol 2002;97(10):2499-507. Abstract