Women & Colon Cancer with Colleen Donahue, M.D.

Colon cancer is the second leading cause of cancer-related deaths in the United States. Although risk of the disease is similar in both men and women, the myth that colon cancer is primarily a male disease seems to persist. As a result, studies have found that women are less likely to undergo preventative screenings for colon cancer. In this episode of Advance with MUSC Health, Colleen Donahue, MD, discusses prevention, diagnosis and treatment options for colorectal health in women.

“I think a lot of people are afraid to get a colonoscopy, and I think a lot of that is a misconception. It should be very similar to a mammogram. No one likes getting their mammogram, but we all know that mammograms help reduce the incidence, or at least catch breast cancers early. Colonoscopy is the same way. Colon cancer and rectal cancer are very curable diseases if they're caught early.”

- Colleen Donahue, M.D.

Topics covered in this show

• Colon cancer is caused by the development of abnormal cells called polyps accumulating in the colon over a period of time. Colon cancer patients can be asymptomatic, while others may present with bleeding or abdominal pain or changes in their bowel movements.
• Adults should start colon cancer screenings (colonoscopies) at age 45, or in some cases, even earlier.
• Despite misconceptions, colon cancer affects roughly as many women as men. However, while the overall incidence of colorectal cancer as well as deaths related to colorectal cancer are decreasing, the numbers are actually increasing in the younger population.
• Women undergo preventative screening less frequently, presumably because women are less likely to discuss colorectal health generally, whether with their physician or their friends and family.
• Colon cancer and rectal cancer are very curable diseases if they're caught early, especially when identified in the polyp stage before becoming cancer. Even so, only 19 percent of people that are qualified for colonoscopies are actually getting them.
• It is possible to have completely benign polyps, even polyps that are not considered precancerous. This is called a hyperplastic polyp and has no chance of ever becoming cancer.
• There are certain hereditary components to colorectal cancers. For those who have first degree relatives (mother, father, brother, sister) with colon cancer, the odds for colon cancer increase. Screening for such individuals is more crucial and should start earlier than the general population.
• MUSC treats colon cancer patients with a multidisciplinary tumor board that includes radiation doctors, oncologists, radiologists, and surgeons. This way, the entire team of specialists can come up with an individualized treatment plan for each person’s specific condition.
• Donahue encourages listeners that colorectal health need not be embarrassing or frightening. She encourages women especially to speak to their doctors about colorectal health and to consider colorectal screenings as equally important as breast cancer screening through mammograms.

Transcript

Erin Spain [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Colon cancer is the second leading cause of cancer related deaths in the United States, and although risk of the disease is similar in both men and women, the myth that colon cancer is primarily a male disease seems to persist. As a result, studies have found that women are less likely to undergo preventative screenings for colon cancer. Here to discuss this issue is Dr. Colleen Donahue, colorectal surgeon at MUSC Health. Welcome to the show. 

Dr. Colleen Donahue [00:00:47] Thank you so much for having me. 

Erin Spain [00:00:48] March is Colon Cancer Awareness Month. So let's start with the basics. Tell me what colon cancer is exactly, how you screen for it, and how effective screening can be. 

Dr. Colleen Donahue [00:01:00] Colon cancer is when you develop a polyp in the colon, which is really just some abnormal cells that develop over time. And they can start changing their cell type and then form a cancer. A lot of times patients can be asymptomatic and never know that they had anything until they get their screening colonoscopy, while other people may present with bleeding or abdominal pain or changes in their bowel movements. 

Erin Spain [00:01:22] So I mentioned that women frequently have this perception that colon cancer is a disease that just affects older white men actually. Where does this misconception come from and what are the actual statistics? 

Dr. Colleen Donahue [00:01:33] Yeah. So, it's completely inaccurate that it affects women less so than men. It's almost 50 percent women and 50 percent men. And what we've found over time is that the overall incidence of colorectal cancer and deaths related to colorectal cancer is decreasing, but it is actually increasing in the younger population and those patients are less than age 50. So originally our screening was always meant to get your first colonoscopy at age 50, when that's now decreasing to the age of 45. 

Erin Spain [00:01:59] Why is that? 

Dr. Colleen Donahue [00:02:00] Honestly, we aren't quite sure yet, and I think that's where a lot of research in colorectal cancer arises -- whether there's a hereditary component to it, or whether there's this thing called the microbiome, which is all about the bacteria, our diet, our exposures and everything that can maybe cause us to get colon cancer at an earlier age. And it's a really important area of study right now that we're still trying to sort out. But we do know it has increased in the younger population. And that's why just this year is when that age of 45 was recommended. 

Erin Spain [00:02:29] And this idea again that women seem to think that maybe their chances are lower. Where do you think that comes from? 

Dr. Colleen Donahue [00:02:37] I think women just talk about it less. No one likes to talk about the colon or the rectum or their bowel movements. And I think if anyone's going to talk about it, men are more comfortable talking about it. Whereas women are more likely to not mention anything to their physician or their friends because they're having a change in their bowel movements. And so because of that, we just don't hear about it as much from women, but it's just as prevalent in women as it is in men. 

Erin Spain [00:02:59] So what do you tell patients who aren't bringing this up? Maybe they're hesitant to be screened. They just kind of brush this off. What do you say to them? 

Dr. Colleen Donahue [00:03:07] It's hard because I think a lot of people are afraid to get a colonoscopy, and I think a lot of that is a misconception. You know, it should be very similar to a mammogram. You know, no one likes getting their mammogram, but we all know that mammograms help, you know, reduce the incidence, or at least catch breast cancers early. Colonoscopy is the same way. Colon cancer and rectal cancer are very curable diseases if they're caught early. We can even prevent colon cancer by catching it when it's in the stage of a polyp before it even becomes a colon cancer. But even with the birth of colonoscopy and how good the technology is, people still aren't doing it. Whether it's because they don't want to do the bowel prep, they're afraid of the anesthetic, anything like that, they would just rather find some other way to screen for it or not do it at all. 

Erin Spain [00:03:51] And there are some less invasive ways to screen. Tell me about those. 

Dr. Colleen Donahue [00:03:56] Yeah, there are. So originally, you know, you hear about just testing the stool for blood. That was called the fecal occult blood test and that was recommended every year. Then they've come up with some other tests. There's the FIT test that's looking at actual DNA. The Cologuard test as well is one of the newer ones. You see the commercials on TV all the time about taking your stool sample and sending it in. The problem with those tests is we don't quite know really how often you should be doing it. We know that they're sensitive in the sense that they're good at picking things up. But sometimes you can have a positive Cologuard and then get a colonoscopy and not find anything. And that's very nerve-racking to patients, you know. Well, I had a positive Cologuard. So what does that mean? And if you do have a positive Cologuard, you need a colonoscopy anyways. So we're still trying to work out what the best screening and surveillance is with those nuanced tests. If the Cologuard will increase screening, then we're going to recommend it. But if you're young and healthy and you can tolerate a colonoscopy, that's really the best screening there is. 

Erin Spain [00:04:54] So just take us through it. You mentioned bowel prep. Just go through what is all involved with the colonoscopy. 

Dr. Colleen Donahue [00:04:59] So the bowel prep is the worst part. I always tell patients that. And there's a lot of different types of bowel preps, and everyone prescribes something different. You know, you hear about the Golytely, which is the most common one. You drink four liters of this horrible tasting drink and then you have a lot of bowel movements, because we're literally cleaning out your colon. And the reason why that's so important is some of these polyps are less than five millimeters in size. They're tiny. That's smaller than the eraser on a pencil, and to be able to see them, the colon needs to be completely clean. And then safety. We can't get in there and have stool everywhere and be able to see anything because then the risk of causing damage during a colonoscopy is too high, so we just won't proceed. So it is really important to clean out the colon. Nowadays, they've come up with some better preps as well, like drinking Miralax mixed with Gatorade, which tends to be a lot better tolerated for patients than taking a couple of Dulcolax pills. But it's not even so much the drink. A lot of it is just having frequent bowel movements that bothers people. But you get through it. You do it in a day, and then you get a colonoscopy. You get sedation for your colonoscopy. And there's different types of sedation as well. You can be put completely to sleep using Propofol. And so for that, you'll be completely out. You won't feel a single thing and you won't wake up to the end, but you're breathing on your own so you don't need a breathing tube or anything like that. There's also other sedation, which we call a twilight sedation. We use a couple of medications where you might be in and out a little bit, but you probably won't remember anything. And the whole point is so you don't feel discomfort, but you're not completely knocked out for it. And different centers do different types of sedation. And so it just depends on where you go for your screening. And also patient preference does come into it as well. 

Erin Spain [00:06:36] So best case scenario and worst case scenario. Just talk me through those. 

Dr. Colleen Donahue [00:06:40] Yeah, so best case, you get there, you do your colonoscopy and we find absolutely no polyps. If we find no polyps and you don't have any family history of colorectal cancer, you don't need another colonoscopy for 10 years. So, 10 years is a pretty significant amount of time and to not have to go through that again. Now, in the worst case scenario, we find a cancer and we take biopsies, but then we can get you started on treatment and we can figure out what needs to be done. And somewhere in between are patients with polyps. We'll go through and remove all of those polyps so they don't become a cancer, because over 10 years, they can form a cancer. And that's why we need to remove them. And then our pathologists can look at them under the microscope and make sure that there's no concerning features. And we just determine if you need another colonoscopy sooner than that 10 year period. 

Erin Spain [00:07:22] So that's good, that polyps don't always indicate cancer. 

Dr. Colleen Donahue [00:07:27] No, you can have completely benign polyps, like polyps that aren't even pre-cancerous. So that's just called a hyperplastic polyp. It's just a clump of normal cells. There's no chance of that ever forming a cancer. Then we form adenomas, and adenomas are the pre-cancerous lesions – so those ones can form a cancer over a certain period of time. And so we remove those, and if we did find a few of them, then you might need a colonoscopy and say three to five years instead of that 10 year period. 

Erin Spain [00:07:52] You talked a little bit about ages for screening and about how that's shifting a little. It can also be different based on your risk. Tell me about those risk factors, including genetic risk factors. You just mentioned family history. 

Dr. Colleen Donahue [00:08:06] So, family history is the most important thing. We know there's certain hereditary components to colorectal cancers. So if you have any first degree relative like your mom or your dad or brother or sister that has colon cancer, it's even more important that you get screened. And basically, the screening starts at age 40 for those patients. So that's even earlier. And the other important thing is to say they got diagnosed at age 45, and we'd even actually start your screening at age 35. So it's 10 years younger than the person at the age they were diagnosed. So it is really important to get that screening done before the age where you could also develop a colon cancer. And then if you have a lot of family members who have had colon cancers, then there might be a genetic mutation that you need to be tested for. One of the most common ones we hear about is the Lynch syndrome. So those are patients that have at least one first degree family member, usually under the age of 50, that have had a colon cancer diagnosed. And then there's certain testing we can do for that, and then you'd be on a different surveillance. So you'd be getting a colonoscopy every year if you had Lynch syndrome to help detect a cancer early. 

Erin Spain [00:09:09] Tell me about MUSC Health and the approach that you all take. 

Dr. Colleen Donahue [00:09:14] I would say, really, the reason why I came here is because I wanted to join the division of colorectal surgery and wanted to be part of a group where it's not just one single person making any decision about a patient. So if a patient comes to MUSC with a new diagnosis of colon cancer, it's not just me making the decision about the treatment. We have this multidisciplinary tumor board that has all the radiation doctors, all the oncologists, all the radiologists and all of the surgeons get on the call together. Even the genetic counselors are there, and we all talk about each new cancer case. That way, we can come up with an individualized treatment plan for each person. So not every treatment plan is the same, and we make it really based on your cancer specifically. 

Erin Spain [00:09:56] So let's talk about that. You have a new case. Just talk through the different stages of colon cancer and how that's determined and some of the common treatments you mentioned that you may prescribe for patients. 

Dr. Colleen Donahue [00:10:08] If you're diagnosed with a colon cancer on colonoscopy, the next step is to stage the cancer, and that just means we want to make sure it didn't spread anywhere. So it could just be within the colon or it could have spread to typically the liver and the lung are the most common places for it to spread to first. So we get a CT scan of your chest and a CT scan of your abdomen to make sure it hasn't gone anywhere else. Now, if it hasn't gone anywhere else, then we know it's at least a local disease. It's not what we call metastatic. So metastatic is where it spread elsewhere. And that won't be a, you know, a big difference in how we treat this. So for colon cancer specifically, if you don't have any evidence of metastatic disease, then the first step is surgery, and surgery is really how we get the true stage of the cancer. You know, it's based on the size of the tumor and more importantly, it's based on the lymph nodes that are involved. So when we do surgery to remove your cancer, we're actually also removing all those lymph nodes in the area that could have developed a cancer or had cancer spread to those areas. So once the pathologist looks through everything, they look to see, a). the size of the tumor, b). was it invading anything else or was it just involved in the colon, and c). how many lymph nodes were involved. And if you have no lymph nodes involved and no other concerning features – and there are certain features that are kind of nuanced in terms of what makes something higher risk – then you don't need any additional treatment. Those patients don't need chemotherapy. But if you did have lymph nodes involved, then those patients would need chemotherapy because we want to get all the microscopic disease that's already made its way out. 

Erin Spain [00:11:35] So basically, what you're saying is colon cancer is highly curable when it's caught at that early stage. Just another reinforcement for these screenings. 

Dr. Colleen Donahue [00:11:44] Right. And that's really why I wanted to be a colorectal surgeon. Everyone asks you, why do you do this? But the truth is I really enjoy surgical oncology, but it can be a depressing field at times. But with colon cancer, it's extremely curable if it's caught early. We have screening for a reason, and it's the same with mammograms. You know, if you're going to get your mammogram, you should also be getting your colonoscopy because we can catch it early and we can treat you and we can cure you. And that's always our goal. 

Erin Spain [00:12:12] Let's talk about the odds of colon cancer returning. What are the odds? 

Dr. Colleen Donahue [00:12:17] It's dependent on whether or not you have a hereditary disorder or not. So if you have, say, Lynch syndrome, then your odds of having a recurrence or a tumor in another location is high, much higher than the general population. And those patients specifically will sometimes even recommend doing what we call a total colectomy where, you know, because they're at high risk of having another cancer down the line. Should we just remove the whole colon right now to take that out of the equation? It's almost similar to what you hear with prophylactic mastectomy. It's definitely less talked about, but you know something because your risk is so much higher than the general population, it's something that we have to counsel patients about. Some patients would rather just take out the area that's involved and then get their annual colonoscopy, which is perfectly fine as long as they stick to their screening, but they have to be willing to stick to their surveillance. However, if they say I never want to deal with this again. I don't want to take the risk. Then it's certainly reasonable to consider doing a total colectomy in those patients. Now, in the general population, the risk of having another colon cancer is much lower. You know, there's always a risk of recurrence and coming back where you removed it. But that's why there were high risk features. We typically treat those patients with chemotherapy after their resection to help prevent that from happening, but it's not zero. 

Erin Spain [00:13:35] Tell me about the difference between colon cancer and rectal cancer. What are the differences and how do you treat them differently? 

Dr. Colleen Donahue [00:13:42] So they're actually completely different and they're treated completely differently. And a lot of people don't realize that because a lot of people will talk about it and they get thrown into the same category. But when we're doing colonoscopies, is it so important to know if the tumor is in the colon or if it's in the rectum because it will completely change the treatment algorithm. And the reason being is because rectal cancer can be slightly more aggressive and it's also more respondent to certain treatments such as radiation, and radiation is not something you typically use in colon cancer. So a patient with a rectal cancer, what that means is that in the first 15 centimeters from the anal canal through the bowel. So basically it's the lower portion of your bowel right before it comes out of the anal canal. And that area is actually almost outside of the abdominal cavity, meaning it has a different lining to it. It doesn't have the same layers to it that the colon does, so it acts a little bit differently. Its blood supply is also a little bit different. So we're talking about lymph nodes and risk of having disease in your lymph nodes. That's going to be a little bit different. And so all of those things are super important when it comes to treatment. But if you're diagnosed with rectal cancer, we do the same staging workup for the most part. You get your CT scan of the chest, you get your CT scan of the abdomen, but we actually also get an MRI of the pelvis. The MRI is the best test to look at where the rectal cancer is in the layer of the rectal wall. Your rectal wall isn't just one single layer, it actually has multiple layers. Colon cancer was all about just the size. Rectal cancer is not about the size, it's about the invasion and how deep it's growing. And then the other thing the MRI looks at is it actually looks at the lymph nodes around the area and if they're suspicious of cancer or not. And those patients, again, they get presented at our multidisciplinary tumor board. And actually, if you have a more advanced rectal cancer, meaning it's in the lymph nodes or it seems to be growing into something, looks concerning like we might have trouble getting it out with a clean margin, those patients get what we call total neoadjuvant therapy. Now, what that means is they're actually getting their chemotherapy and radiation before surgery. What that does is the radiation helps prevent recurrence. And so basically you get your total neoadjuvant therapy, and then we proceed with surgery to give you a better shot of having a cure. So, in that sense, it's completely different from colon cancer where you would do surgery first and then potentially you're doing chemotherapy depending on if it's in the lymph nodes. 

Erin Spain [00:16:08] Is rectal cancer also typically detected during a colonoscopy? 

Dr. Colleen Donahue [00:16:13] It's detected exactly the same way. The colonoscopy, I can not reiterate, is so important, and we know that about only 19 percent of people that are qualified for colonoscopy are actually getting them. It's an extremely low percentage. It's gotten better over the years, but it's still really low. 

Erin Spain [00:16:30] I would love for you to speak directly to the women listening who, you know, have been avoiding this topic. All these topics that are related to colorectal health. What would you like to say to them? 

Dr. Colleen Donahue [00:16:39] I think the most important thing is to realize how common these things are, and that it's OK to talk about and to not be embarrassed about. It's something that we do every day here, you know, in the colorectal division. We're constantly seeing patients with these issues that we wish more people would talk about it. We wish more people would get screened. And so we just have to reiterate to patients that as best they can: don't be embarrassed and don't be afraid. 

Erin Spain [00:17:02] This is a question we ask everyone who comes on the podcast. What do you do to optimize your health and live well? 

Dr. Colleen Donahue [00:17:09] I like to exercise. I'm a horrible runner, but I like to run. I'm really slow, but I find it helps clear my mind at the end of the day. So, that's my go-to, like getting outdoors, going for a slight jog. That's definitely my thing.

Erin Spain [00:17:21] All right. Well, this is such good advice. Thank you so much.

Dr. Colleen Donahue [00:17:24] Thank you so much for having me. 

Erin Spain [00:17:30] For more information on this podcast, check out advance.MUSChealth.org.