Colon Cancer: Screening can detect disease early, reduce deaths

Coach Ike Bullard stood in the gym at Gregg Middle School and calmly lined up his shot as basketballs whizzed by. The energetic din of students is Bullard's rhythm of life at the Summerville school, and there's nowhere he'd rather be.

A year ago, he was diagnosed with Stage II colon cancer. The disease had progressed quietly, with no signs, deep in his intestines. The 10 pounds he lost, he attributed to exercise.

"I had probably not been to the doctor in 20 years except for sinuses," Bullard said.

But when the former Marine Corps helicopter pilot decided to check out his VA benefits, a routine fecal occult blood test, which tests stool samples for blood, indicated an abnormality.

The 63-year-old coach still put off the colonoscopy until after the football season. When the time came, he opted for very little sedation. "I looked up and saw two tumors on the screen," he said. "The doctor said,

'You've got cancer.' I was in shock."

In 2009, more than 2,170 people in South Carolina will be diagnosed with colon cancer, and more than 730 will die from the second leading cancer killer, according to the American Cancer Society.

But screening does not only catch cancer early, it can actually prevent cancer from developing by removing polyps, or growths, in the colon that may turn cancerous. About 90 percent of colon cancers begin as polyps, experts say.

"If a person has appropriate screening, it can reduce the death rate from colon cancer in that individual by 90 percent," said Dr. Rudolph Rustin, a Mount Pleasant colorectal surgeon. "That's better than breast cancer screening."

Rustin, who estimated he has performed 15,000 colonoscopies in his career, said colon cancer screening doesn't get the same attention because it is in an "unpleasant" part of the body.

Four major health care providers in Charleston have teamed to raise awareness of this killer. The Ralph H. Johnson VA Medical Center, Trident Healthcare System, Roper St. Francis Healthcare and the Medical University of South Carolina a few years ago formed the American Cancer Society's Healthcare Partners Committee, compiling their cancer registry data to study Charleston's cancer burden.

A need for colon cancer education, screening and prevention became evident. Between 1993 and 2004, more than 42 percent of colon cancers were diagnosed as Stage III, meaning they had spread to lymph nodes, or Stage IV, which is when the cancer spreads to other organs.

These late-stage cancers are not curable, although treatments may prolong life, said Dr. John Allison, former committee chairman and VA staff surgeon. While this finding is not significantly different from national data, area experts set the goal of reducing late-stage diagnosis to 35 percent by 2012.

"We have to get out in the community and promote early detection in colon cancer," Allison said.

Bullard's cancer had not spread beyond his colon. Surgeons removed 15 inches of his large intestine and 3 inches of his small intestine. He decided to forgo chemotherapy since the odds of his cancer returning were the same.

Surgery is the primary treatment for colon cancer, said Dr. Walter D. "Bo" Blessing Jr. of Surgical Associates of Charleston. Minimally invasive laproscopic surgery, which has a quicker recovery, may be an option for patients, Blessing said. Radiation and chemotherapy also may be prescribed.

After surgery, Bullard bared his stapled abdomen to friends, urging them to get colonoscopies. Four months later, about 12 had been screened, he said. "They were clear."

Bullard's recent colonoscopy also was clear. In his 12th year at Gregg, he described his decision to teach at age 38 as a "calling."

"I'm glad I have a few more years to do that."

In the know

What are the risk factors for colorectal cancer?

--50 years or older.

--A close relative who has had colorectal polyps or colorectal cancer.

--Inflammatory bowel disease, such as ulcerative colitis or Crohn's disease.

--Women with genetic risk for breast and ovarian cancer also may have increased chance.

Who should get screened?

--Anyone 50 years or older. If you have risk factors other than age, talk to your doctor about screening earlier.

Which screening method should I choose?

Many factors go into choosing the best screening for you. Age, medical history, insurance and convenience are points to consider.

You and your doctor may choose among, or a combination of, the following methods.

--Digital rectal exam is when a doctor inserts a gloved, lubricated finger to feel for abnormalities. Requires no cleansing of the colon, but can detect abnormalities only in the lower part of the rectum. Recommended annually.

--Fecal blood occult tests are low-cost stool smears that can be done at home but do not detect precancerous polyps and are prone to false positives without dietary restrictions. A colonoscopy may be required if abnormalities are found. Recommended annually.

--Sigmoidoscopy is a flexible lighted tube put into the rectum. Requires less-extensive cleansing than a colonoscopy and can be done without sedation, but allows a view of only the rectum and the lower part of the colon. Recommended every five years in conjunction with annual fecal blood occult tests.

--Double-contrast barium enema is an X-ray of your colon after an enema with a fluid called barium. This test does not require sedation and allows a full view of the rectum and colon, but may not detect some small polyps and cancers. Cleansing is required, and a colonoscopy may be required if abnormalities are found. Recommended every five years.

--Virtual colonoscopies are CAT scans of the colon after it has been filled with air. These tests have gained attention, but many providers remain wary until more studies are done. Cleansing is required, and a colonoscopy may be required if abnormalities are found. No firm guidelines exist on recommended frequency.

--Colonoscopy is the gold standard because it allows a view of the full colon, and doctors can remove polyps and some cancers during the procedure. It is similar to sigmoidoscopy except a longer tube is used to examine the entire colon. Requires cleansing of the colon and often some level of sedation. Recommended every 10 years.

How do I cleanse my colon?

Your doctor will prescribe a restricted diet the day before and provide one of several laxatives to clear your colon of fecal matter. While unpleasant, this step is critical. "It is probably the most important part of the colonoscopy," said Dr. Walter D. "Bo" Blessing Jr. of Surgical Associates of Charleston. Your doctor needs to get a good look that will last 10 years.

There is usually no cramping or pain, just a lot of going to the bathroom. This often is described as the "worst" part of the colonoscopy because most patients are sedated for the procedure.

If you are a motivated patient and your appointment is late in the day, ask your doctor about split dosing, which means taking half the prescription the night before and the second half on the day of the procedure about six hours before it's scheduled. This will give your doctor the best possible chance to catch abnormalities.

Dr. Brenda Hoffman, professor of gastroenterology at Medical University of South Carolina, said, "Split dosing is an excellent idea because the small bowel produces a mucous that comes down and coats the right side of the colon. Most missed lesions are on the right side"

Are colonoscopies dangerous?

Colonoscopy carries a small but real risk of tearing a hole in the colon. The published risk for perforation is 0.9 per 1,000 procedures, said Dr. John Allison, staff surgeon at the Ralph H. Johnson VA Medical Center. That risk is slightly lower if no biopsy is done and no polyps are removed, and slightly higher if those procedures are done.

Will insurance cover my colonoscopy?

Many insurers, Medicare and Medicaid will help pay for screening. Check with your provider.

Who should do the colonoscopy?

Experience counts. Dr. Rudolph Rustin, a Mount Pleasant colorectal surgeon, recommends going to a doctor who provides more than 100 colonoscopies a year, and choose one who can remove polyps and carry out biopsies at the time of the scoping.

Colonoscopies usually are performed by gastroenterologists or surgeons. Sigmoidoscopies are performed by a primary care physician.

Reach Jill Coley at 937- 5719 or jcoley@postandcourier.com.

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