Episode 15 - Colorectal Cancer Screening

Episode 15: Colorectal Cancer Screening

 

The sun rises over the San Joaquin Valley, California, today is June 5, 2020.

Have you heard about a new once-a-day gabapentinoid for postherpetic neuralgia? It’s called Gralise®. Keep it in mind, but also be mindful of the price. According to GoodRx, 30 tablets of 300 mg may cost $200 with a discount coupon. Consult your patient’s formulary to verify its coverage.

On Tuesday, May 24, at 9:32 PM, a 3.7-magnitude earthquake was felt in east Bakersfield. The quake’s epicenter was estimated at Corrientes Street near Kern Medical, according to USGS. There was no damage, and the shaking was described as “light” and “a typical Californian earthquake”. This serves as a reminder for emergency preparedness. Make sure you have a plan and good home storage in case of a major event. 

Finally, something different than COVID-19 caught national attention on May 25, 2020. Unfortunately, it was not a positive note. An African-American man named George Floyd was killed by a policeman in Minnesota. This has caused national commotion and has heated up the debate about racism in the US. Hopefully by the time you listen to this episode, justice has been served.  

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

“If you are not willing to learn, no one can help you. If you are determined to learn, no one can stop you.” –Zig Ziglar.

If you are determined to learn, you are just unstoppable. Your residency experience can be enriched by your determination to learn. Dear residents, make sure your eagerness to learn works in your favor as a driving force during this unique period of your life. Today we have a resident with a strong determination to learn. She has successfully overcome many obstacles and she’s here with us today as a PGY3. Welcome, Dr Fareedy.

Question number 1: Who are you?

My name is Amna Fareedy. I am a third-year resident at Rio Bravo Family Medicine Residency Program in Bakersfield. I was born in New Jersey and moved to Pakistan during high school. I relocated back to the USA after finishing my medical school and getting married. 

I am also a mother to two very active children. My hobbies include reading and watching period dramas, but between my children and residency that has been on a halt for a while. My only entertainment at home currently is watching baby shark with my children.

Question number 2: What did you learn this week? 

This week I learned about the different colorectal cancer screenings. As primary care physicians, preventive visits are very important for our patient’s well-being. At age 50, colorectal cancer screening becomes part of preventive care in average risk patients.  I have observed that patients can be hesitant in getting themselves screened for colorectal cancer (CRC) which can be due to number of reasons that I will highlight as we progress in discussion. 

Comment: This is a very good topic. I’m surprised to know that the American Cancer Society (ACS) recommends that people at average risk start screening at age 45 (2018). People who are in good health and with a life expectancy of more than 10 years should continue regular colorectal cancer screening through the age of 75. For ages 76-85, the decision to be screened should be based on a person’s preferences, life expectancy, overall health, and prior screening history. People over 85 should no longer get colorectal cancer screening. The USPSTF recommends screening at age 50 (2016, being revised).

Three different ways to screen for colorectal cancer

Multiple screening tests are available to detect CRC and adenomatous polyps which differ in sensitivity, specificity, availability, effectiveness, and cost.

Stool-based test: Fecal immunochemical test (FIT) for blood in stools

This test directly measures the hemoglobin in stool. 

Test Procedure: FIT is a simple test performed on stool sample provided by the patient in a special collection container. It is performed annually.

Advantages and disadvantages

It is convenient and has a higher adherence rate. There are no pre-requisites to be completed prior to testing no dietary and medication restriction.Does not require bowel prep, sedation or anxiety of an invasive procedure.It requires only one sample as compared to the FOBT which requires three.It is more sensitive than gFOBT for colon lesions.When compared with gFOBT, FIT screening has higher detection rate for CRC and advanced adenomas due to higher sensitivity and higher screening participation rate with FITFIT is less sensitive for detection of right sided than left sided colon lesions.

Comment: Screening for colorectal cancer = Screening for polyps.

Multitargeted stool DNA test with FIT (Cologuard®) 

It is a composite of test that include assay to test for DNA KRAS mutations gene amplification to test for biomarkers associated with colorectal neoplasm, and to test for hemoglobin that might be shedding in to stool from the colon.

Patient collects the stool in a special collection kit and mails it to the company for testing. It has to be received by the company within 72 hrs of collection.

Advantages and disadvantages:

Testing is done at home.No medical dietary restrictions. No bowel prep or sedation. If test is positive, then follow up with colonoscopy. If negative, follow up every three years instead of annually.Patient may not completely collect the full stool sample as instructed by collection kit.Stool sample needs to be received by the company within 72 hours of collection. 

Comment: In our clinic, all the MAs have the ordering form, just sign it and ask your MA to fax it. Patient will be contacted by manufacturer. You will get the result to discuss it with the patient. 

Colonoscopy

It is the most commonly used screening test in United states. It needs to be performed by trained clinician using endoscope to directly visualize the colon. It is performed every 10 years. 

Advantages and Disadvantages: 

Definite test for detection of precancerous adenomas and CRC with high sensitivity and specificity.It allows for biopsy to be taken. It requires vigorous bowel preparation.Sedation is used during colonoscopy.Patient might need another attendant on discharge due to sedation effect. Sedation related side effects.Colonoscopy related bowel injuries perforation bleeding.Less effective in detecting right sided compared to left side colon lesions because of contour or location.

Comment: For the record, we did not cover flexible sigmoidoscopy, CT Colonography, Methylated SEPT9 DNA (mSEPT9), but those are other options to screen for colorectal cancer and adenomatous polyps. 

Polyps

Pedunculated and sessile: Both can turn into cancer, terms only describe the shape (mushroom-like or not). 

Hyperplastic, Hamartomatous, and inflammatory (normally not cancerous, only in certain cases – size, number, location and certain syndromes).

Sessile serrated polyps or adenomatous polyps (considered precancerous polyps and require close surveillance). The GI specialist will normally give patients a follow up instruction. 

Question number 3: Why is that knowledge important for you and your patients?

As primary care physicians, this knowledge is important so we can offer our patients all the options available for colorectal cancer screening. Limiting patients to one choice, for example colonoscopy, results in non-adherence due to different factors discussed earlier.

Patients can be offered all the choices: FIT, FOBT, Cologuard®, sigmoidoscopy, etc. in addition to colonoscopy. If patient’s results are positive, further intervention and recommendations can be offered, which is better than not having any screening at all.

Comment: Colorrectal cancer is the second leading cause of cancer death in the US, almost 50,000 patients die every year.

Question number 4: How did you get that knowledge?

Many of my patients are resistant to be screened for fears of colonoscopy. I want to offer them different options.

Where did that knowledge come from?

For this topic, I specifically read up-to-date test for screening for colorectal cancer, the ACS website, and USPSTF current recommendations.

Speaking Medical (Medical word of the Week): Smegma
by Steven Saito

Smegma, also known as penile cottage cheese,is a white or yellowish secretion found between the glans of the penis and the foreskin of men and other mammals. It is an oily mix of sebum with dead cells that may become “cheesy and smelly” when left stagnant. The combination of warmth and smegma creates a rich breeding media where bacteria can grow and create a characteristic stench. This can lead to infections as well. Smegma is not exclusive to men as women also secrete smegma around the clitoris and labia minora. Believe it or not, smegma is essential for lubrication and good health of the genital organs. Just keep it under control with regular hygiene. An alternative definition by Urban dictionary is “a delicious butter substitute.” 

Espanish Por Favor (Spanish Word of the Week): Diarrea
by Fermin Garmendia

Hello, I am Dr Garmendia and I’m here with our section Espanish Por Favor. The Spanish word of the week is diarrea. When you see the spelling of this word, you can quickly realize it is diarrhea, but the pronunciation is different. Diarrea consists of watery or loose stools. The patient may present to you and tell you: “Doctor, tengo diarrea.” It is a common complaint among our patients, and you need to investigate the characteristics of the stools, any blood? Any mucus? Also, inquire about duration, frequency, triggers, and alleviating factors. Many of our patients relate diarrea to parasites or other infections, and you know it is not always the case. I invite you to read about the work up of diarrhea to learn more, but now you know the Spanish word of the day, diarrea.  

For your Sanity (Medical Joke of the Week)
by Steven Saito

Last week we gave you three questions and we got many good answers. We picked the first person who answered correctly and the winner of our contest is [drum roll] [SURAJ, ADD THE NAME HERE], congratulations! 

Here are the answers to our questions.

For the treatment of acute cluster headache, in what nostril is it recommended you administer an intranasal triptan? Dr Manzanares explained that we should administer the intranasal triptan in the nostril contralateral to the symptoms of the acute cluster headache, i.e. if your headache is on the right side, administer Imitrex in the left nostril.What is the other term used for “wet-to-dry” dressings in wound care? Dr Tu recommended the use of the term “moist-to-dry” because the dressing should not be soaking wet, but just moist.Why do we use single-dose vaccine vials instead of multidose vaccine vials? Dr Saito explained that we use single dose vaccine vials to avoid use of thimerosal. Thimerosal is a mercury-containing preservative.

Now we conclude our episode number 15 “Colorectal Cancer Screening”. Dr Fareedy explained the difference between FIT, Cologuard® and colonoscopy. Remember to offer different options to screen your patients who are 50 years and older for colon cancer. Smegma may not be the most elegant of the human body secretions, but it has many benefits. Personal hygiene is key to keep smegma under control and prevent disease. What’s diarrhea without an h? It’s the Spanish word diarrea (Suraj, pronounce dee-ah-RAY-ah). We are happy for [ADD NAME OF WINNER HERE] who is not only wiser for listening to this podcast but also $20 richer. 

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. Our podcast team is Hector Arreaza, Alyssa Der Mugrdechian, Fermin Garmendia, and Seven Saito. Audio edition: Suraj Amrutia. See you soon! 

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References:

American Cancer Society Guideline for Colorectal Cancer Screening, May 30, 2018, https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html, accessed on May 28, 2020.Polyps, F!GHT Colorectal Cancer, https://fightcolorectalcancer.org/prevent/colon-polyps/ , accessed on May 28, 2020.  Colorrectal Cancer: Screening, US Preventive Services Task Force (USPSTF), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening, accessed on May 28, 2020. Ahmed, Murtaza, “What is Smegma?: A Guide to the Unappetizing Biofluid That is Smegma”, July 1, 2015, Myheart.Net, https://myheart.net/articles/smegma/