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Featured topic and speakers
What causes colon cancer? Is colon cancer becoming more common? Is cancer screening effective? Can colon cancer happen at a young age? Can a FIT test detect colon cancer?
Our guest is Doug Corley, MD, PhD, chief research officer for The Permanente Medical Group. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Doug Corley, MD, PhD, chief research officer, The Permanente Medical Group
Transcript
Dr. Corley: Our study suggests that timely, regular screening decreases the risk of death from colon cancer by about 50%. That's incredible, cutting in half within just a decade or so the second most common death of cancer just from being able to do screening.
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about the rising rates of colon cancer in younger adults and the test that's helping one health system catch it earlier and improve patient outcomes.
Our guest today is Dr. Doug Corley, chief research officer for the Permanente Medical Group in San Francisco. And I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Corley, it's a pleasure to have you today.
Dr. Corley: Well, thank you so much. Privilege to join you. And thank you for sharing this important topic.
Unger: And I've been reading a lot about it. Colon cancer has been increasing in younger adults for years. And so, your work to improve detection is more necessary now than ever. Why don't we just start for the folks out there that might not understand the extent of the problem? Can you give us a big picture idea of what we're seeing in terms of these increases?
Dr. Corley: Sure. Well, so colorectal cancer is still the second most common cause of cancer death in the United States. So, it's a substantial problem, and it causes a lot of both mortality, people dying and morbidity, people having problems with their health.
The overall incidence of it, though, has been decreasing since the 1980s. And that's likely related to screening and prevention, probably mainly among people who are over 50 years old because that's who it's been recommended for.
But what we've seen with this is then that the incidence has gone up by about 2% per year in people who are younger than 50. This is mostly in people who are 45 to 49. So, by 2019, one of the recent years where this was looked at, about one in every five colon cancers were in people who were under the age of 54.
So that's up from 11%. It went up to about 20% from about 10 to 15 years earlier. And the death rates from colon cancer just as much as the incidence or the frequency of it going up also have increased about 1% annually in people younger than 50. So, most cancers by far still occur in older people.
But younger people are at increased risk compared to what they were. And we're seeing this also in Kaiser Permanente in Northern California. Most of these cancers in younger people are diagnosed in those who are in the ages of 45 to 49. So, it's still pretty rare in people who are younger than 45, but it has definitely increased in that group also.
Unger: Now, of course, the natural question is, why do we think that there is an increase like this in that somewhat younger age group?
Dr. Corley: The definitive causes are hard to tease out. We and others have looked at differences between people with what's called early onset colon cancer and also older onset colon cancer in people who have not had cancer at all. Part of it is probably an inherited risk, but that's something that's kind of stable. That really shouldn't change that much over time, over 15 years.
The biggest new risk factors seem to be being overweight or obese. This increases the risk of many types of cancers, but also of colorectal cancer. Decreased exercise also increases cancer risk. And there's also some possibilities that changes in the body's microbiome—those are the bacteria that live in the gut—influence cancer risk.
And those bacteria also can change from a lot of different things. They can change from differences in diet, from taking antibiotics, from exercise. There have even been reports that certain types of energy, such as those admitted by cell phone carried in pocket might increase the risk.
And any of these may interact with your inherited risk. So knowing your family risk is important for guiding screening and prevention recommendations. And it's probably some combination of these things, which is leading to the overall increase in younger people.
One of the interesting things people say, well, why isn't it increasing in older people? And as we were just talking about, that's probably partly related to the fact that we've been having a decrease in incidence. I think if we weren't doing screening, we would probably be seeing an increase in older people too.
Unger: Yeah. Well, I'm one of those people who got the message and am having regular colonoscopies to make sure that anything might be caught early. But for responding to this new trend that we're talking about, there is a key new tool that is having an impact. I'd love you to tell us more about that.
Dr. Corley: Sure. So the main thing is to be able to get screened. And then what are the different types of tests that are available to be able to help you to be able to be screened? You mentioned colonoscopy. That's one test. And that's helpful because it gets a direct look inside the colon.
Another test is our stool-based test. One of them is called the Fecal Immunochemical Test. And this is a test that looks for small amounts of blood that are in the stool. It's very helpful because it's non-invasive. It can be done at home.
Only those people who have positive tests need a colonoscopy to the best of the information that we have right now in terms of decreasing the number of cancer deaths, doing this on a regular basis is about the same as a colonoscopy.
There may be a little bit of a difference in terms of cancer incidence. Colonoscopy seems to be somewhat better at decreasing cancer incidence because it's better identifying polyps and removing polyps. But the studies have shown that having more than one option increases screening.
And so, within Kaiser Permanente and some other settings, we have started to be able to do outreach for those who are not up to date. And this has led to greater than 80% of people being screening up to date. And when we started the outreach program, screening doubled from about 40% to about 80%, using that mixture of colonoscopy for those who wanted it.
And then if someone was not up to date with screening by some other method, then mailing a FIT test to their home where they could then return it. And so this really provides this multiple different modes of screening and increased patient choice around those.
Unger: Do you see them as interchangeable? And can they work in combination? I mean, obviously, I'm probably on an every five-year schedule, for instance, on a colonoscopy. What about those interim years? Is there a role for the FIT testing there?
Dr. Corley: That's a great question. It hasn't been looked at in that way in some high-risk people. And there are some studies that are going underway right now nationally, including within Kaiser Permanente, that are looking at the different roles for FIT potentially, more in people who are lower risk.
You've had a negative colonoscopy. Do you need to continue to be able to have a more invasive exam? But it hasn't really been looked at as like the combination test of doing both.
Unger: Well, for those of you who've been through the preparation for a colonoscopy, a FIT test sounds very appealing.
Dr. Corley: It has a lot of strengths. Colonoscopy is invasive. It requires you to take a day off. There's the factor of having to be able to take the bowel prep. There's some small risk with it. It's a sedated procedure. And that combination of things has led to not everyone having it done.
And so in most settings where colonoscopy is the only option, you tend to get screening rates of maybe 60% or 70%. But when you increase the number of options, then there's going to be people who choose the alternative rather than colonoscopy. And then there'll be people who chose colonoscopy.
The other thing is is that being able to reach people in their home is a really important part of being able to have an approach that really is able to get everyone, even people who may be younger, who otherwise aren't coming into the doctor on a routine basis and so may not have that contact that prompts it.
People who live farther away or in rural areas. People who work and it's hard to be able to take a day off. And people who may just not want to deal with some of the other parts that you talked about, regarding the colonoscopy, and only have a colonoscopy if the test is positive.
So there are a lot of positives about it. And that's one of the reasons why the U.S. Preventive Services Task Force kind of equally recommends colonoscopy and FIT for benefit in terms of decreasing the risk of death from colorectal cancer.
Unger: That's really helpful. And last year, you published a study in JAMA Network Open™ talking about the benefits of FIT screenings and the impact that they've had on patients. Can you share some of the findings with us?
Dr. Corley: Sure. So there haven't been a lot of studies that have looked at what's happening in real life, kind of in large populations. So Kaiser Permanente in Northern California has about 4.5 million patients. That's about one out of every 70 people in the United States.
And this study looked at within that population, which has the FIT program that I described where everyone who is not up to date with screening has it mailed to their house. And they looked at those who died from colon cancer and those who didn't.
That study found that those who had had at least one FIT test within the prior five years were about one third less likely to die from colorectal cancer. Similar to almost all other studies of different types of colon cancer screening, including colonoscopy, the association was stronger for cancers on the left side of the colon than on the right side.
That's likely because cancers on the right are a little different. The polyps and the cancers are harder to see directly, decreasing detection by colonoscopy. And they're less likely to bleed, decreasing detection by FIT.
But still, like a one third reduction is a pretty substantial decrease in mortality. And we would anticipate it to be even stronger over time, repeating the test annually as currently recommended by most groups in the United States. For the second most common cause of cancer death in the United States to be able to have that type of reduction was a really exciting finding and supported the program.
Unger: And yet, despite that gargantuan number that you just cited, it seems like a lot of people still aren't getting treated for colon cancer. Why do you think that is, and how can health systems help to close that gap?
Dr. Corley: I mean, screening takes effort. And as we were talking about some of the options, such as colonoscopy, can be a big deal. The bowel prep that cleans you out, sedated, taking a day off from work, having an invasive procedure.
That's where the options become important for different people's preferences. There have even been studies that have looked at offering people options versus offering just one versus the other. And when you offer an option, the total number of people who get screened goes up.
The other is being able to reach people in their homes and the convenience of it. The last part, which is more on the part of the health care system, is the tracking, outreach and follow-up. So a major part of this work also is just being able to say, who's up to date with screening? If someone's not up to date, then we're going to contact them.
This does take effort. But if you think about it, it's not that different than going to your dentist. Your dentist knows whether you've come in the last six months. They send you a reminder and a prompt. This is doing the same thing for the second leading cause of cancer death in the United States, to be able to make sure that people have their screening.
Unger: That makes so much sense. Number one, that there is an option, number two, awareness of an option, number three, being able to do that at home, all really important factors in changing this situation for, as you point out, one of the leading causes of death. When you look ahead, what else is it going to take to address the rise of colon cancer in this younger population?
Dr. Corley: The most effective thing we have is screening. It's so impactful compared to most other medical interventions. Our study suggests that timely, regular screening decreases the risk of death from colon cancer by about 50%. I mean, that's incredible, cutting in half within just a decade or so the second most common death of cancer just from being able to do screening, having early detection and treatment of the cancers and then prevention through ...
So probably a major part for younger people is increasing awareness among younger people in part of the changes in the screening guidelines in the United States, which now suggests starting screening at age 45 for people who are at average risk rather than what used to be at age 50. I think people often kind of like lock these dates in their heads. They're like, oh yes, when I hit 50, I will start this. That time mark has been moved back.
The second thing is the best test is the one that really gets done. So having health care systems that are organized around this and offer options helps to be able to get it done.
Reaching people in their homes—young people are probably less likely to have contact with the health care system. They just don't have as many other health problems. They're not coming in for high blood pressure screening, or they're not coming in for treatment of other things. And so being able to identify who it is and then being able to reach them in their home.
It's possible that some other interventions around increasing exercise, decreasing overweight may help for prevention. That may help for multiple problems in terms of heart disease and other cancers, including colorectal cancer, although the most effective tool we have right now is screening. So that's where the awareness, the tracking, the outreach is going to probably play the biggest role in addressing the rise of colorectal cancer in young people.
Unger: And just to clarify something, is there any change in the time between screenings if you're using the FIT approach?
Dr. Corley: There is. In Europe, it's done every two years. In the U.S., most of the groups recommend doing it every year.
For colonoscopy, the standard interval is 10 years, but then it depends also on what you find so that if you have a family member who's at a younger age or you have a polyp finding, then it's recommended more often. And for anyone who's high risk, such as a family member at a younger age, then those people are recommended to have colonoscopy rather than FIT.
Unger: All right, that is really important information. Clearly a lot of work to do. But what a huge upside in terms of saving lives. And we're so encouraged to see the progress that you and the health system are making. Dr. Corley, thank you so much for joining us and telling us about your work.
If you found this discussion valuable, you can support more programming like it by becoming an AMA member at ama-assn.org/joinnow. That wraps up today's episode, and we'll be back soon with another AMA Update. Be sure to subscribe for new episodes. And find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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