Friday, March 8, 2019

Colon cancer screening: Is there an easier, effective way?

Confused about when to get your next Pap test? Anxious because your doctor said you don’t need another Pap for five years? Well, you are not alone.

For several decades, getting a yearly Pap test has been the standard for cervical cancer screening. Cervical cancer, which still kills about 4,000 women annually in the United States, is really a preventable disease. The goal of cervical cancer screening is to detect areas of significant precancerous cells in the cervix (cervical dysplasia) and treat them before they become invasive cervical cancer. Early detection is key and for a long time the Pap test — which looks for abnormal cells — was the only tool available to screen for cervical cancer. Women were encouraged to get one yearly.

Then along came the discovery that HPV or human papilloma virus plays a key role in the development of cervical cancer. Researchers have studied the biology of HPV and cervical dysplasia. We now know that certain strains of HPV increase the risk of developing cervical cancer. And we also have a good understanding of how long it takes for some types of cervical dysplasia to become cervical cancer. Based on this new knowledge, experts concluded that women were being overscreened with annual Pap smears and overtreated for abnormal cells that were unlikely to ever become cervical cancer. Doctors started testing for high-risk strains of HPV, and new screening guidelines reflect this knowledge. The current recommendations for cervical cancer screening in average-risk women in the United States include:

    start screening at age 21
    stop screening at age 65 (in low-risk women with no prior history of severe dysplasia)
    women age 21-30: Pap test every three years
    women age 30-65: Pap test every three years or co-testing (Pap and HPV) every five years.

New and better screening techniques thanks to HPV testing

Now newer research supports the belief that a woman’s HPV status is the strongest predictor of her risk for cervical cancer. Randomized control trials have shown that screening using HPV testing alone or in combination with a Pap test allows for earlier detection of severe dysplasia and offers better protection against cervical cancer than a Pap test alone. In fact, recent interim guideline updates offer the option of high-risk HPV testing alone every three years to replace the current screening options. Although testing for HPV has advanced cervical cancer screening, it has not yet advanced the experience of cancer screening for women. Unfortunately, the current method for HPV testing requires a speculum exam just like a Pap smear.

A recent study from the Netherlands published in BMJ continues to support this recommendation. Dr. Maaike Dijkstra and associates reported that women who have HPV are at a markedly increased risk of developing severe cervical dysplasia and cervical cancer compared to women who are HPV negative. They concluded that women with a negative HPV test have a very low risk for cervical cancer. Using that conclusion, they suggest that a woman over the age of 40 who is HPV negative may wait longer than five years between her Pap tests. It is important to note that this increased interval is not yet recommended in the U.S.

For sure, there have been many changes in how we screen for cervical cancer in the last few years and there are certainly more to come. Likely HPV testing will eventually be adopted as a way to assess cervical cancer risk, and screening intervals will be determined based on the result.

One thing is for sure, gone for good are the days of the annual Pap test. As hard as it may be to let go of old habits, there is good science to support these changes. But remember, it is still important to see your gynecologist every year, because there is more to your annual visit than just screening for cervical cancer.
Many of the flavorings that add a special touch to our favorite holiday foods confer the gift of brain health at the same time. Researchers have discovered that cloves, cinnamon, nutmeg, and other spices that we mix into baked goods and savory dishes contain nutrients that sharpen memory, reduce stress, or improve sleep, among other benefits.
Delicious and beneficial

Your kitchen cabinet contains a number of seasonings that have been linked to positive effects on brain health and functioning. These flavorings are often incorporated into holiday cooking, adding a special touch to our holiday festivities. Spices and herbs have a long history as a safe component of human diets and traditional health practices. Their effects on the brain can be significant, and we need more research to determine the potential of using compounds found in common seasonings as medications.

I don’t recommend taking any spice in large quantities, and it’s always best to check with a doctor before making significant changes in your diet. However, unlike many pharmaceutical products, common seasonings generally cause no undesirable side effects for most individuals when used as part of a normal diet. Enjoying them all year long — not just during the holidays — seems to be a natural and delicious way to strengthen the brain.

Many herbs and spices contain nutrients that have been linked to brain benefits, and ongoing research is adding to the list of their positive effects. The seasonings most likely to be featured in cakes, cookies, breads, and favorite savory dishes served over the holidays are described below.
Cinnamon

The bark of a tree native to Southeast Asia, cinnamon has been shown to have antioxidant, antidiabetic, and antibacterial properties. An animal study published in the July 2015 issue of Nutritional Neuroscience found that an extract made from the spice helped protect lab rats from cognitive impairment and brain damage associated with oxidative stress. Brain benefits associated with cinnamon consumption in humans include reduced inflammation, improved memory, increased attention, and enhanced cognitive processing. Serving ideas: Sprinkle cinnamon into your coffee, add it to fresh fruit, or mix it into your breakfast oatmeal. Better yet, enjoy a cinnamon bun!
Nutmeg

Nutmeg grows on a type of evergreen indigenous to Indonesia. The spice contains various compounds that boost mood, help relieve pain, and relax blood vessels and lower blood pressure. Some research suggests that a nutrient found in nutmeg may help slow cognitive decline in individuals with Alzheimer’s disease and promote the recovery of brain tissue following a stroke. Sprinkled in warm milk, it appears to help induce sleep. Serving ideas: Great with baked goods, or added to egg dishes, casseroles, and even burgers. Try adding it to brown rice, or grating it over whipped cream.
Cloves

Made from the dried flower buds of the evergreen clove tree, cloves are also native to Indonesia. The spice is loaded with antioxidant power. Research comparing clove with more than 1,100 other foods found that it had three times the antioxidants of the next highest source, dried oregano. Cloves are also a natural anti-inflammatory and antimicrobial agent, a local anesthetic, and have been found to have antifungal properties. A compound found in cloves has been shown to be 29 times more powerful than aspirin in helping to prevent blood clots. Serving ideas: Delicious added to baked goods, cooked grains, bean soups and chili, applesauce, smoothies, and cooked cereals.
Ginger

This spice, made from the root of the ginger plant, has been shown to be an effective pain reliever, with active compounds that resemble those of capsaicin, another well-known pain reliever found in hot peppers. The spice also helps reduce nausea, control inflammation, counters the activities of cell-damaging free radicals, acts as a blood thinner, and has been found to help protect brain cells from deterioration associated with Alzheimer’s. A 2012 study involving 60 middle-aged women found that a daily dose of 800 mg of ginger extract helped improve working memory and attention. Serving ideas: Use grated fresh ginger in salad dressings and marinades. Cook ginger with vegetables, such as squashes, sweet potatoes, and green beans. Add ginger powder to baked goods, tea, or fruit smoothies.
Cardamom

A relative of ginger and turmeric, cardamom has shown antibacterial properties, and antioxidant properties that help protect brain cells from free radical damage. A study published several years ago in the Indian Journal of Biochemistry and Biophysics found that consuming just ½ teaspoon a day for three months along with a healthy diet helps normalize blood pressure and lower risk for stroke by relaxing the arteries and the muscles of the heart. Serving ideas: Brew your coffee or tea with cardamom, add it to stews or soups, or sprinkle it into batters and dough for tasty baked goods. It’s also delicious with smoothies and hot breakfast cereals. As parents, we sometimes forget that habits learned early can stick with us for a lifetime. We cut corners and just figure that we’ll fix things later. Unfortunately, that doesn’t always work out. This is particularly true with preschoolers, both because they are at a point when they are learning all sorts of habits — and because they can be opinionated and very stubborn. This can be particularly true when it comes to eating!

That’s why you need to be patient and persistent — and just as stubborn — when it comes to feeding your preschooler. Here are the three biggest mistakes to avoid:

1. Choosing foods based on what they want, rather than what’s healthy. It’s totally understandable why parents do this; after all, nobody wants their child to go hungry. So they fill the plate with chicken fingers and French fries and skip the vegetables. They serve white bread and not whole grain, they let them eat chips instead of apple slices for snacks. The kid is happy and eats up, so the parents are happy. The problem is that not only is the child not eating a healthy diet, the child isn’t learning to like the foods that can keep him healthy for a lifetime.It can take a bunch of tries before a child figures out that kale, strawberries, or brown rice taste great.

Don’t be a short-order cook. Prepare healthy food for everyone (which is key — you’re going to have to eat healthy too for this to work) and insist that your child at least try everything. You can have a back-up food (something super simple and healthy, like yogurt or leftover food you can quickly microwave), but your child needs to eat some of what is served before he gets it. Sure, he might be a little hungry when he finishes. But knowing that you aren’t going to give in, and that he’ll be hungry if he doesn’t eat, may make him more likely to eat next time.

2. Letting them fill up on liquids. It’s amazing how even just a little bit of milk or juice can cut a child’s appetite. So many children carry sippy cups around — which not only is bad for the teeth and increases the risk of obesity, but can make kids less interested in eating meals. Parents often don’t think twice about giving their child milk or juice, as they think of thirst as separate from hunger, but it’s important to think twice. Give children water in between meals instead — and at mealtime, have them eat first and then drink.

3. Overdoing the snacking. Here’s another thing parents don’t think twice about: letting their child have something to eat when they are hungry. But just as with drinking milk or juice, having a snack can make children less hungry for a meal. Children can eat between meals, and when there is a long time between meals, they should eat. But there should just be one snack between meals (like a mid-morning and a mid-afternoon snack, instead of constant access to food), it should be a small amount (not a whole sandwich or big bowl of cereal, for example), and it should be healthy, like some fruit with nut butter or a yogurt or some cheese.

If you start these habits early, they will stick and become what your child is used to. It may be a struggle at the beginning, especially if you have been making these mistakes, but it’s worth the effort. They can help your child be healthy not just now, but for the rest of his life. Are you, or is someone you know, postponing their colonoscopy? Maybe it’s the idea of that prep. At best, it requires being home and near a toilet for a day. Worse, it can make people feel awfully ill. Or maybe it’s the invasiveness of the test. At best, it’s unpleasant. At worst, there can be serious complications, including an instrument puncturing the bowel, bleeding, and organ damage. It’s also time-consuming, requiring time off work for you and whoever will be driving you home.
Why is a colonoscopy worth the hassle?

Cancers of the colon and rectum are common, and lives can be saved with early detection. Colorectal cancer is the fourth most common cancer in the United States and the second leading cause of cancer death. There are well over a million people living with the diagnosis, and 134,000 new cases are expected this year. About 4% of all adults will be diagnosed with colorectal cancer in their lifetime; having a first-degree relative with colorectal cancer or precancerous polyps, a personal history of polyps, advancing age, obesity, alcohol use, smoking, and African-American race all increase the risk substantially.(1, 2, 3)

The five-year survival rate for these cancers is about 90% when the cancer is caught before it spreads at all, but only 68% when it has started to spread, and 10% when it is widely spread (metastatic).(3, 4) For this reason, experts agree that it makes sense to screen people at average risk starting at age 50 and up to age 75, with the decision to continue screening after that on a case-by-case basis.(3, 4)

According to the 2016 guidelines from the U.S. Preventive Services Task Force (USPSTF), there are six acceptable ways to screen for colorectal cancers and precancerous polyps: procedures like sigmoidoscopy and colonoscopy; special imaging techniques (CT colonography); basic stool tests for blood (because bleeding in the intestine can be a sign of cancer); the FIT test, which is a fancier, more sensitive stool test for blood; and the combined stool DNA test that looks for molecules, gene mutations, and blood. Which test to use depends on the patient’s situation and preferences, and the USPSTF has called for more research in order to be able to make more precise recommendations.(5)
Cologuard: The new kid on the colon cancer screening block

Recently my patients have been asking about Exact Sciences’ Cologuard combined stool DNA test, which was approved by the FDA in 2014. You may have seen it advertised on TV, featuring a cute little talking box. Medicare and Medicaid will cover the entire cost of this test (about $500) once every three years for average-risk people who have no gastrointestinal symptoms.

The test is easy-peasy. One of us goes to the website and prints out the order form, the patient fills in the insurance information, and I sign the paper, which gets mailed to the company. They in turn mail the patient a little box with the stool collection kit. The patient goes about their usual routine, without any change to diet or prep whatsoever, poops into the cleverly designed toilet cover/collection jar, and mails it back to the company within two days. The company runs the tests, and the numerical results from each test component are run through a special equation, with a cutoff score for a positive or negative result.(7) They send the results to me, and then I report to the patient. A positive test means that further evaluation is necessary, and that involves a colonoscopy looking for a polyp or cancer.
Just how good is Cologuard?

Based on the one major study cited,(6) it is pretty darned good: Cologuard detected 92% of colorectal cancers and 42% of advanced polyps. As a comparison, the FIT test detected 74% of cancers and 24% of advanced polyps. So it’s better than the only other real non-invasive option, and without the painful prep, potential discomfort, and potentially serious risks of a colonoscopy or CT colonography. (It is important to know that both of these stool tests are more likely to have a false positive result. That means that the stool test can suggest cancer when there isn’t any, and to know for sure, a patient will need a colonoscopy or CT colonography after all.) Right now, the test is covered by insurance every three years, but more research is needed to know if that is an appropriate interval; eventually, the test may be recommended more or less often than that.

Cologuard sounds so wonderful. And it may actually be, but patients should know that the one major study that provided the data upon which most of the recommendations are based was 100% funded by Exact Sciences, the company that makes the test. Even the one other smaller study showing similar, supporting results was authored by co-inventors of the Cologuard technology and scientific advisors to Exact Sciences.(8) It’s really important to know that, and to take this amazing little talking box with a big grain of salt. I can understand why the USPSTF is calling for more research, and why doctors aren’t abandoning the good old, dependable, but pain-in-the-rear-end colonoscopy as a basic screening test. Yet.

Am I recommending the Cologuard for my own patients? You bet. I have many patients whom I’ve been encouraging to have their colonoscopies for years, and for one reason or another, they have delayed. Or, there are some patients with medical issues for whom a colonoscopy may be logistically difficult or too risky. In their cases, the stool tests are very viable options, definitely better than no screening, and maybe better than traditional screening. We just don’t know for sure yet.

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