A Growing Epidemic | Oncology
Gastrointestinal cancers can strike nine structures in the human body, from the esophagus to the anus and all parts of the digestive system in between. While some forms are highly curable, others lack such a positive prognosis. Fortunately, doctors say, healthful lifestyle choices can help lessen the chances of developing these diseases.
Prevention is key to fighting this growing epidemic. "If you look at the 1.6 million cases of cancer that are diagnosed each year, one-fifth are GI cancers," says Dr. Richard Goldberg, physician-in-chief at the Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute.
Esophageal cancer is the third-most-frequent GI cancer and has increased 300-fold in the past 10 years, says Dr. Shakil Karim, chief of medicine for Licking Memorial Health Systems. Not only is the frequency of these diagnoses changing, but so is the location. While in years past, smoking and drinking damaged the upper esophagus, leading to squamous cell carcinoma, patients now are developing esophageal cancers lower in their digestive tracts, in deeper cells rather than in the surface cells. That has led to an increase in adenocarcinoma.
"We're seeing it right above the stomach," Karim says. The culprit is likely acid reflux, he says. Repeated exposure to stomach acid changes the composition of the esophageal cells, allowing cancer to develop. Poor diet and obesity-particularly among men who carry weight around their middles-can exacerbate the reflux and increase the damage.
Goldberg says esophageal cancer is four times more common in men than in women. If caught early, surgery and chemotherapy can sometimes be effective in battling the disease, but there is a low survival rate overall. According to the National Cancer Institute, 17,460 Americans were expected to be diagnosed with esophageal cancer in 2012. Of those, 15,070-more than 86 percent-were not expected to survive.
Difficulty swallowing and weight loss are typical symptoms of esophageal cancer. Men, African-Americans and older patients are more at risk. To minimize the chance of developing esophageal cancer, physicians recommend avoiding tobacco as well as heavy drinking and dietary choices that exacerbate reflux.
The No. 2 most prevalent GI cancer affects the pancreas. The National Cancer Institute estimated that 43,920 Americans would be diagnosed with pancreatic cancer by the end of 2012, and 37,390 people would die of the disease.
"Unfortunately there is no screening tool for pancreatic cancer, so early detection depends on symptom presentation," says Dr. David Arrese, a surgical oncologist with OhioHealth Columbus Surgical Specialists.
"You can do a CAT scan, but the majority of cases that are detected are too advanced to treat," says Dr. Kanwaljit Singh, a hematologist/oncologist with Fairfield Medical Center. "It is largely incurable, and patients generally die within about a year."
Pancreatic cancer claimed Apple co-founder Steve Jobs as well as actor Patrick Swayze. Because the disease is so prevalent, some in the medical community have debated routine scans to catch it earlier, but the expense and additional radiation exposure largely outweigh the benefits, most doctors say.
There's also no way to tell if someone will develop pancreatic cancer, Singh says. "It can run in families, but most patients have no identifiable risk factors." There are some clues, though: Smoking and diets high in red meat have been linked to the disease, and there is some association with both caffeine and alcohol. Those who have chronic pancreatitis are also at an increased risk, Singh says.
The pancreas makes digestive enzymes and insulin, which regulates blood sugars. Common symptoms of pancreatic cancer are linked to those functions, including abdominal pain, indigestion, bloating, painless jaundice and itching. Often, patients who have been diagnosed with diabetes but don't have typical diabetes-related risk factors discover that pancreatic cancer is the culprit.
If the cancer is discovered early and has not spread, surgery can remove the diseased cells. If, however, the cancer has reached the lymph nodes, it is very likely that the disease will recur quickly, Singh says.
The most frequently occurring GI cancer-and second only to prostate and breast cancers in cancer deaths-is colorectal cancer. It affects the colon and/or rectum, both parts of the large intestine. According to the National Cancer Institute, 143,460 new diagnoses were expected in 2012, with 51,690 resulting deaths.
Colorectal cancer is an equal opportunity killer. "Gender distribution is about 50/50," says Arrese. Common symptoms include rectal bleeding and a change in bowel habits that may include alternating diarrhea and constipation, he says.
OSU's Goldberg adds fatigue and anemia to the list of symptoms, as well as jaundice, dark urine and light-colored stool. "Patients may notice a mass in the belly, but we don't want to see that, because it means the cancer is large," he says.
"The cure rates are very highly correlated with how advanced the tumor is at the time we diagnose it," Goldberg says. "If we catch it in the early stages, we can cure almost all of them."
"The five-year survival rate is better than 90 percent if the cancer is found early," says Karim. "If it is found late, the survival rates are abysmal. They drop to 10 percent."
When colon cancer is detected, the gold standard for treatment is to remove the affected section of the colon. "The colon has layers," Karim says. "If the malignancy is only present in that first layer, you do the surgery and you're done. But as the tumor grows, it invades the deeper layers." If the cancer is contained within the colon, survival rates are high. Once the cancer invades the abdomen, survival rates begin to plummet.
The best strategy for stopping colon cancer is to catch the disease before it begins. Colon cancer begins as a polyp, a very slow-growing bump inside the colon. Polyps come in all shapes and sizes and are easily detected with a colonoscopy. Doctors recommend that most people-men and women-undergo a colonoscopy beginning at age 50, unless a close relative had colon cancer earlier. Screenings for African-Americans often begin at age 45, since that population tends to be affected younger, Goldberg says.
If a polyp or cancer is found, the condition is treated and the patient returns in three to five years for a checkup. Otherwise, no repeat screening is needed for 10 years. "Polyps take from eight to 10 years to grow from nothing into cancer," Karim says. "Once there is a malignancy, they grow extremely rapidly."
Colorectal cancer tends to be seen more often in Western countries where the typical diet is high in fat and low in fiber. "The lowest incidence of colon cancer is in populations like those found in Southeast Asia, where people use meat more as a condiment, instead of eating a 12-ounce steak," Goldberg says.
To prevent colon cancer, follow the common sense rules many Americans ignore: Eat more vegetables, get up and move around, and avoid smoking and excessive drinking.
Goldberg tells recovering colon cancer patients to walk 40 minutes a day, four times a week. "Exercise helps remove toxins from the body, and when you're moving, you're not only moving the muscles," he says. "You are also moving the bowels, and that can have a protective effect."
Fiber also can help protect the colon. "The stool is in contact with the wall of the colon, and inflammation results," Goldberg says. "Fiber dilutes the toxins."
Aspirin may be protective because it blocks inflammation. Vitamin D and calcium also may help maintain colon health. Scientists are still trying to determine why people who take these substances for other reasons seem to have a lower incidence of colorectal cancer, Goldberg says.
"An ounce of prevention being better than a pound of cure, we truly believe that with appropriate screening procedures, we can prevent people from developing colon cancer," says Karim.
Karim attributes the rise in colon cancer not only to lifestyle, but also to people living longer. Family history plays a part in about 26 percent of cases, but genetics can contribute in other ways, as well. "We all have genes that keep us from developing polyps, and as we get older, those genes weaken," he says. "Because people are living longer, we are looking for colorectal malignancies in people who are 65 and older but who are otherwise healthy."
Putting off that colonoscopy? You're not alone.
"People believe that the prep will be absolutely horrible," Karim says. Advances in technology, however, have made it easier. The day prior to the test, the patient mixes a tasteless, colorless powder into any noncarbonated beverage. "You can put it in water, apple juice, Gatorade-anything-and it's just like drinking that beverage," Karim says.
The medication, which induces diarrhea, is designed to clean out the large bowel so the doctor can see all the surfaces and look for abnormalities. The doctor uses an endoscopic device inserted through the anus to check every part of the colon. Polyps are removed and biopsied. "Every polyp goes to the pathology lab to make sure that it wasn't penetrating the deeper layers," Karim says.
Patients should not drive after the appointment because sedatives administered during the colonoscopy can cause grogginess and disorientation. "The most common question I get after the procedure is 'When we are going to start the procedure?' " Karim says.
"I saw a 34-year-old die of colon cancer, and that's hard to accept because the alternative-a colonoscopy-was so easy," Karim says. "It's one morning out of your life, and it can save your life."
Kristin Campbell is a freelance writer.
Reprinted from the February 2013 issue of Columbus C.E.O. Copyright © Columbus C.E.O.