Colorectal cancer often presents with no symptoms, which is a scary thought considering more than 150,000 new cases are diagnosed in the U.S. each year. In recent years, people in their 30s and 40s are being diagnosed more frequently than ever before. Dr. Patrick Boland, a medical oncologist in the Gastrointestinal (GI) Oncology Program at the Rutgers Cancer Institute of New Jersey, the state’s only NCI-designated Comprehensive Cancer Center together with RWJBarnabas Health, said knowing your family history and getting screened as early as age 45 are crucial when it comes to catching and treating cancer early on. We asked him what we can do to reduce our risk of cancers of the colon and rectum, and why it’s so important to get your routine colonoscopy.
New Jersey Family: What is colorectal cancer, and what are its signs and symptoms?
Dr. Patrick Boland: The colon is the large intestine. It’s one of the last parts of the digestive system. The rectum is the last part of the colon. Colon cancer is an invasive tumor that forms in the colon that can potentially spread, causing bigger issues.
Sometimes the symptoms are different from the colon versus the rectum, but it’s all the same tube. Many people with colorectal cancer will be asymptomatic, even when it spreads. A lack of symptoms doesn’t mean you don’t need to get screened.
Some symptoms people may have are rectal bleeding or a persistent change in bowel habits, such as sudden constipation. There’s a risk of things such as colon blockage. Partial blockage can cause pain or cramping, but most often when colorectal cancer is diagnosed, people don’t have any pain whatsoever. With all cancers, there is the potential for weight loss.
NJF: How many people are diagnosed each year, and what do we know about the age of people diagnosed and the subsections of that population?
Dr. Boland: The general estimate is about 150,000 people a year in the U.S. are diagnosed. That’s a pretty large number. Fortunately, most cases diagnosed are in the early stages, meaning stages one to three, and haven’t spread yet.  More than half of people diagnosed are in their early to mid-60s or younger.
The rates are relatively similar between men and women. African Americans are often diagnosed at a more advanced stage, or their prognosis may be a little bit worse.
ScreenNJ is a statewide service that provides education about cancer prevention and detection to the community and professionals. ScreenNJ supports NJ residents to obtain cancer screening through navigation and mobile health services regardless of their ability to pay. For more information about ScreenNJ visit screennj.org.
NJF: What does the global increase in colorectal cancer diagnoses before age 50 mean in terms of risks and screening?
Dr. Boland: For age 55 and younger, we’ve seen there’s really been an uptick in the last number of years. Then when you look at people younger than 40 and 30, for sure there’s been an uptick. In fact, from the most recent evidence, colorectal cancer is the leading cancer killer in men under age 50 and the second leading cancer killer in women under age 50.
For a long time, the screening recommendation was to start at age 50, unless you have  a family history. In the last several years, there’s been data that’s emerged that has pushed to lower that age to 45. The U.S. Preventative Services Task Force,which is pretty conservative in terms of what they will endorse, has shifted their recommendation to starting screening at age 45 for people who are average risk and don’t have a family history.
Still, a lot of people don’t get screened or aren’t up to date on screening. That’s still an issue that we have, I think, as a society in general.
NJF: Why do you think people are being diagnosed younger and younger?
Dr. Boland: The groups that are at the biggest risk right now, I think, are those who are old enough to be screened and haven’t been, and those who are too young to get screened. On the other hand, the rate of colorectal cancer is actually dropping in older age groups, probably in part related to screening.
The bottom line is, we don’t really know why the rates are going up, but it’s really being seen across the world. It’s most visible in countries where there’s Western culture. Certainly, the thought is that some of it is related to the foods we’re eating and the way our lifestyles have changed dating back decades.
ScreenNJ is a statewide service that provides education about cancer prevention and detection to the community and professionals. ScreenNJ supports NJ residents to obtain cancer screening through navigation and mobile health services regardless of their ability to pay. For more information about ScreenNJ visit screennj.org.
NJF: What increases the risk for colorectal cancer? What can we do to lower our risk?
Dr. Boland: The thing that is overshadowed is knowing your family history.
More than light alcohol use, extra weight, obesity, diabetes, smoking, and diets that are higher in red meats but lower in fiber and fruits and vegetables are factors that could increase someone’s risk.
Getting regular exercise and plenty of fresh fruits and vegetables, not smoking and limiting alcohol use and red, smoked, and processed meats, are all potentially protective and are in your best interests.
Some studies done on colon cancer survivors showed that the risk of recurrence or being diagnosed with another cancer was lower in people who live a healthy lifestyle. There is a point where damage can be done, but you can still benefit from stopping or changing behavior.
NJF: Are there other diseases or other cancers that are related to colorectal cancer?
Dr. Boland: The most common hereditary colorectal cancer syndrome is Lynch Syndrome: it’s understood that more than 1 in 300 people are affected by Lynch Syndrome, though many may not be aware of it. With Lynch syndrome, we see a risk of multiple cancers, with uterine cancer being another more common cancer seen.
Recently there has been a push for the majority of patients diagnosed with colorectal cancer to have genetic testing dose, to see if they might be affected by a hereditary condition, like Lynch Syndrome. This is often done by a blood test and is especially important for younger patients and those with a family history. For patients, the two most important things they can do related to these risks are 1) find out about their family cancer history and 2) ask their doctor whether they should have genetic testing done.
NJF: We know that a colonoscopy is crucial for colorectal cancer screening. What are the latest guidelines in terms of when and how often we should get screened?
Dr. Boland: I think the best screening test is the one that gets done. Colonoscopy is the best test because it’s a test where in addition to findings cancers, they can find early growths (polyp) and then the polyps can be removed before they become cancerous. This helps to reset the clock. The advantage of the colonoscopy is it’s one of the few screening tests where you can take something that would turn into cancer and get it out.
The guidelines are to start—if there’s no other compelling family history—at 45 and then every 10 years. Typically, the thought is that it can take 10 years to go from a little growth or change in the colon to a polyp to cancer. Between that, screening would be more symptom-guided.
Typically, when someone is diagnosed with colon cancer, the recommendation is they get a repeat one within a year. Then usually the follow-up is based on that. Often it’s every three to five years afterwards. Sometimes things will be tailored where it’ll be more frequent.
If there’s a strong family history, it merits a discussion about when you should start or how often you should do it. There are some guidelines surrounding that, depending on the situation.
ScreenNJ is a statewide service that provides education about cancer prevention and detection to the community and professionals. ScreenNJ supports NJ residents to obtain cancer screening through navigation and mobile health services regardless of their ability to pay. For more information about ScreenNJ visit screennj.org.
NJF: What other screening is available besides a colonoscopy? Are at-home tests beneficial?
Dr. Boland: The major options for screening are a colonoscopy, which is the entirety of the colon; or a sigmoidoscopy, which is basically doing part of the colon, but a little bit more frequently.
Then the other option is stool-based tests. We look for microscopic blood in the stool; we call it fecal occult blood (FOBT). The next generation of that, what we call FIT testing, is a more sophisticated way to detect microscopic blood. Additional variations of this testing can detect tumor DNA in the stool in additional.
The at-home tests, if done regularly and are negative, are reassuring. If someone is adamantly opposed to a colonoscopy, I think there’s value in that you’re getting that test done. The catch is, if it’s positive, then you’re going to be advised to get a colonoscopy done. There’ll be stronger reason at that point.
NJF: People tend to shy away from the colonoscopy because of the prep. What are your thoughts on that?
Dr. Boland: The prep is actually the most important part, because you really want to get things cleaned out so that when the doctor goes in there, they have good visibility. If it’s not cleaned out, it’s like driving in a fog; you lose your landmarks, you can’t see stuff so well.
There are multiple different options for the prep, like liquids or pills, and some are shown to clean the colon out more. Ultimately, every option must give you diarrhea to clear things out. Typically, you consume clear liquids for at least a day. You cannot have red dyes or anything like that. After they do the procedure, you can eat normally again.
Dr. Patrick Boland is a medical oncologist and a member of the Gastrointestinal (GI) Oncology team at the Rutgers Cancer Institute of New Jersey. He graduated from Jefferson Medical College (now Sidney Kimmel Medical College) in 2006. Following completion of his residency at Boston University Medical Center in 2009, he went on to oncology fellowship at Fox Chase Cancer Center, completing this in 2013. He spent the first several years of his career at Roswell Park Cancer Institute, as a GI oncologist, focusing a large part of his time on cancers of the lower intestinal tract (colorectal, small bowel, and anal cancers). He has expertise in the treatment of cancers across the GI tract and in clinic treatment of a variety of conditions. He is passionate about clinical and translational research and believes research is the key to improving the care of all patients.