Expanding Awareness About Screening for Colorectal Cancer: The Role of the Pharmacist

By: Yvette C. Terrie, B.S. Pharm, R.Ph., Consultant Pharmacist

The heartbreaking news of the death of beloved and talented actor, Chadwick Boseman on August 28, 2020 at the young age of 43 years old due to stage 4 colon cancer took the world by disbelief and rocked the world with great sadness due to the loss of such an incredible human being. Mr. Boseman was known for his illuminating smile, for being a great humanitarian and always giving back to the community. He was also known for his kindness, his profound wisdom, his compassion and generosity including visiting pediatric oncology patients amid his own private 4 year battle with cancer and of course for being an immensely talented actor in some of the world’s most favorite films.

The news of his death has sparked numerous conversations about colon cancer, its clinical presentation, risk factors and treatments. According to the American Cancer Society excluding skin cancers, in the United States, colorectal cancer is the third most common cancer diagnosed in both men and women.¹ Additionally, the ACS indicates that  in the U.S., colorectal cancer (CRC) is the third leading cause of cancer-related deaths in men and in women, and the second most common cause of cancer deaths when men and women are combined. ¹ It is projected to be responsible for an estimated 53,200 deaths during 2020.¹ The American Cancer Society’s estimates for the number of colorectal cancer cases in the United States for 2020 are:

• 104,610 new cases of colon cancer
• 43,340 new cases of rectal cancer.¹

The ACS also indicates that the number of CRC cases diagnosed in those under 50 years is soaring and in 2020, 12% of CRC cases will be diagnosed in those under 50 years, representing an estimated 18,0000 cases.²

Colorectal cancer in the US: 2020 Estimates ³

• New cases: 104,610
• Deaths: 43,340
• 5 -year relative survival rate for localized stage (Colon cancer): 90%
• 5-year relative survival rate for all stages combined (Colon cancer): 63%
• 5 -year relative survival rate for localized stage (Rectal cancer): 89%
• 5-year relative survival rate for all stages combined (Rectal cancer): 67%

Despite the aforementioned alarming statistics and the overwhelming evidence that screening strategies can diminish mortality rates, screening for CRC remains suboptimal.⁴

• Results from a study published in the Archives of Internal Medicine indicated that many patients are reluctant to have a colonoscopy to screen for colon cancer. The study enrolled 997 participants who were assigned to or given the choice of having a colonoscopy or a fecal occult blood test. The study revealed that only an estimated 38% of those who chose or were assigned to a colonoscopy actually had one.⁴
• In a recent publication in the Journal of Gastroenterology and Digestive Systems, researchers evaluated the knowledge of high risk patients about their need and proper interval for repeat surveillance colonoscopy. Results showed that 28.6% were unaware of either the need for a repeat colonoscopy or the proper surveillance interval. Of these, 16.6 % were unaware of the proper three-year interval to obtain a follow-up surveillance colonoscopy. In addition, 12 % were not even aware that they required a follow-up surveillance colonoscopy.⁵

Typically, the early stages of CRC are asymptomatic, and CRC generally develops slowly over a period of years. Symptoms of colorectal cancer may include rectal bleeding, blood in the stool, change in bowel habits, narrow stools, abdominal cramping or pain, decreased appetite, unintended weight loss, or anemia.³ It is important to note that 80% of CRC cancer cases have no previous family history of CRC and 55% of CRC cases in the U.S. are attributable to potentially modifiable risk factors.³  Modifiable risk factors include: being overweight or obese, physical inactivity, smoking, high consumption of red or processed meat, low intake of calcium, fruits, vegetables, and whole-grain fiber, and heavy alcohol consumption. ^1,3

Examples of Risk Factors for CRC ^3,6

Personal, hereditary and medical risk factors include:

• Older age: Rates in younger adults have increased in recent years, but colorectal cancer is more common after age 50
• Personal or family history of colorectal cancer or adenomatous polyps
• Hereditary syndromes: About 5% of people who develop colorectal cancer have inherited gene mutations. These may include: Lynch syndrome (hereditary non-polyposis colorectal cancer, or HNPCC), familial adenomatous polyposis (FAP), Peutz-Jeghers syndrome (PJS), or MUTYH-associated polyposis (MAP)
• Race and ethnicity: In colorectal cancer, African Americans have the greatest incidence and mortality rates in the US. Studies indicate that African Americans bear a disproportionate burden, with a prevalence of CRC that is >20% higher than in Caucasians and an even greater difference in mortality.^7,8 In particular, African Americans are more often diagnosed with CRC at an earlier age and with more advanced disease; and African Americans have a larger proportion of CRCs in the proximal colon. ^8,9
• Ashkenazi Jews have one of the highest risks in the world.
• Personal history of inflammatory bowel disease and type 2 diabetes 

The Importance of Colonoscopy Preparation

One of the most common reasons patients do not get colonoscopy screenings is fear of the bowel preparation. According to patients' experiences and reported barriers to colonoscopy, most patients perceive the bowel preparation to be the most burdensome part of colonoscopy.  There are many myths and misconceptions about bowel prep and this misinformation contributes to many patient fears about colonoscopy prep and the test itself.

As frontline health care professionals, pharmacists can be instrumental in expanding awareness about colon cancer prevention and treatment as well as in dispelling myths and misconceptions. Pharmacists can also counsel patients about newer prep solutions that require less volume. Additionally, many GI doctors now advocate using the split dose regimen which divides the solution into two equal doses. This new split dose method involves drinking half of the prep solution in the evening before the colonoscopy and the remainder of the liquid on the morning of the procedure. Pharmacists can also encourage patients to have an open dialogue with their primary health care providers about their individual risk factors and about screening tests such as a colonoscopy which is considered the gold standard of screening. Colonoscopies can detect malignant tumors, and it also permits for both identification and removal of adenomatous polyps. ^10,11   

Recommended screening provides a great potential for preventing cancer from developing by removing polyps that could ultimately progress to cancer. The American Cancer Society recommends colon screenings beginning at the age of 45 (instead of 50) for all adults who are at average risk for colon cancer. ³ The complete guidelines from the ACS for CRC screening can be found at : https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html

During counseling, patients should be reminded to adhere to their doctor’s instructions to ensure adequate bowel prep and pharmacists should ensure that they understand the correct protocol for split day dosing. While medical centers have different protocols for colonoscopy preparation. Patients should always be reminded of some key strategies:

General Colonoscopy Prep Diet Recommendations

• A few days before the colonoscopy procedure—Start eating a low-fiber diet: no whole grains, nuts, seeds, dried fruit, or raw fruits or vegetables.
• The day before the colonoscopy procedure—Don't eat solid foods. Instead, consume only clear liquids like clear broth or bouillon, black coffee or tea, clear juice (apple, white grape), clear soft drinks or sports drinks, gelatin, popsicles, etc.
• The day of the colonoscopy procedure—As on the previous day, clear liquid foods only. Don't eat or drink anything two hours before the procedure. ¹²

When counseling patients about colonoscopy prep, patients should also be provided with  written education tools including visual aids which are simple and easy to follow.  Studies have indicated that the use of educational booklets were demonstrated to improve bowel preparation and quality indicators such as cecal intubation rates.¹³  It is important that patients understand that proper bowel prep is a key component of a successful colonoscopy. Smartphone applications have even been developed to guide patients through the preparation process. Patients can also be directed to resources such as the American Society for Gastrointestinal Endoscopy at https://www.asge.org/screenforcoloncancer/home that explains the steps involved and importance of optimizing bowel preparation for colonoscopy. In a recent press release, the CEO of the Colorectal Cancer Alliance stated that, “With education and awareness to defeat the stigma, resources for those diagnosed, and innovative research toward cures, we can end colorectal cancer in our lifetime.”¹⁴

Conclusion:

The tragic and unexpected loss of Chadwick Boseman has shed light on the need to increase awareness about colon cancer and the significance of routine cancer screenings. Pharmacists should seize every possible opportunity to engage patients in dialogue and encourage them to evaluate their risks for CRC with their primary health care providers. 

In May 2018, Chadwick Boseman delivered the commencement address at Howard University’s 150^th  commencement. In his powerful and awe-inspiring speech, he stated, “ Purpose is the essential element of you. It is the reason you are on the planet at this particular time in history. Your very existence is wrapped up in the things you are here to fulfill.” ¹⁵  Rest in peace, Mr. Chadwick Boseman. Your life was filled with purpose and you left a lasting impression on many people. You will never be forgotten, and your legacy will live on in the hearts of your family and friends and all who love you. You will also be remembered lovingly by all of your fans who had the privilege of witnessing your awesome talent and powerful acting performances on the big screen. You touched the lives of many people in your work as a humanitarian, as a man of faith, as a leader, as an inspiration to many and as an awesome actor and the world will always remember your remarkable and inspirational spirit as well as your illuminating smile. You were not only a super hero on the big screen, you were a real life super hero that made the world a better place.

Yvette C. Terrie, Consultant Pharmacist, Medical Writer and creator of A Pharmacist’s Perspective (https://apharmacistsperspective.blogspot.com/ ).

References:

1. Key statistics for colorectal cancer. American cancer Society website. 2020. https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html . Accessed September 11, 2020.
2. Simon S. Colorectal cancer rates rise in younger adults. American Cancer Society website. https://www.cancer.org/latest-news/colorectal-cancer-rates-rise-in-younger-adults.html. Published March 5, 2020. Accessed September 16,2020.
3. Colorectal cancer fact sheet. American Cancer Society website. https://www.cancer.org/content/dam/cancer-org/cancer-control/en/booklets-flyers/colorectal-cancer-fact-sheet.pdf   Reviewed February 2020. Accessed September 15,2020.
4. Spiegel BM, Talley J, Shekelle P, et al. Development and validation of a novel patient educational booklet to enhance colonoscopy preparation. Am J Gastroenterol. 2011; 106:875-883.
5. Rothschild E. Lack of knowledge about colonoscopy in high risk patients; clinical and public health challenges. Journal of Gastroenterology & Digestive Systems. June 8, 2020.
6. Risk factors. StopColonCancerNow.com website. https://www.stopcoloncancernow.com/colon-cancer-prevention/risk-factors 
7. Siegel R., DeSantis C., Jemal A. Colorectal cancer statistics, 2014. CA Cancer J Clin. 2014;64:104–117.
8. Augustus GJ, Ellis NA. Colorectal Cancer Disparity in African Americans: Risk Factors and Carcinogenic Mechanisms. Am J Pathol. 2018;188(2):291-303. doi:10.1016/j.ajpath.2017.07.023.
9. Dimou A., Syrigos K.N., Saif M.W. Disparities in colorectal cancer in African-Americans vs whites: before and after diagnosis. World J Gastroenterol. 2009;15:3734–3743
10. Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening. Am J Gastroenterol. 2009; 104:739-750.
11. Inadomi JM, Vijan S, Janz NK, et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med. 2012;172(7):575-582. doi:10.1001/archinternmed.2012.332.
12. Preparing for a colonoscopy. Harvard Health website. https://www.health.harvard.edu/diseases-and-conditions/preparing-for-a-colonoscopy   Updated August 31, 2020. Accessed September 17, 2020.
13. Lee A, Vu M, Fisher DA, et al. Further validation of a novel patient educational booklet to enhance colonoscopy preparation: benefits in single-dose, but not split-dose preparations. Gastroenterology 2013;144: S191.
14. CDEO statement on Chadwick Boseman’s death. Colorectal Cancer Alliance website. https://www.ccalliance.org/news/press-releases/chadwick-boseman-alliance-ceo-statement
15. “Purpose is the essential element of you”: Listen to Chadwick Boseman’s 2018 Howard University commencement speech. WUSA9 website.  https://www.wusa9.com/article/features/producers-picks/remembering-chadwick-boseman-howard-univeristy-remember-maryland-howard/65-9eac77f5-f203-4224-bb0b-b77e23fd803d   Published August 29, 2020. Accessed September 16, 2020.