Colon Cancer Pain

(announcer)major funding for second opinion is provided by the blue cross and blue shield association,an association of independent, locally-operated and community-based blue cross and blue shieldcompanies, supporting solutions that make safe, quality, affordable healthcare availableto all americans. (announcer)second opinion is produced in association with the university of rochester medical center,rochester, new york. (music) (dr. peter salgo)welcome to second opinion, where you get to

see firsthand how some of the country’sleading healthcare professionals tackle health issues that are important to you. now, each week our studio guests are put onthe spot with medical cases based on real life experiences, and by the end of the program,you’re going to learn the outcome of this week’s case and you’ll be better ableto take charge of your own healthcare. i’m your host, dr. peter salgo, and todayour panel includes dr. kathleen wolin from washington university in st. louis, specialguest molly mcmaster, dr. john monson from the university of rochester medical center,our second opinion primary care physician, dr. lou papa, is here from the universityof rochester medical center.

our patient today is wendell. he’s 57 years old. we meet him in his primary care physician’soffice, because he’s got blood in his stool and he’s worried about it. he had a benign polyp, in the past -- lou papa)mm-hmm. peter salgo)-- about one centimeter, removed from his colon when he was 50, and he’s 57 now, sothat puts it seven years ago. he’s had follow-up colonoscopy a year later,and then another one two years after that,

and then another one five years after that. all of them were, quote, clean -- lou papa)okay. peter salgo)-- unquote, except this one that had the polyp. lou papa)all right. peter salgo)by the way, he’s not doing any stool blood tests since then, no coag testing. and this bleeding’s brand-new, it’s somethinghe just recognized? peter salgo)yes.

peter salgo)he was worried about it, he had the polyp before -- lou papa)right. peter salgo)-- came in. lou papa)well, i mean, blood per rectum is always a concern. i mean, it can be anything as benign as ahemorrhoid or some perianal or around the anus irritation to something more worrisomehigher up, even as high as the stomach. peter salgo)so what’s your real concern?

what’s your -- for that matter, what’shis real concern? well, his real concern is probably -- we’vebeen educated enough hopefully that everybody has alarm bells that go off when they seeblood in the stool, because it raises a concern for some form of cancer. you know, colon cancer comes to mind, butany gi cancer would raise that concern. peter salgo)now, molly, what happened to you? (molly mcmaster)well, i was playing with some kids one day and went in to use the bathroom and foundbright red blood in the toilet bowl from -- peter salgo)how old were you?

(molly mcmaster)-- number two. i was 21 years old. peter salgo)tell me a little bit more. (molly mcmaster)well, i called my primary care physician and i -- you know, i said, on the phone, “ijust went to the bathroom, there was blood. i don’t know what to do,” and they said,“ah, you know, it could be hemorrhoids, it could be this, it could be that.” she said, you know, “why don’t you comein tomorrow? we’ll take a look.”

and so i made an appointment for the followingday, and the next day when it was gone, i canceled my appointment. peter salgo)did you have any other symptoms other than the blood? (molly mcmaster)had a little bit of abdominal pain, but i didn’t think much of it as a girl who getscramps once a month. you know, i didn’t think too much of itat the time. over the course of the next six months, inever had blood again, but i -- it kind of went along pretty slowly, but by the end ofthe six months, i was throwing up anything

that i ate, i wasn’t going to the bathroombut paper thin. the problem there was that it happened soslowly over time that i didn’t realize that that wasn’t normal anymore. i had horrible abdominal pain. i was losing weight, but i’m a college girl,so i’m thinking this is great. you know, i had all the symptoms that youwould find on a symptom card or on a brochure for colorectal cancer, and i didn’t gettested for it. peter salgo)well, wendell did go to the doctor, did get alarmed by this bleeding, and his doctor referredhim to a gastroenterologist.

molly, were you sent to a gastroenterologist? now we’re six months into this. (molly mcmaster)six months into it i was finally sent. i had x-rays done twice, and then was stillhaving the same problems. my primary care physician sent me finallyto a gastroenterologist. so they -- you know, they sat me down. they put me in my little paper gown and hefelt my belly and he felt my back, and he said, “you have irritable bowel syndrome. i want you to take fibercon in the morningand metamucil at night, and, you know, if

you” -- i had just been fired from my jobbecause i was calling in sick so much, so i was driving home from colorado to new york,where my family was, and i would be leaving the following week, and he said, “if youget home and you’re still having problems, follow up with your doctor there.” peter salgo)now, i want to stop here just for a moment. you went to see a gastroenterologist who,after hearing the story of blood, hearing the story of decreasing stool caliber, havingthe story of pain and bloating that you told me, said you have irritable bowel syndromeand sent you home? (molly mcmaster)mm-hmm.

peter salgo)sound like a good idea to you? john monson)no, not at all. i mean, for a couple of reasons. firstly, irritable bowel syndrome, a verycommon condition, producing a lot of symptoms such as bloating and loose or irregular motionsand abdominal pain, but it’s a diagnosis of exclusion. lou papa)absolutely. john monson)you cannot make that diagnosis until you’ve ruled out other significant diagnoses, inthis particular instance the main one being

colon cancer, but any other condition thatcould cause the symptoms like colitis or whatever it might be. i say it again, ibs is a diagnosis of exclusion. it is not a clinical diagnosis. so, you know, in molly’s case the problemis she was 21. you know, that was working against her. you’re not meant to get colon cancer at21, and you -- peter salgo)but the demographics of this disease skew older, don’t they?

kathleen wolin)they do. they -- you know, most people who are diagnosedare in their 60s or 70s. you know, cancer in general is a disease ofpeople who are older, and that, as molly’s case shows, doesn’t mean that people don’tget it at a younger age, but the reason we recommend screening start at 50 is becausethat’s when most cases tend to be diagnosed. peter salgo)all right. we’re going to leave molly in her car, drivingeast. meanwhile, wendell goes to his gastroenterologist’soffice and get an immediate colonoscopy. peter salgo)now, why wendell and not molly?

john monson)it’s the age thing, really. it’s just an index of suspicion. first of all, wendell has a history of polyps,he’s in the system, he’s had a colonoscopy before, he’s going to get a colonoscopy. lou papa)and i think in molly’s case you -- blood in the stool is not normal regardless of yourage, and she -- her symptoms were new. and it’s -- although you -- we’re talkingabout colon cancer, there’s other conditions, other serious gastrointestinal disorders thatcould cause that type of picture as well that really should be sought after, just like johnsaid that it’s not just --

peter salgo)what’s in your differential? what do you think? lou papa)well, you know, there’s inflammatory bowel conditions that can occur, ulcerative colitis,crohn’s disease. there’s abnormal blood vessels that cangrow in the gi tract that can cause that, and if she didn’t have the bleeding, ifthat was -- just happened to be hemorrhoids, she continues to have symptoms. there’s things like, you know, celiac diseaseand other gastrointestinal disorders that really need pursuit this is a person who didnot have symptoms, correct? and now has fairly

significant symptoms over a short period oftime. (molly mcmaster)i’m not sure the right questions were being asked of me, either. things like family history might have gottenme a colonoscopy. i found out six months after i had been diagnosedthat my mother had polyps removed when she was 32, so that gives me a family history. you know, but i was also the 21-year-old collegegirl who didn’t want to talk about poop. i didn’t want to be talking about thosethings. i remember going to the hospital for my firstset of x-rays and this adorable x-ray tech

asking me, “good morning, molly. when was your last bowel movement?” and i thought, oh, my god, he didn’t evenbuy me dinner. i can’t be talking about that with him. so it’s definitely a disease -- there’sembarrassment involved, and at 21 i didn’t -- you know, i’m not sure that i was standingup for myself the way that i should have been, either. kathleen wolin)i don’t think that embarrassment is limited to 20-year-olds, though, either.

(molly mcmaster)no, it’s not. it’s not. kathleen wolin)i think, you know, it’s a major barrier for getting people from all ages into thedoctor’s office, and, you know, the doctor can recommend colonoscopy, but the peoplemay not follow up on it. they may have the appointment, like you said,and cancel it because they’re uncomfortable with it, or they hear the prep is uncomfortable. so, i think, you know, it’s not just youngpeople who have this discomfort talking about this.

peter salgo)so wendell gets his colonoscopy, and they find a lesion at the hepatic flexure. does a lesion at the hepatic flexure, in wendell,mean wendell has colon cancer? john monson)well, it’ll be based on -- if they see the lesion, they’ll take a biopsy of it. ninety percent of people who have rectal bleedingdo not have colon cancer. they have something simple and benign that’ssafe and that would be fixed. most people who get a colonoscopy that havea lesion identified, most of those lesions are benign polyps.

peter salgo)molly, when last heard from you were heading to your mom, dad? (molly mcmaster)to my parents’ house. peter salgo)and you got home. then what happened? (molly mcmaster)i got home on a thursday night, and long story short, my mom tried to make me eat some soupand i threw up all night long. and i remember my mother coming in to me andsaying, “do you want me to take you to the emergency room?” and i said, “no.

don’t worry, it’ll go away,” becausei was so used to this -- peter salgo)mm-hmm. (molly mcmaster)-- as this was my life. in the morning -- i was still getting up throwingup bile in the morning, and my parents kind of dragged me to the car and brought me toa nurse practitioner, who put me in for some x-rays and they said, “you have somethingin your large intestine.” sent me directly to the hospital and said,“you need emergency surgery,” and luckily one of our neighbors did my surgery for us-- for me. they took out 25 inches of my large intestineand a tumor the size of his two fists.

peter salgo)and did they tell you at that time what the tumor was? (molly mcmaster)no. they wanted to be a thousand percent surethat it was truly cancer before they told me. peter salgo)and they told you. (molly mcmaster)they told me on my 23rd birthday. that’s how i woke up. peter salgo)and at that point, here you are deny, deny,

deny. you knew how long you’ve waited, and nowthey tell you this big tumor was sitting in your belly all that time and it’s cancer. peter salgo)what are you thinking? (molly mcmaster)i thought, “my world is over.” i thought, “i’m going to die.” i immediately started thinking, “i’m notgoing to go through chemo. i’m not going to lose my hair. i’m not going to be that poor little sickmolly.”

i started thinking of ways that i could killmyself, because i didn’t want to have to go through all the things that a cancer patienthas to go through, and by the time he left i was ready to park the car in the garageand commit suicide. peter salgo)this is not the face of colon cancer that most people think of, right? this is not a typical case of colon cancer. john monson)no, it’s a -- well, it’s unusual on a number of levels. of course, you know, the horrible story ofthings not being addressed for six months

or so is not what anybody would want to occurand -- number one. number two, you know, in somebody so young,21, 22, 23, et cetera, that’s unusual. but the presentation as an emergency is notthat unusual. still we see somewhere between 15 and 20 percentof patients with colon cancer present like this as an emergency with relatively advanceddisease. john monson)that’s totally unnecessary. well, wendell, after the biopsy was done,was also told that he had colon cancer, and only a few weeks had passed since his initialsymptoms of blood in his stool. now, he was really good about getting screening.

i mean, wendell kept coming back. you remember he had all the recommended colonoscopies. peter salgo)why didn’t the screening catch this colon cancer that he presented with? lou papa)well, no screening is perfect. the screening is based on the best estimatethat you’ll pick up most lesions early enough, and cancer doesn’t have to pay attentionto the rules. you know, there can be a very fast-growingmalignancy that you still have to -- and that’s why it’s important for patients to knowthere’s two different ways of looking at

there’s the screening, where i’m feelingfine, i’m getting my colonoscopy. because you get the screening you don’tget a -- you know, a pass go free card. if you have symptoms in between, they stillhave to be evaluated. those are two different things. john monson)if he hadn’t been fully engaged in this program, he probably wouldn't have had itpicked up at one centimeter. he would have had it picked up at 21 centimeterslike molly. not every polyp turns into a cancer, but asignificant number of polyps will turn into a malignance, a cancer if left alone.

now, as it happened, he followed the rulethat lou mentioned, because the rule says you can be done in ten years, unless you getsymptoms in the meantime. if you get symptoms in the meantime, you know,rule number one goes out the window, you come back. so he came back -- it’s a -- john monson)-- and he got scoped. we know that since you started screening withcolonoscopy, fewer people die of colon cancer. it doesn’t mean that it’s perfect forevery individual, but overall it works.

peter salgo)i just want to put a little button on this one, too. wendell had rectal bleeding. molly, you had rectal bleeding, gas, abdominalpain, nausea. are these typical for colon cancer? (molly mcmaster)can i jump in really quickly -- peter salgo)please do. (molly mcmaster)-- and just say that the most common symptom they say is no symptom at all.

(molly mcmaster)so, for what you said earlier, to the people that are out there saying, “oh, i don’tneed to go,” that’s wrong. the most common symptom of colorectal canceris no symptom at all, and that’s why you do need to go. that’s the important message, but the symptoms,when they occur, rectal bleeding, your pain -- peter salgo)you had bloating? (molly mcmaster)i had everything. peter salgo)change in stool diameter?

(molly mcmaster)yes. peter salgo)are these all typical out of the textbook? john monson)yeah, they’re pretty common symptoms. i mean, you know, if we -- we keep going backto molly because it’s such an interesting and unusual story, but she had rectal bleeding. a lot of people have rectal bleeding. she had symptoms as well. john monson)that’s what changes the whole game. all right.

let’s pause for a minute. i want to sum up some of what we’ve beentalking about. while screening for colon cancer is effective,it is not 100 percent effective. so, paying attention to symptoms, changesin your body can help make a diagnosis of colon cancer earlier, and it goes withoutsaying earlier is better. our case today is about wendell. he’s 57. he’s just been diagnosed with colon cancer. molly mcmaster is also here, and you werediagnosed with colon cancer when you were

23 years old. before we get into treatment, i have somequestions. i want to talk about the epidemiology of coloncancer, which means who gets it. kathleen wolin)right. peter salgo)who gets it? kathleen wolin)men and women. generally people over age 50, so 60, 70 isa mean age of diagnosis. it’s the third most common cancer in theunited states in men and women. peter salgo)and in the united states, how many people

die of colon cancer every year? john monson)the number of people who get colon cancer or colorectal cancer is, i think, 160,000,and the number who die annually is decreasing, which is a good thing, but it’s somethingin the region of one in four will die of colon cancer or colorectal cancer, and that coversall stages, from the earliest cancers to the most advanced cancers. peter salgo)kathleen -- kathleen wolin)but we’re doing better because we’re getting it earlier --

kathleen wolin)-- and so the mortality rates are going down, and that’s in large part because of screening. peter salgo)what are the epidemiologic associations with colon cancer, comorbidities, other conditions,other things? kathleen wolin)diabetes is associated with colon cancer. we tend to see higher rates of colon cancerin diabetics. obesity is associated with colon cancer, sopeople who are overweight are going to have higher rates of colon cancer, more likelyto get it. so these are the -- these sort of lifestyleand comorbidity things.

so we can talk about smoking, we can talkabout physical activity, we can talk about diet. being physically active prevents colon cancer. it also prevents colon polyps. peter salgo)you were very active. peter salgo)you know, she failed another one of these epidemiologic associations. kathleen wolin)right, right, right, and -- you know, and i think one of the things that molly’s caseis interesting, in many ways, people in cancer

tend to fixate on the exceptions to the rules. kathleen wolin)so when we talk about smoking, people say, “well, i know, you know, my uncle john,he smoked and -- you know, and he drank three scotches a day until he was 90,” so, youknow, they kind of tend to dismiss the epidemiology. kathleen wolin)a huge, huge segment of this population in the united states does nothing for physicalactivity at all. everybody in the country was physically active,that alone, we could prevent about 25 percent of colon cancers, but we’re not going toprevent a hundred percent of colon cancers. so, you know, you start adding those thingsup, the physical activity and the healthy

weight and the dietary choices, and, you know,you get to somewhere between 50 and 80 percent of colon cancer could be prevented, if everybodywas doing everything right. peter salgo)molly, they told you you had cancer, but they told you more. what kind of cancer did they tell you youhad? (molly mcmaster)i had -- peter salgo)what stage was it? do you remember? (molly mcmaster)stage duke’s b2 was how they staged it for

peter salgo)a duke’s b2. (molly mcmaster)they said that it was -- like i said, it was the size of my doctor’s two fists was howhe -- in layman’s terms, and he said it had grown through the bowel wall and was touchingother organs, but it didn’t get into any lymph nodes. peter salgo)and wendell is told he has duke’s c. what’s all this duke’s business and staging about? john monson)well, we tend not nowadays to use the duke’s staging.

nowadays, in common with almost all cancers,we have moved to the stage i, ii, iii and iv using -- john monson)-- the tumor, lymph node, metastasis system, which is otherwise known as tnm. so a duke’s b, in what we would call oldlanguage, is something that has not involved lymph nodes but has grown through the sideof the bowel wall, so it’s not contained completely within the bowel wall, but hasn’tspread to lymph nodes or anywhere distant. peter salgo)and wendell has duke’s c. john monson)which means it has involved the regional lymph

nodes but, as yet, has not spread to anywhereelse. both of these, by the way, remain surgically-curable conditions. peter salgo)so wendell needs surgery. what kind of surgery does he need? john monson)well, he needs surgery, basically removes the offending segment of bowel. in his case it’s the hepatic flexure, whichis at the right side, the junction between the right and transverse.

so we would remove the right side of his colon,send that off to pathology to be staged. that’s how they tell that you’ve got lymphnodes involved or not. join the two ends of the bowel together, andlet him recover. and if he heals up that join, he’ll be backeating and drinking in 24 hours and recover from surgery. and then when the pathology information comesback, that’s the information we need, the bits about the lymph nodes, et cetera, thatwe can sit down with wendell and say to him, “this is the stage you have. this is what we would recommend you have interms of additional therapy,” and roughly

about 50 percent of patients we would recommendhave a finite, four-month course of chemotherapy as a belt and braces to add on to the surgery. peter salgo)wendell was put on oral chemotherapy -- john monson)mm-hmm. peter salgo)-- 5-fu, it’s 5-fluorouracil, for four months after his surgery, and what do the 5-fu do? what does it do in someone like wendell? john monson)well, the theory being if wendell has a tumor of that stage, there may well be microscopiccells floating around in his body that no

scan will ever pick up. and we know from large-scale internationaltrials, saying treatment versus no treatment, that if you give people four months of 5-fubased therapy, that their long-term outcome is better. their risk of recurrence, in other words thecancer coming back, is significantly reduced, and their chance of surviving long term issignificantly increased. peter salgo)and again, you’re talking about statistics, which is morphing right into what you’rethe expert in. peter salgo)you’re the one who has all the data that

says if you do this your chances are betterbut there’s no guarantee. kathleen wolin)right, and -- you know, and the lifestyle things we talked about for prevention aregoing to play into wendell at this course of treatment, as well. you know, we know that, again, physical activityand weight management are really important things for cancer survivors, particularlycolon cancer. you know, as much as people can do duringthose courses of treatment and certainly after to engage in a healthy lifestyle, the betterthey’re going to be. we have data that suggests that being physicallyactive, that maintaining a healthy weight

is going to improve your disease-free survival,which means reducing your risk of recurrence, reducing your risk of mortality, so improvingyour survival. so those same lifestyle choices, you know,they aren’t just conversations -- kathleen wolin)-- of prevention. they’re conversations for healthy survivorship. peter salgo)molly, you had the surgery. peter salgo)did you have the chemotherapy? (molly mcmaster)i did. i --

peter salgo)what is the 5-fu like? (molly mcmaster)-- did -- well, that’s the interesting thing, because i have a friend who did the same treatmentthat i did, and i played ice hockey once a week while i was in treatment, and she couldbarely get out of bed. so i think it varies from person to person. peter salgo)what kind of follow-up did you have? (molly mcmaster)in the beginning, they weren’t really sure what to do with me, because i am kind of arare case. so he had me on the three-month plan for along time.

he would have me just come into his officeand do a cea test every three months, and finally i had to ask him for six months. annually, i still, at this point -- i’mgoing to be 12 years out. i still go in annually for a cat scan andchest x-ray. peter salgo)a cat scan every year? peter salgo)no chances there. (molly mcmaster)and also colonoscopy every three years, and funny because my gastroenterologist told me,“oh, i think you’re good. you can go for five years,” and i’m notthere yet.

i’m -- peter salgo)uh-huh. and with that i want to pause for a minuteand sum up what we’ve been discussing. treatment of colon cancer should involve amulti-disciplinary approach. treatment is effective, but knowing who isat risk, following preventative advice, and screening steps. also key, knowing you’re at risk, maintaininggood health habits, and also getting screened, important. lou papa)one other thing we need to touch upon --

lou papa)-- it’s very important. she is not the only patient. she’s not the only person that’s at risknow. she has family members that need to considerscreening, and that’s critical. that’s another part of this, that this extendsto the rest of her family that need to speak to their doctor about getting colon cancerscreening. kathleen wolin)you know, it’s a real challenge for, you know -- i mean, lou, in primary care, whati hear time and again from primary care docs is how many things that they’re trying tocover in these visits --

kathleen wolin)-- and talking to patients about family history is a big one, and getting -- you know, i thinka lot of times in families we’re reluctant to talk about health issues, and there’sa big generational divide limiting that information transmitted down, but it’s really -- youknow, it’s really important for people, as they’re in their 30s and 40s, in particular,to understand, you know, what health issues their -- kathleen wolin)-- their parents and grandparents had, so that when they go in to the doctor’s office,lou knows that -- kathleen wolin)-- this patient has family history of colon

cancer, so they need to get screened at 40instead of 50. peter salgo)molly, you have taken what just sounds like an awful situation, i mean dreadful, and youturned it around. you’ve dedicated yourself to educating others. (molly mcmaster)after i was diagnosed, my doctor told me, “oh, you’re the only one in the country. there’s no way there’s anybody else outthere like you,” and i -- kind of two-fold, there were two reasons i wanted to kind ofdraw awareness to myself. one was i didn’t believe that i could possiblybe the only one.

and, two, because you can’t put an 80-year-oldman in front of a 23-year-old man or woman and say, “don’t let this happen to you.” you can, however, put a 23-year-old girl infront of an 80-year-old man and get a reaction out of it. (molly mcmaster)and i’m out to make people’s jaws drop, because when they see me they don’t thinkcolon cancer. (molly mcmaster)and that’s the whole point to what i’ve been doing. so the first of my crazy projects was to inlineskate from new york to colorado, where i had

been going to school when my symptoms started. i also heard two words related to you, colossalcolon. (molly mcmaster)colossal colon? peter salgo)want to share about that? (molly mcmaster)i would love to share about my colossal colon. i actually got the opportunity to tell mystory on the today show way back when with my friend amanda, who had also been on the5-fu, and after the show katie couric basically said to me, you know, “if you think of anythingcrazy for colorectal cancer awareness month, let us know and we’ll have you back on theshow.”

and just a couple months later my friend amandadied, and so between katie’s comment and losing my friend amanda i wanted to do somethingcrazy to raise awareness, and what better than a 40-foot-long, 4-foot-tall, crawl-throughreplica of a colon, because, you know, it gets people talking about it, which is thefirst step to getting them screened. the thing about it is that people don’trealize, you know, we’re out to get people to talk about it, and i have been in a mallwith the big, giant colon and i’ve seen people walk by and say, “oh, my gosh, thatis disgusting. i am not going in there. i’m not going to look at that.”

and the best part of it is they have no ideathat i have done my job, because now they’re going to go home and they’re going to sitat their dinner table and they’re going to say, “you won’t believe what i sawat the mall today,” and that’s the first step to getting people screened. peter salgo)thank you so much for coming. it isn’t easy to talk about your health. i know you do it all the time, but it doesn’tmean that it’s easy, and we, all of us -- i think i can speak for all of us -- (dr. peter salgo)-- appreciate your being here.

peter salgo)but, unfortunately, we are out of time. we hope that you continue the conversationon our website. there you’re going to find the transcriptof this show, more videos about colon cancer, links to resources about colon cancer. our web address is second opinion dash tvdot o-r-g. again, thanks for watching. thank all of you for being here, especiallyyou, and i’m dr. peter salgo. i’ll see you next time for another secondopinion.