Colon Cancer Warning Signs

>> announcer: "second opinion" is broughtto you by bluecross blueshield. accepted in all 50 states. bluecross blueshield. live fearless. >> announcer: "second opinion" is producedin conjunction with u.r. medicine, part of university of rochestermedical center, rochester, new york. >> dr. peter salgo: this is "second opinion," andi'm your host, dr. peter salgo.

this week, special guest rose arp is herebecause she is turning 50 and she has some questions about her health. >> rose arp: well, you hear all the time thatyou should be having mammograms because, you know, you can get breast cancer. and if they find it earlier enough, then theycan cure it, you know, rather than finding it later and not surviving or even -- i'malways hearing you should have a colonoscopy. peter salgo: she's here today for a secondopinion. peter salgo: thanks so much for being here,rose. we are looking forward to getting your secondopinion as we go along during the show.

i'm looking forward to a lively discussion. let's get right to work. let me introduce you to your "second opinion"doctors, and they're gonna be hearing your story for the first time. they're dr. otis brawley from the american cancer society,our "second opinion" primary-care physician, dr. lou papa, from the university of rochestermedical center, and dr. gilbert welch from dartmouth medical school.

welcome to you all. otis brawley: thank you. peter salgo: and you're coming up on a bigbirthday. >> rose arp: well, i'll be 50 this year, andi'm actually really happy about being 50. peter salgo: all right. what do you do for a living? >> rose arp: i am the deli/bakery managerat a little grocery store in custer, south dakota. peter salgo: in custer, south dakota.

>> rose arp: mm-hmm. peter salgo: and before we launch into thisdiscussion, do you have any specific health concerns that are bothering you, worryingyou? >> rose arp: no. so, can we all agree right here that roseis a healthy person? she believes she's healthy. she feels well. and what we might be discussing, if we'regoing to look at her health history, might be screening for things she doesn't know shehas, right?

and can we set up a definition? i know we might get to this later, but let'sput all our cards on the table. we're gonna discuss screening for disease. there's a difference here between screeningfor disease or doing a screening test in somebody who has a symptom of a disease. can you make that distinction? lou? lou papa: yeah, a screening test is typicallydone exactly in somebody like you. you're feeling well.

you have no symptoms. and we have data that if we do a test or doa procedure, that it has a benefit to you in terms of your well-being, in terms of yourlife expectancy, in terms of your quality of life. case finding is, you're coming in, and you'resaying, "i have blood in my stool," "i'm having chest pain." doing those same type of tests -- that's notscreening. that's symptom-driven testing. peter salgo: now, lou, she's in your office,and she's come to you with this health history

-- you can ask her anything you'd like -- howwould you set up this interview to determine whether or not you'd want any screening tests? lou papa: well, 50 -- you know, everybodytalks about 50 being that magic age, and it's only magic in the sense that you're gettingold enough to have certain diseases, so, statistically, certain tests are better. so, there are certain things that are important. i'd like to know your family history, aboutany disease processes in your family history, like diabetes, hypertension, certain cancers. peter salgo: well, are there any?

thyroid problems is about the only thing. lou papa: that's about it. great. >> rose arp: yeah. lou papa: so, getting that family historyis useful. getting other symptoms that she may have -- thatmay change me from a screening point of view to a case-finding point of view, and thenrecommending certain screenings that are generally recommended across the board because of theirbenefit. peter salgo: now, when you talk to most americans,i think, about screening, what they think

about is cancer screening, at least in partbecause of you guys. otis brawley: [ chuckles ] peter salgo: and, rose, i know that you havespoken to us about perhaps getting some preventive cancer screenings. what worries you? what cancers bother you or disturb you? and if they find it early enough, then theycan cure it, you know, rather than finding peter salgo: okay. what is the goal here?

when you're -- gilbert welch: well, that's a great question. peter salgo: what is the goal of cancer screening? gilbert welch: well, the goal of cancer screeningis to reduce cancer-related mortality. it's to help prevent cancer death. gilbert welch: and the question of how wellit does that is, of course, an ongoing question, which we're always learning more about. and it's a lot closer call than most peopleever realize. peter salgo: so, let us take that as yourdefinition.

any cancer screening, in your view -- letme see if i can -- i don't want to put words in your mouth. but any cancer screening, in your view, thatdoesn't reduce the death rate from cancer comes under closer scrutiny. maybe we shouldn't be doing it? gilbert welch: oh, absolutely. and i would think most patients -- and, rose,i'd ask you this question. if you heard about a cancer screening test,i would guess that you would think that that would be something that would help you livelonger.

otis brawley: one of the things that disturbsme -- and, actually, you've written a lot about this. a lot of people look at survival data andsay that survival increased because of a screening test -- therefore, it is good. the purpose of a screening test is not toincrease survival, the time in which a person knows that they have cancer. the purpose of a screening test is to preventthat person from dying from the cancer. so, i want to see a cancer test that's associatedwith decrease in at least cancer-specific mortality.

you would want to go to overall mortality. i'm not interested in a cancer test that increasessurvival. let me go back one step further. let's talk about the definition of cancer. gilbert welch: oh, boy. peter salgo: all right? because i read your stuff. i watched your talk. gilbert welch: right.

peter salgo: it was fascinating. when you look at what we do to diagnose cancer-- we take a little piece of tissue. we stain it. we look at it under a microscope. and this goes back a century and a half, whenthe only tissue we got was from people with cancer so far spread, they were gonna diefrom it. peter salgo: does that still apply to cancersthat we find with these screening tests that are microscopic? otis brawley: you're exactly right.

you know, we have been using a 19th-centurydefinition of cancer for 160-some-odd years. it was given to us by german pathologists. most of those people, by the way, were atautopsy. they had already died from their cancer. peter salgo: the ultimate cancer screening. otis brawley: that's right. what we're doing now is -- we have progressedour technologies with x-ray, c.t. scanning, mri, ultrasound, all of those inventionsof the latter half of the 20th century, to the point that now, in the early 21st century,we can find a 5- or 6-millimeter lesion in

a woman's breast, say it looks like what killedsomeone 160 years ago. and then we assume that that 5-millimeter thing that looks likesomething that killed 160 years ago is going to kill that woman. peter salgo: but that may not be the samedisease. otis brawley: that's exactly right. it may not be. gilbert welch: and if i could just jump inhere. what otis is talking about is really how ourefforts to find cancer early has exposed new uncertainty about exactly what it means tohave cancer.

and ironically, back in the 1950s, a surgeonat the cleveland clinic described this heterogeneity of cancer that i think is important for peopleto understand. and he talked about it in terms of the barnyardpen of cancers. and there are three animals in the barnyard. there are the birds, the rabbits, and theturtles. and the idea of early detection is to fencein these animals. well, you can imagine it's hard to fence ina bird. the bird's already flown away, and that representsthe fastest-growing segments of cancer, cancers that have tended to spread by the time they'redetectable.

the rabbits are hopping around, and if youbuild enough fences, you can catch them. and those are the tumors that screening mightbe able to help. but then there are the turtles, and thoseare the pathologic abnormalities that are labeled cancer, but they're not going anywhereanyway. peter salgo: so, maybe we need to change thename. gilbert welch: and we -- so, that's why -- andthe problem is, screening's really good at finding turtles, at finding these early lesionsthat aren't going anywhere. and that's why there's been an interest inwhether we should change names. peter salgo: i want to come back to that,but the word "cancer" is scary, right?

>> rose arp: yes. oh, absolutely. peter salgo: now, you had a mammogram, right? peter salgo: that found a lump. tell me about that. >> rose arp: well, my husband found the lump,and i've had previous mammograms. and all that comes back is dense tissue becausei have cysts. so, even for me to find a lump, they're alllumps. lou papa: right.

>> rose arp: so, how do i stay on top of thatto know if there's a bad one? peter salgo: it's a real issue, isn't it? gilbert welch: it's a huge issue. i mean, whenever we look hard at women's breastswith mammography, we identify a lot of abnormalities, and a lot of women do have lumps in theirbreasts. and one of the side effects of looking forcancer early is you find a lot of things that need further evaluation, and i don't knowhow that made you feel. how did that make you feel? were you nervous that or was it fine or wasit painful?

>> rose arp: you know, it's strange becausewhen i had the lump, i freaked out, and i wanted it out. and they said, "well, we'lldo a biopsy. then you can get it removed." when they did the biopsy, my body just kindof freaked out. and i was like, "okay, i'm fine with my lump. i'll keep it. i'm good. just leave me alone." lou papa: but there's also -- part of it alsofrom the primary-care point of view is the

radiologic equivalent of that 'cause peopleget so many scans now, there's little ditzels picked up all the time on c.a.t. scans and ultrasound that raise that samekind of fear, and they're not as accessible. otis brawley: i'm especially worried aboutwhen mri issues to do imaging of the breast and find a lot of these what we call falsepositives. peter salgo: just -- if you'll permit me towalk with you... peter salgo: ...through this lattice of decisionmaking, let's take them one at a time. is that okay with you? >> rose arp: sure.

peter salgo: great. all right. cancer screening -- why don't we start withmammography? do you want one? does she need one? otis brawley: there are number of organizationsthat make recommendations about breast cancer screening. some will say that you should start gettingscreened every year starting at the age of 40, with a mammogram.

some would add a clinical breast exam. some say -- and the american cancer societysuggests -- age 45. and then some say age 50. quite honestly, what you need to think aboutare, what are the risks and benefits of mammography? because there are risks. there are benefits. peter salgo: what's the risk? come on. you're looking for cancer.

>> rose arp: they're smashing it. they could burst something. otis brawley: she's already experienced someof the risk. some of the risk is false positive. mammography -- and i think you'll agree withme with this. mammography is a much better test for a womanin her 60s than it is for a woman in her 40s. number one, the woman in her 40s is at lowerrisk of having cancer, but it's harder to read a mammogram for a woman in her 40s versusa woman in her 50s. the test doesn't work as well, and she's lesslikely to actually have the disease.

that's a combination that leads to, she'smore likely to have a false positive, more likely to be told, "there's something wrongwith your breast. you need additional studies, or you need abiopsy." woman can be frightened, actually, away frommammography. gilbert welch: i want to come to the -- andwe've been talking about the false-alarm problem. and the false-alarm problem is a very realone and extraordinarily common in u.s. mammography. over half of women in a 10-year course ofannual mammography will have at least one false alarm. the unfamiliar harm about mammography is beingtold you have a cancer that was never going

to bother you. and wherever we look, areasthat do more mammograms, u.s. counties that do more mammography, they have more cancer. that's because they're finding more of theturtles, and that means, ironically -- it's the turtle issue. peter salgo: and let me focus this 'causewe're gonna move on to some of these others. gilbert welch: okay, but can i -- peter salgo: please finish your thought. gilbert welch: i just want to finish one thought. ironically, one of the risk factors for breastcancer now is mammography.

and it's not because it's creating breastcancer. it's because it's finding a set of cancersthat weren't being found before. otis brawley: if i can -- peter salgo: please. otis brawley: i'm a little more pro-mammographythan gil. however, one thing i worry about is, peoplethink mammography is far better than it actually is. most expert groups actually agree that mammographyin women in their 40s decrease relative risk of death by about 20%.

let me translate that into you. 80% of thepeople who are destined to die from breast cancer in their 40s are still gonna die frombreast cancer even if they get regular, good mammography, good diagnosis, and good treatment. and keep in mind, i'm the guy who writes studiesabout how a third of women in the united states with breast cancer get absolutely awful care. gilbert welch: and that's the key. that's the place where you and i agree. the key is treatment, is good treatment. by the way, it's also where the good newsis in breast cancer.

breast cancer treatment's a lot better nowthan it was 20 years ago. peter salgo: if i may, with tamoxifen... gilbert welch: yeah. huge, huge. peter salgo: ...and some other drugs, we haveturned perhaps a rabbit into a turtle. gilbert welch: absolutely. peter salgo: i want to take a vote right now. yes or no -- mammograms for her at 50, 60,whatever? lou papa: i'm a primary-care doc.

i would do a mammogram. peter salgo: yes. otis brawley: i would do a mammogram. gilbert welch: i'd say it's a choice. it's not a public-health imperative. you'd have to weigh what you think about thebenefits -- and i believe there is some benefit, but it's very small -- against the more commonharms. and there's no right answer. it's a value judgement.

peter salgo: okay, let's move on. cervical cancer, pap smear -- yes, no? what's the value for her? what do you think? lou papa: you've been getting pap smears regularly? >> rose arp: when i lived in chicago, i gotthem every year. since i've moved, i think i've had two. lou papa: i probably would get one now. otis brawley: i think that a pap smear everythree to five years is beneficial.

one of the problems has been people have beengetting pap smears every year. doctors -- doctor groups used to recommendthat in the 1980s and into the 1990s. many doctors still do them every year, despitethe fact almost all groups went to every 3 to 5 years more than 15 years ago. lou papa: but your pap smears have been normal. >> rose arp: right. lou papa: yes. that's very important. >> rose arp: but i did have a bad one.

peter salgo: listen. >> rose arp: i had a bad one probably 17 yearsago... gilbert welch: mm-hmm. lou papa: okay. >> rose arp: ...and just blindly listenedto my doctor, who said, "well, these are some bad -- it's like pre-pre-- i think we shouldlaser these out." well, i've had problems ever since of justhaving an area of pain. >> rose arp: the doctor said that's fine. well, he's not living my life.

i'm sorry. >> rose arp: and i probably should have justleft it alone, in my opinion. gilbert welch: and to be fair, this is onearea where i think general medicine is moving towards being much more conservative. i mean, ironically, cervical cancer screeningis a place where the expert panels in the specialities are dialing it back, and that'sa good thing. lou papa: but i have to defend primary care. lou papa: i don't have that luxury. i don't have that luxury to say, "whateveryou want."

they're looking for me to recommend what needsto be done. and i depend a lot on the consensus of theexperts. >> rose arp: well, this was a gynecologistthat... lou papa: right, right. peter salgo: but i'm gonna give you guys achance to give me a nuanced vote... otis brawley: okay. peter salgo: ...as opposed to thumbs down,thumbs up. it's not the roman colosseum. yes, no, or dial back the frequency?

lou papa: of what? peter salgo: of pap smears. lou papa: pap smears -- i think i'd like toget another one, and it depends on what that shows. otis brawley: for a woman who has had normalpap smears, i'd recommend pap smears every three to five years or dna testing, whichis the new technology on the block, every five years. gilbert welch: there are a lot of questionsthat might be relevant here -- "are you having multiple sexual partners?"

or whether you're in an established relationship-- you know, that would play into our decisions about these things. lou papa: and that's why i'm saying i wantto know what it shows. if she has a completely normal pap smear,i'd go down your road. so, we are dialing back. peter salgo: okay, let's go on to colon cancer. peter salgo: and the screening test for coloncancer, without any symptoms like blood in the stool, would be a colonoscopy at regularintervals, right? otis brawley: well, you know, in the unitedstates, we love colonoscopy.

there are several countries in europe thathave used stool blood testing, pointing out, by the way, if you look at the science -- listento me carefully -- the science to support the fact that annual stool blood testing reducesrisk of colon-cancer death is actually stronger than the science to show that colonoscopysaves lives. >> rose arp: do they do that there? otis brawley: i did not say that colonoscopyis worthless. i didn't say colonoscopy doesn't save lives. i said the science to support stool bloodtesting is stronger. lou papa: and that's only because they'vedone those better studies.

they haven't really done the definitive studyfor colonoscopy. gilbert welch: and that's exactly right. lou papa: and i think that's important. gilbert welch: but the definitive study forcolonoscopy is being done right now. it's a v.a. cooperative study, and it will be head-to-head,fecal occult blood f.i.t. testing versus colonoscopy. otis brawley: that being said, i think thatbetween stool blood testing, sigmoidoscopy, colonoscopy -- and stool blood testing canbe looking for actual blood with an immunochemical

test, or it can be looking for dna signaturesof polyps and cancer. people ought to get one of those tests, andthey ought to start regular screening of some sort at about the age of 50. peter salgo: this is where your comment -- lou papa: as primary care, we're on the frontline. we don't have the luxury of waiting 12 years. and at least my understanding is there's beena drop-off in the death rate of cancer death, and a lot of it is colorectal cancer. gilbert welch: and this is important.

yes, there -- and this is good news, anotherpiece of good news. colon cancer is disappearing as a cause ofdeath. it's one half of what it would have been whenmy father died of it in 1978. peter salgo: is that because of somethingwe're doing, or is it the disease changing? gilbert welch: that's a very important question. lou papa: but that's true of cervical cancer,as well. there is no definitive study done on cervicalcancer. peter salgo: what's happening here? otis brawley: let's slow down, guys.

slow down, guys. there's been a 40% decline in colon cancerdeath, starting from about 1970. that's pre-screening, okay? gilbert welch: that's right. otis brawley: some of the decline is due toscreening. some of the decline is due to treatment. some of the decline is due to people justbeing aware that something's changed in their bowel movements and going to get checked out. gilbert welch: and some of it's a decreasedincidence.

>> rose arp: well, i had a colonoscopy about12 years ago because i had some blood. lou papa: so, that was different. okay. gilbert welch: that's different. that's diagnostic. right. so, they found a polyp, said, you know, "you'regonna have to have another colonoscopy at some point." you know, it was benign, you know.

so, i'm sitting here approaching 50 going,"all right, do i have a colonoscopy? do i put --" 'cause my doctor's not saying,"hey, you should do this." lou papa: well, it depends on the type polypit is, right? there's different types of polyps. >> rose arp: but i don't know 'cause we nevergot the records. otis brawley: well, let's say if you're a50-year-old female with no history, i think a colonoscopy is a great test to get. if you have a normal colon, you need to getit again 10 years. certain polyps, i would want to come backin two to three years, certain types of polyps.

certain small polyps, i would say we can wait10 years. stool blood testing is great. you got to do it three times a year everyyear instead of a colonoscopy every 10 years. sigmoidoscopy, if you can find a doc who'swilling to do it, because, reimbursement and other things, it's hard to find nowadays -- youneed to get that every three to five years. but you need to make a choice. if you have an abnormality or history of anabnormality, you need to go talk to a g.i. doc, try to figure out what that history was,and you should be getting colonoscopy much more frequently than every 10 years possibly.

peter salgo: let me move along. we've had our vote. we're gonna go to the other big one. do you smoke? yes? no? lou papa: you smoke?! forget everything else. peter salgo: [ laughs ]

lou papa: no. i'm serious. otis brawley: that's true. lou papa: forget everything else. if i could trade you to get off the cigarettesfor never getting another mammogram, never getting another colonoscopy, get rid of thedamn cigarettes. otis brawley: i'd agree. gilbert welch: well, that's a really importantpoint, and i think it helps put things in perspective about...

peter salgo: the risk of smoking versus thescreening risk of looking for -- gilbert welch: well, and also that what we'redoing here with cancer screening is really at the edges of what predicts human health. peter salgo: smoking is a bigger hammer. otis brawley: smoking increases risk of deathby dramatic numbers. peter salgo: and it's not just lung, right? it's all comers. otis brawley: it's more heart disease... gilbert welch: heart and cancer.

peter salgo: kidney. gilbert welch: all causes double. peter salgo: colon. otis brawley: yeah. peter salgo: so, i want to go now to lungcancer screening with c.t. scanning... peter salgo: ...all right, 'cause that's thenew, hot deal. peter salgo: lou? lou papa: well, it depends.

peter salgo: oh, thanks. lou papa: no, the guidelines are pretty clear. she's not old enough, all right? she's 50. so, the guidelines recommend that you startat age 55 every year if you've smoked for 30 pack-years and you have not -- if you'vestill been smoking within the last 15 years. otis brawley: 30 pack-years is you smoked2 packs per day for 15 years or a pack per day for 30 years. peter salgo: or 30 packs for one year.

otis brawley: or 30 -- yeah. lou papa: so, that starts at 55, ends at around79, i think. and the reason why is that's where your biggestbang for your buck is. otis brawley: and i should point out thatpeople who have smoked more benefited from that study more so than people who had smokedless. gilbert welch: keep in mind the basic principlesoperating here. and i've been the one suggesting no -- orarguing -- giving you the weakest suggestions for screening, and yet this would be the placewhere i would make the strongest suggestion, if you really were a 35-pack-year smoker becausethis is a really high-risk person if you have

a heavy smo-- and that's an important -- there'sa very important part about who stands to benefit from screening -- people at exceptionallyhigh risk. lou papa: but keep in mind -- those studies,when they look at those studies, in those individuals that they found abnormalities,96% of them were benign. peter salgo: so, we're gonna vote and moveon. c.t. scan? otis brawley: i would hope that i could convinceyou to stop smoking. >> rose arp: i've quit more times than...

gilbert welch: i'm going with dr. brawley on that one. lou papa: if you've quit more times than youhave -- you're more likely to quit smoking, but there's no doubt the best thing you coulddo for your health is get rid of the smoking. peter salgo: this takes care of the four thatare of particular interest to this beautiful young woman. >> rose arp: [ laughs ] peter salgo: all these screening tests formen and women or changing lifestyles that you decrease your cancer risk in the firstplace -- what's more effective?

lou papa: oh, changing lifestyle. otis brawley: changing lifestyle. gilbert welch: yeah, changing lifestyle. peter salgo: i think i'm gonna quote you. tell me if i'm quoting you correctly thatall this screening stuff -- i think both of you would sign on, as well -- has the potentialof turning people into patients... gilbert welch: yes. peter salgo: ...as opposed to healthy peopleliving their lives. otis brawley: yes.

peter salgo: is that fair? otis brawley: that's fair. peter salgo: then let's call it a day. we may have to reconvene because this is agreat discussion. rose, thank you so much for sharing your storywith us. panel, just insanely great. thank you for being here. and i'd like to know what you think abouttoday's discussion and rose's second opinion by tweeting us or by commenting on our facebookpage.

and now here's this week's "second opinion5." david dougherty: hello. i'm dr. david dougherty, and i'm here to tell youfive of the biggest risk factors for cancer. the first risk factor is tobacco use, whichis far and away the most preventable cause of cancer. lung cancer is the number-one cause of cancer-relateddeaths in the united states, and tobacco use is responsible for over 90% of those deaths. not only does smoking increase risk for lungcancer.

it is linked to many other cancers, includingleukemia. the next risk factor is being overweight andhaving decreased physical activity. obesity has been estimated to cause nearly20% of all cancers, and increasing physical activity can reduce this risk. the third risk factor is excess sun exposure,including ultraviolet light exposure from tanning beds. skin cancer risk increases with increasedtotal lifetime sun exposure, as well as repeated intense exposures or sunburns. to reduce the risk of skin cancer, all individualsshould limit time spent in the sun, use sunscreen,

wear protective clothing, and avoid tanningbeds altogether. another risk factor is infections, which canbe responsible for 15% to 20% of new cancers worldwide. these include hpv, hepatitis b and c, andhiv, and are typically spread through contact with infected blood or body fluids. and lastly, alcohol intake, even in moderatequantities, increases the risk for many different cancers. in fact, current smokers who also drink alcoholcan have significantly increased risk for cancers of the head and neck and digestivetrack.

although there can be beneficial effects ofmoderate alcohol use on cardiovascular health, the increased risk of cancer may offset thesebenefits. and that's your "second opinion 5." peter salgo: thank you so much for watching. and remember -- you can get more second opinionsand patient stories at our website at secondopinion-tv.org. you can also send us your show ideas and shareyour own health story. maybe -- just maybe -- we'll invite you tobe on the show with us. you can continue this conversation on facebookand twitter, where we are live every day with breaking health news.

peter salgo, and i'll see you next time foranother "second opinion."