March is colorectal cancer awareness month, and experts want you to know that if you're between 50 and 70, you need to get screened...and it's not as miserable as people assume. Jane Bolin, BSN, JD, PhD, the associate dean for research at the Texas A&M College of Nursing and a professor at the Texas A&M School of Public Health, breaks down the process.
- Christina Sumners: Welcome to Science Sound Off. I’m Christina Sumners.
Tim Schnettler: And I’m her co-host, Tim Schnettler.
Christina Sumners: And we’re here today with Dr. Jane Bolin. Welcome to the podcast.
Jane Bolin: Thank you.
Christina Sumners: Could you tell our listeners just a little bit about yourself?
Jane Bolin: Well sure. Currently, I have dual roles. I am the Texas A&M Associate Dean for Research at the College of Nursing and I’m also a tenured full professor at the Texas A&M School of Public Health.
Christina Sumners: Wonderful. We’re here with you today to talk about colon cancer screenings and prevention. And I know you’ve done a lot of work in that area, especially in the Brazos Valley.
Jane Bolin: We have. We are currently serving 17 counties in this greater Brazos Valley region and we have been working in cancer prevention generally and colon cancer specifically since 2011, which was our first major funding opportunity through the Cancer Prevention and Research Institute of Texas along with the College of Medicine and College of Nursing.
Christina Sumners: Wonderful. So tell us a little bit about that first grant. What were you doing with it? What was it all about?
Jane Bolin: Sure. It was a joint effort because of the shared passion for cancer screenings between myself and my team at the Southwest Rural Health Research Center and Dr. David McClellan, who was at that time the Director of the Family Medicine Residency with the Texas A&M College of Medicine. Both of us had had parents, our mothers had passed away due to colon cancer. And so it was a topic that was near and dear to our hearts. And when the Cancer Prevention and Research Institute of Texas announced funding for programs that would not only prevent but educate and screen, we shared our dual sort of vision for what we could put together to institute a program for colon cancer prevention and screening in the greater Brazos Valley.
Christina Sumners: Wonderful. And let’s take a step back for just a second. What is colon cancer, colorectal cancer? Are they the same thing?
Jane Bolin: Yes, generally. So colon cancer would be abnormal cancerous lesions that are actually up in the colon. Colorectal cancer would also involve the end of the colon or the rectal area, which is actually quite common. You’d be surprised how common it is. And so the term is colorectal cancer. Screenings and that it’s generally there are a number of degrees of findings that one might see when they’re doing screenings, but certainly with appropriate screening you can visualize cancers in the colon.
Christina Sumners: And so is that why screening is so important? It’s because you can see these cancers?
Jane Bolin: Yes, they’re very slow growing. They generally start with precursors to cancers like polyps or diverticuli, which are reverse pouches in the colon that tend to gather and accumulate waste matter. And certainly that’s what the colon’s for. It’s the waste viaduct for our digestive system. And so polyps hang down and diverticuli are recesses. And any kind of abnormal finding like that would be noticed by a physician and those areas can be removed through either surgical, but with a colonoscopy, polyps can be just excised pretty easily. But with a colonoscopy, the physician can also see abnormal inflammation, Crohn’s Disease. And those are also known to be precursors to cancer. And so treatment would be important to reduce inflammation and keep a watchful eye on that area for the person that may be experiencing that.
Tim Schnettler: So we always hear, early detection or early findings is the key to all of this. And the way you’re talking, this is something that really early detection is a huge part of.
Jane Bolin: It is. You’re exactly right. So for the person who hasn’t had a, what we refer to as a first degree relative who has had cancer, the normal screening period would start around age 50 for your first colonoscopy. But then it’s good for 10 years or generally recognized because of the slow-growing nature of colorectal cancer. And so if a person has a colonoscopy, it’s generally agreed that that’s good for 10 years. Then, you have your second one at 60 and then you’re good from there on out, if there are no abnormal findings. If there are polyps found, then it’s recommended that they’d be excised or removed and that it be repeated within 2-3 years, depending on the size of the polyp. So, being able to visualize it because it’s so slow-growing and remove the abnormal lesion, it is far better for the person than actually having colon cancer because it’s so painful.
Tim Schnettler: You mentioned, I can’t remember the term you used first…
Jane Bolin: Degree relative?
Tim Schnettler: First degree relative. Is that like mother, father, uncle, aunt? What technically is a first degree relative?
Jane Bolin: Those that you mentioned, mother, father, brother, sister, aunt, or uncle would be considered a first degree relative. And the recommendations are that if colon cancer has been diagnosed in a first degree relative, then the family members start their screenings 10 years earlier than the age of diagnosis of the person who had it first.
Christina Sumners: So you mentioned a few of these risk factors for colon cancer. So that would be Crohn’s Disease, other inflammation.
Jane Bolin: Right, polyps. Crohn’s Disease, inflammatory bowel syndrome, a first degree relative having had it. But it’s also associated with obesity, generally. It’s also associated with a diet that’s high in processed foods. And also associated with high consumption of alcohol among other things. There are a number of factors, but I think the most serious are the first degree and then having active symptoms yourself.
Christina Sumners: And what are those symptoms?
Jane Bolin: Well it’d be symptoms of irritable bowel, which would be the cramping in the lower intestine. Certainly, anyone who notices blood in their stool should immediately be screened and have a full colonoscopy. And the good part about a colonoscopy now, it’s not just limited to the lower descending bowel, but it actually, the scopes now are smaller, flexible, and they can reach all the way up to where the large colon and small colon join at the cecum or what we refer to as the appendix. And so part of screening is to get that scope all the way up to the very end of the large bowel or the colon, so that the scope is seeing it. And then to slowly withdraw through the entire colon, visualizing throughout the diameter of the colon as one withdraws it very, very slowly and looks at it all the way out. And then if there are any abnormalities found that to just actually excise them right there through a wire. I won’t go into it. But it’s actually very easy and then those tissue samples are removed and then examined by pathologists.
Christina Sumners: So let’s talk a little bit more about the process. You mentioned once you actually get in there for the colonoscopy, I know people are often scared about what the prep is like.
Jane Bolin: Right. That’s probably the very worst thing about colon cancer screening, if you’re going to have a colonoscopy because it’s two days of prep that’s not very pleasant. Because one is generally fasting and not eating solid foods or anything other than clear liquids. And so it’s not very much fun. It’s a bit of a process to go through until the scope is over. So it’s basically cleansing the bowel. And so what we do over at the clinic and what we would try to make it culturally appropriate, we have bilingual promotoras or CHWs that are there assisting the staff and the physicians and the nurses and they give them their medication or it’s not really medication, but it’s just something that will quickly cleanse the bowel. And so everything, there’s no residual left behind and the person conducting the colonoscopy can really see the bowel very clearly.
Tim Schnettler: As someone who is approaching the age of 50, knowing that this is on the horizon for me. I mean, what you just talked about, ease my fears a little bit more. You know, there’s always been that oh my gosh a colonoscopy and I’m sure a lot of people out there have that same reaction to it, but it’s something that’s so important and really it’s not that difficult a procedure, is it, other than what you just talked about?
Jane Bolin: Yes. You’re exactly right. And they’ve narrowed that window down for cleansing now to one day really. You stop eating the day before and then the one day of clear liquids is really just one day. And then you go in early the next morning for the procedure. So it’s just that. And by having the colonoscopy with the scope, you can then, assuming everything’s clear, then sort of be assured that I’m good for another 10 years.
Tim Schnettler: Right.
Jane Bolin: Whereas if you have the FIT test or the stool sample test that detect blood or the other DNA that might be associated with cancer that’s a year-to-year thing. So you’re going through it every year. And then if there’s any abnormality, you’re going to undergo a colonoscopy anyway.
Tim Schnettler: Right.
Jane Bolin: So there are many things that can make a false positive such as having had steak the night before or red meat. And then you have that false positive and you’re gonna undergo a colonoscopy anyways. So because insurance covers it, it’s just that one day of undergoing the prep and it’s a bit of a discipline, but then you feel, at least I did, I feel good afterwards because it kind of cleanse my system.
Tim Schnettler: Exactly. It’s one day for a prevention for a life, almost for a lifetime, or for the rest of your life.
Jane Bolin: Exactly. So it’s worth it in my opinion. It’s 10 years of phew, nobody saw anything. That’s great.
Christina Sumners: And just for the procedure itself, how do you all train the family medicine residents and how to do their procedure?
Jane Bolin: So actually the training occurs over at the Family Medicine Residency Clinic. They have some champions there who are actually certified by the American Society for Gastrointestinal Endoscopy. They’ve undergone that requisite number of colonoscopies. We, through the generosity of the grant itself from CPRIT, were able to purchase a simulator, a computer simulator that comes programmed with various kinds of things, abnormal things, that may be seen when one performs a colonoscopy. So the residents go through all those modules, if you will, and it has a scope that they’re manipulating up through it, it’s hand-eye coordination and they’re manipulating the scope up through this simulated colon. It’s interesting, if they bump into the side of the colon, the simulator groans like a patient would. And they know that they need to back off and come at it another way because it’s not easy getting around the curves and corners. So they undergo that initial training, then they go in and watch with the senior residents and the physician in charge. And then finally as they advance through their three years of family medicine residency, they themselves will be performing the colonoscopy and hopefully they’ll by end, and the plan is that, and it has worked in fact, that they all have the requisite number of trained and observed colonoscopes or actually having performed those themselves. That when they get out and they go to small rural hospitals or go into a town that they will have the necessary skills that their hospital or clinic will certify them to conduct those exams. Because not everyone can go into a big city to have a GI specialist perform it for them. And we find that rates are higher in rural areas. We found that the stage of diagnosis of colon cancer is far worse in rural areas. So that makes mortality rates higher for colon cancer. And it is the 2nd highest cause of death in the United States related to cancer.
Christina Sumners: Even though it’s so preventable with the proper screening.
Jane Bolin: Right. It is one that grows very, very slowly, but most people don’t experience symptoms often until it’s too late.
Christina Sumners: You mention that insurance does cover colonoscopies, but what about for people who don’t have insurance or don’t have good insurance?
Jane Bolin: Great question. The CPRIT funding for the Family Medicine Residency, and the Health Science Center, and the School of Public Health, and the College of Nursing has actually provided free colon cancer screenings now for close to 2,500 patients in the greater Brazos Valley who don’t have insurance or are underinsured. So, they often times may only get 50% of it paid for by their insurance company and to go to a GI specialist, it may be in the several thousands of dollars to undergo this procedure. So this grant actually pays for the clinic, the time, and the scopes, the prep, and the percent of the staff time needed to instruct the patient. All that takes money. And we have performed now close to 2,500 free colonoscopies with the CPRIT funding. So, it’s a great situation, win-win for the Health Science Center and the residents of the greater Brazos Valley.
Christina Sumners: So of those people that have been screened, what percentage actually had some sort of precursor or actual cancer?
Jane Bolin: 35% of the colonoscopies that have been performed have shown abnormal pathology and 25% of those had revealed cancer precursors, which would be the polyps or the abnormal tissue. Of those, approximately 20 have been actually diagnosed with colorectal cancer and have gone in for treatment. We, through the use of community health worker, promotoras, have gotten the word out either through Radio Alegria and other mediums such as back-to-school events, or health fairs, different avenues of educating the public. We have close to 200,000 individuals that we’ve reached through this cancer training program. Over 12,000 have been reached face-to-face and 41,491 professionals have been reached about this through our letters. And I’m sure you want to know about the results, right?
Christina Sumners: Yes.
Jane Bolin: Of course and we have to track that. And we’re very proud of the outcomes. So, of the total number of colonoscopies, we track carefully to ensure that we’re meeting the American Society of Gastrointestinal Endoscopy guidelines. And we have in 96 percent of our cases, we have attained the cecum, which is a benchmark for a total colonoscopy screen. So the cecum, remember, is where the large bowel and small bowel meet. And that’s the very end of the colon. Now the standards or benchmarks require a 95 percent rate, so we’ve exceeded that. We’ve met that. Overall, adenoma or cancer detection rate is expected to be at 20 percent We’ve met that at 27 percent of the time, I mean we’ve detected 27 percent adenomas. In females, it’s as high as 26 percent. Even higher in males, we’re seeing higher cancer rates in males, which is not unusual because of the reluctance to go in for screenings generally anyway, spend time in terms of health care. We also look at the total withdrawal time of the scope back out the colon to assure that it’s being visualized as carefully as possible. And the physicians at the Family Medicine Residency took a total of 18 minutes per patient to visualize the colon as it’s slowly withdrawn. And then that’s part of their teaching function because they’re all looking at it and observing things. The total mean withdrawal time recommended is just six minutes.
Christina Sumners: Oh wow, so we’re spending three times as long?
Jane Bolin: Yes, three times as long to observe the colon. So we’re very proud of the outcomes that this program has demonstrated. The physicians who are in charge of this program all have excellent records in terms of the sheer numbers in volume that they’re doing. So it has been an excellent program for the Family Medicine Residency in terms of having that extra special something to train family medicine residents including the public health, nursing. Now, the College of Nursing is also much more involved in the breast and cervical cancer screening. And we do make available FIT testing. But recognizing that the colonoscopy is something that has to be done in a clinical setting that the Family Medicine Residency, it certainly has an excellent record now.
Christina Sumners: And the School of Public Health is involved through getting the word out about these screenings?
Jane Bolin: Getting the word out, engaging School of Public Health students in their practicum, they’re out providing presentations, health fairs, going to back-to-school events, and just in general, educating the lay public about the importance of this.
Christina Sumners: And if someone in the Brazos Valley is interested in the program, and maybe doesn’t have insurance, but knows they need a colonoscopy, what’s the best way for them to get in contact?
Jane Bolin: Our website, the C-STEP website will put it up on the podcast, it has a contact person, as well as the Family Medicine Residency on 29th and Briarcrest. So we’ll make that information available, the phone numbers to call, and who to engage with. And we do have bilingual CHWs, our community health workers who can instruct the patient. And we do also engage with patients to arrange rides and transportation. So, it should be a much easier process for people to get this important screening.
Tim Schnettler: Say there’s a listener outside the Brazos Valley listening to this, are there programs similar to this outside of the Brazos Valley where someone can go?
Jane Bolin: There are, yes. We recently expanded our residency training program to Cuero, adjacent to Victoria. They’re in the DeTar, Cuero Counties and so A&M has expanded it. We do referrals, so if someone who says, I’ve noticed bleeding and I would really like to be screened, but I’m uninsured, we have gone ahead and contacted the folks at CPRIT and received permission to go ahead and conduct a colonoscopy even though they’re not really in our 18 county service area. So, yes we have sought permission to go ahead and do that if someone has outright symptoms.
Tim Schnettler: And you mentioned that y’all expanded it to Cuero and some others. Is there plans to try and expand it even further, or are there other areas where y’all are looking to get into?
Jane Bolin: Yes. We have currently plans to expand actually down to the lower Rio Grande Valley to the McAllen area and to literally make it available all the way up into the areas served by healthy South Texas.
Christina Sumners: Dr. Bolin, you mentioned that there’s some other screening test that maybe they’re not as good, not as effective. What are these other options and why do you recommend a colonoscopy rather than some of these other tests?
Jane Bolin: Other tests are tests that take a sample of the stool and put it on a reactive test strip and then it’s tested for either DNA markers or blood or immuno signs of the fact that cancer’s present. So take the FIT test, well F-I-T stands for Fecal Immuno Test strip and it detects immuno DNA related residual in the stool that has been identified as being associated with colorectal cancer. But it also, these same tests, will also pick up blood that may be a false positive, so if someone has eaten red meat that will be a false positive. Or may pick up something else that may have been associated with, let’s say, consuming aspirin, for example, has been known to cause the bowel to have some bleeding in some individuals. And so that also could be a false positive. And any kind of false positive leads to a colonoscopy anyway. And so it makes sense in terms of time and cost to just go ahead and have that colonoscopy once every 10 years.
Christina Sumners: And I’ve heard about a virtual colonoscopy. What is that and is that as good as a regular colonoscopy?
Jane Bolin: A virtual colonoscopy would be the ingestion of a small device that would be passed through with a bowel movement, but as it descends through the colon, it allows the person who is observing the data generated by this device to observe the colon, the inside of the colon, as it’s passing through.
Jane Bolin: For a virtual colonoscopy, you still have to do the prep part of it?
Jane Bolin: Yes.
Christina Sumners: So, it doesn’t really save you much in terms of the experience for the patient.
Jane Bolin: Probably not. I’ve never had one.
Christina Sumners: Got it. That makes sense. Well we’re just about out of time, but Dr. Bolin, is there anything else you’d like to let people know?
Jane Bolin: Again, this is an important screening. It’s something that is truly lifesaving and colon cancer screening does save lives. I can’t emphasize that strongly enough. It’s not a pleasant thing to have colon cancer and it is a painful death and it’s tragic that more people don’t undergo this simple procedure, relatively simple procedure, once every 10 years for two times in their life to avoid the pain associated with colorectal cancer. So, I strongly urge all of our listeners to make that appointment and get this screening done.
Christina Sumners: And I think that’s a really great message to end on. Thank you so much, Dr. Bolin, for being with us today.
Jane Bolin: Thank you for having me. I appreciate it.
Christina Sumners: And thank you all for listening. This has been another episode of Science Sound Off, and we will see you next time.
To schedule a colonoscopy with Texas C-STEP, contact Angie at 979-436-0443.
For more information about the program, contact Janet Helduser at 979-436-9466.