cancer prevention

Colonoscopy Quality and Impact on Cancer Risk: My Experience at Holy Cross

  • Posted Mar 08, 2019
  • hchadmin

By Dr. Patrick Amar

Colon cancer is the third leading cause of cancer death and is preventable in up to 95% of cases. The purpose of a screening colonoscopy is to prevent the occurrence of colon cancer in the future. Without screening of any sort, the likelihood of a patient at average risk of getting colon cancer is 1 in 18. Colonoscopy is a tremendously powerful cancer prevention tool but unfortunately suffers from a number of potential pitfalls. It is both appropriate and critically important for patients and referring providers to inquire about quality measures when selecting a physician to perform colonoscopy.

I have collected data on over 1,500 consecutive colonoscopies which I personally performed over a two-year period. For each of these procedures, I collected data on which portion of the colon was reached, the quality of the bowel preparation, the number of polyps removed and the recommended interval for repeat colonoscopy. For any patient with polyps removed, I subsequently correlated these numbers with their pathology results and revised the polyp counts accordingly, to reflect only those polyps which were found to be adenomatous or serrated. These two particular pathology findings are directly correlated with cancer potential and are the target lesions for which we ask patients to undergo colonoscopy.

The first and most obvious measure in assessing quality of colonoscopy is the rate of completion of the exam. Clearly, examining only a portion of the colon leaves patients at risk for precancerous polyps in the areas not visualized. A colonoscopy is considered complete when the cecum (beginning of the colon) is intubated, as identified by several landmarks. The benchmark minimum recommended standard for this measure is 95% cecal intubation. My cecal intubation rate is 99.6%.

Cecal intubation is not a perfect measure of a complete colonoscopy, however. The cecum can sometimes be mistaken for other parts of the colon, especially the hepatic flexure. This leaves the potential for entire large segments of the colon not to be examined at the time of a colonoscopy. The solution that many gastroenterologists have proposed, to ensure 100% certainty of a complete colonoscopy, is intubation of the end of the small intestine (terminal ileum), which has a distinctly different appearance than the colon on endoscopic evaluation. This also affords the opportunity to evaluate for small bowel pathology which may otherwise be undiscovered (I have diagnosed several cases of Crohn's Disease in this manner). There is no recommended benchmark for intubation of the terminal ileum on screening colonoscopies. Nonetheless, I can proudly say that I have a 98% rate of intubating the terminal ileum for screening colonoscopies, thus dramatically reducing the likelihood of an incomplete examination.

The next and perhaps most important measure in determining quality of colonoscopy over a large number of procedures is the likelihood of discovering precancerous polyps. As noted above, these are either adenomatous or serrated on pathology. Patients with numerous or larger polyps are at an especially increased risk of colon cancer. The measure most commonly used is referred to as Adenoma Detection Rate (ADR), or the percentage of patients who are found to have at least 1 precancerous polyp at the time of screening colonoscopy. The minimum benchmark recommended for adenoma detection rates is 25% among male patients and 15% among females. The national average for ADR is 26% among community physicians and 29% among physicians in academic settings. My personal adenoma detection rate (ADR) is 54%.

The reason that this number in particular matters greatly is that there is tremendous variability in adenoma detection rates among different physicians. A recent study published in the New England Journal of Medicine which examined over 300,000 screening colonoscopies revealed Adenoma Detection Rates ranging from 7.4 to 52.5%. Analysis of this data revealed a dramatic decrease in the likelihood of patients being diagnosed with cancer up to 10 years after their colonoscopy was performed ("interval cancers"), if the performing physician had a higher ADR.  For every 1% increase in adenoma detection rate, patients had a 3% decreased risk of cancer over the following 10 years. Patients undergoing screening colonoscopy by the highest-performing physicians by ADR rates had up to a 69% incremental decrease in "interval cancer" risk compared to the average. This is over and above the baseline reduction in colon cancer risk offered by an "average" colonoscopy.

This measure, however, also has its limitations. The gastroenterology literature discusses the danger of a "one-and-done" colonoscopy. This refers to the tendency for some physicians to overlook adenomas beyond the first one discovered, either due to inattention or in the interest of moving a colonoscopy along. This gives rise to a measure called "adenomas per positive," which refers to the total number of adenomas discovered in patients who had at least one precancerous polyp. This is meant to counteract the tendency for a "one-and-done" colonoscopy and ensure that patients are getting the best cancer protection possible. The published data reveals a national average of 1.9 Adenomas Per Positive among academic centers and 1.65 among community physicians. My personal Adenoma Per Positive rate is 2.44, meaning that in patients who have at least 1 precancerous polyp, the likelihood is that I will find between 1 to 2 additional precancerous lesions.

There are polyp types which do not present an increased risk of cancer to patients. The most common type is a hyperplastic polyp which carries no precancerous potential unless it is part of a specific and rare polyposis syndrome. Likewise, the finding of a "mucosal excrescence" or other benign pathology findings do not represent precancerous tissue and are not counted in a physician's adenoma detection rate. These polyps most frequently occur in the rectosigmoid colon and are often removed by physicians, inadvertently leading many patients to think that they may beat increased risk of colon cancer. Removal of these polyps does not benefit patients in any way and does place them at some increased risk of post-procedure bleeding.

There are a number of key factors which have been found to impact a physician's adenoma detection rate. These include appropriate withdrawal time of the colonoscope during examination of the colon, the quality of the patient's bowel preparation, irrigation and suctioning of any stool residue at the time of examination and appropriate use of available advanced technologies to improve adenoma detection.

The importance of withdrawal time in assessing quality of colonoscopy became widely disseminated approximately 10-15 years ago. It was apparent that there was a tendency for some physicians to rush the colonoscopy examination, thereby decreasing the likelihood of finding precancerous polyps. The recommended minimum average time for withdrawal of the colonoscope was established at 6 minutes, a threshold which correlated with a significantly increased likelihood of finding precancerous polyps.  My personal average for withdrawal time is 8.9 minutes, which would be expected to result in improved adenoma detection. This is also considered the most important measure of quality of colonoscopy examination at the individual procedure level, ensuring that the examination was not compromised by being unduly rushed.

A significant change in the approach to bowel preparation was instituted several years ago, with patients being encouraged to use a "split-dose" bowel preparation regimen. This means that rather than having patients drink the entire bowel preparation on the day prior to the examination, they are instructed to drink the second half of the bowel cleansing solution on the morning of the procedure itself. By decreasing the time interval between administration of laxatives and the performance of the actual procedure, patients have less time to re-accumulate adherent liquid stool on the bowel wall and have improved visualization at the time of colonoscopy. This greatly increases the likelihood of finding either flat or sessile polyps as well as polyps with serrated pathology. I have utilized a split-dose bowel preparation protocol for over 5 years and have noted dramatically improved visibility at the time of colonoscopy. This has resulted in patients having their preparation rated "good" or "excellent" 94% of the time, improving the likelihood of discovering pre-cancerous polyps.

That being said, no patient has a perfect preparation at the time of their colonoscopy. Adherent liquid stool is especially problematic in preventing detection of smaller or sessile polyps. The tendency is simply to examine the colon "as is" and bring patients back at shorter intervals in order to compensate for less than adequate preparation. It is my opinion that once the patient has made an appropriate effort with bowel preparation and has taken the time and expense to have a colonoscopy performed, it is my duty to "clean up" to the best of my ability, within reason. I typically irrigate the colon with a very generous amount of water in order to remove any remaining adherent stool and thereby further improve adenoma detection.

Holy Cross was fortunate to purchase the newest generation colonoscopes from Olympus approximately 5 years ago, namely the 190 series. There is a specific setting on these scopes called Narrow Band Imaging (NBI) which facilitates the discovery of sessile or serrated polyps. Unfortunately, most physicians utilize this setting very little, if at all. I utilize NBI for the entirety of my colonoscope withdrawal, in order to improve adenoma detection rate and can personally attest that it has significantly impacted my ability to find flat or serrated polyps.

Additionally, there has been a tendency to overuse colonoscopy and have patients return at intervals which are shorter than recommended by professional societies. Many physicians developed a tendency to have patient's return for their "five-year" repeat examination, even in situations where bowel preparation was adequate and there were no precancerous polyps discovered. The recommended interval in such circumstances is 10 years. Additionally, when patients are found to have precancerous polyps, the recommended intervals are frequently overly-shortened. Use of appropriate intervals for follow-up colonoscopies after index examinations lowers the patient's individual procedural risk and also lowers the cost to a health system, overall. I am mindful to provide patients with a 10-year repeat interval for normal examinations if I can confidently do so, unless personal risk factors dictate otherwise. Likewise, I strive to adhere to the recommended intervals for follow-up of precancerous polyps, rather than bringing patients back more frequently than they truly require.

Achieving excellence when taking care of patients does not occur in a vacuum or with a single person, however. I work alongside a very dedicated staff of endoscopy nurses, technicians and unit managers. I am also blessed with tremendously talented and hard-working office staff, many of whom have worked with me for over 10 years and share my passion for providing excellent care. It is my sincere hope that I can continue to do so and that our endoscopy unit will continue to strive to be a leader in outstanding patient care with the support of a hospital that I am proud to be affiliated with - Holy Cross.

Dr. Patrick Amar practices with the Holy Cross Medical Group in Fort Lauderdale. He may be reached at 954-928-1778.


Breast Cancer Prevention Begins with You

  • Posted Sep 26, 2017
  • hchadmin

Did you know that according to the Centers for Disease Control and Prevention (CDC), breast cancer is the second most common cancer in women in the United States? 

October is National Breast Cancer Awareness month and Holy Cross Hospital would like to take this opportunity to encourage you to care for yourself, and your loved ones, by reminding you of the importance of preventive care.

Thankfully, breast cancer prevention begins with a variety of factors you can control, which include: 

•Managing a healthy weight. Being overweight or obese increases the risk of breast cancer. Eating a healthy diet and getting plenty of exercise can help reduce your risk.

•Breast-feeding. Breast-feeding your children may offer some protection against breast cancer. 

•Hormone therapy. If you're currently taking hormone therapy for menopausal symptoms, ask your doctor about options. According to the National Cancer Institute, long-term combination hormone therapy increases the risk of breast cancer. 

•Restricting alcohol consumption. Your risk of developing breast cancer rises with an increase in alcohol consumption. Limit yourself to no more than one drink a day.

While taking care of your physical health is a great way to help prevent any disease, so is maintaining a healthy spirit. For example:

•Staying positive. Research shows that happiness and optimism are associated with lower rates of breast cancer. Focus on your thoughts — stop negative ones and replace them with positive ones.

•Managing stress. Utilizing a few stress relievers, like deep breathing, muscle relaxation and keeping a journal, can be helpful in controlling the impact stress has on your body.

•Maintaining a balanced lifestyle. Don’t stretch yourself too thin – make sure to have time for proper nutrition, sleep, work and play.

•Creating a circle of support. Maintaining a close network of family and friends can provide you with emotional support when you need it. 

Lastly, getting health screenings and tests from your doctor is key in sustaining your health and helping prevent health conditions like breast cancer. 

Having a primary care physician (PCP) who can coordinate your care is vital to your good health. If you don’t have a PCP, finding one is easy! Just visit your insurance carrier’s website, look for the “find a doctor” area and follow the instructions.  Or use the physician finder at www.holy-cross.com!

Come to our Beyond Breast Cancer event on Thursday, October 5 at the Dorothy Mangurian Comprehensive Women's Center at Holy Cross HealthPlex. Register here or call 954-351-7804.

How can I reduce my cancer risk?

  • Posted Aug 29, 2017
  • hchadmin

Dr. Omar Rashid, Surgical Oncology & General Surgery, offers tips on how to prevent cancer on Sharecare.com.

You can reduce your risk of cancer by following these recommendations for cancer prevention, based on the latest research and international consensus guidelines:

Fitness and weight: Maintain a healthy weight without being underweight.

Sitting is the new smoking: Avoid a sedentary lifestyle and maintain physical activity for 30 minutes a day.

Read more and follow Dr Rashid


Playing It Safe in the Summer Sun

  • Posted Jul 18, 2017
  • hchadmin

Summertime is all about fun in the sun and promoting spiritual health by getting outside to commune with nature.

But, did you know that according to the Skin Cancer Foundation, one in five Americans will develop skin cancer, the most common type of cancer in the United States, and one dies of skin cancer every hour?

With the beautiful weather and days spent outdoors at the park, the beach and the golf course, your skin may be getting more sun exposure now than at other times of the year.

It's a great time to safely take part in outdoor spiritual practices like gardening and spending time in nature. 

While you're enjoying the great outdoors, it’s important to be aware of how much sunlight you get. Ultraviolet (UV) radiation is the main cause of skin cancer and can also cause damage to your eyes. For these reasons, avoiding overexposure to UV light is the simplest form of prevention.

July is UV Safety Month. Here are some simple steps from the Centers for Disease Control and Prevention (CDC) to help prevent overexposure to UV rays:

  • Seek shade, especially during midday hours
  • Cover up with clothing to protect exposed skin
  • Wear a hat with a wide brim to shade the face, head, ears and neck
  • Wear sunglasses that wrap around and block as close to 100 percent of both UVA and UVB rays as possible
  • Put on sunscreen with broad spectrum (UVA and UVB) protection and sun protective factor (SPF) 15 or higher
  • Avoid tanning beds and sunlamps – the UV rays from them are as dangerous as the UV rays from the sun

You can also schedule a skin examination with your health care professional, including your Primary Care Physician (PCP), to catch early signs of cancer before they become a serious threat.

Getting annual physicals and tests from your doctor is key in sustaining your health and preventing disease. Having a PCP who can coordinate your care is vital to your good health. A PCP typically specializes in Family Medicine, Internal Medicine or General Practice.

If you don’t have a PCP, finding one is easy! Just visit your insurance carrier’s website, look for the “find a doctor” area and follow the instructions. Or, let Holy Cross Physician Partners help you.

Photo: courtesy of Sharecare.com

Lung Cancer Screenings $99

  • Posted Feb 22, 2017
  • hchadmin

The Michael and Dianne Bienes Comprehensive Cancer Center is offering a $99.00 Low Dose CT Lung Screening, which includes the radiologist's reading fee!

Where do we call to schedule?  954-202-0277

Who is eligible?  Self-pay patients 

Prescription required? Any M.D. can write a script for a Low Dose CT if the patient meets the criteria.

1.Why get screened?  Early Detection! Lung Cancer causes more deaths than any other cancer.  Of all causes of death, lung cancer ranks second behind heart disease.  The high number of deaths is due to in part to lung cancer being found after it has spread.  CANCER SCREENING can help find lung cancer at an early stage when it can be CURED.

2.Am I at risk for lung disease?  Risk factors include:

  • Tobacco Smoking          
  • Major contact with radon  
  • Contact with asbestos or other cancer-causing agents  
  • Having had certain other cancers
  • Parent, sibling or child with lung cancer•Having had other lung diseases
  • Contact with second-hand smoke

3.Should I start now? Start before cancer symptoms appear. The goal of lung cancer screening is to find lung cancer when treatments will work best.  Treatments usually work best before there are symptoms of cancer.  However, at this time, most lung cancer is found after symptoms appear.

4.Get the best screening test: Low-Dose Computed Tomography (Low-Dose CT).  It is the only screening test proven to reduce the number of deaths from lung cancer.  LDCT takes many pictures of the inside of your chest/lung from different angles using x-rays.  The amount of radiation used is much lower than standard doses of CT.


Vitamin D: the next vitamin superstar or just another passing fad?

  • Posted Feb 02, 2011
  • Charles D. Russo, MD, FACC

Before we can understand the excitement about vitamin D we need to know what it is and where it comes from. Vitamin D is one of the fat soluble vitamins that functions as a regulator and some nutritionists think more like a hormone or a pro hormone. A hormone directs functions in other tissues at distant sites by being released into the bloodstream. It orchestrates what cells do by binding to receptors on the membranes and even in the nucleus. It regulates blood calcium level with the help of other hormones and therefore is crucial in bone formation and health. It also aids in the normal functioning of insulin producing cells in the pancreas. Besides its now obvious role in helping aid in the prevention of diabetes, it may also have some role in multiple sclerosis. The data for this is mostly observational in that if people spend more than 10 years of their lives further away from the equator usually above 35° latitude (less yearly sun exposure) their risk for multiple sclerosis increases 100%. There may also be a role for vitamin D in psoriasis, schizophrenia, cancer prevention (i.e. colon) and in the prevention of atherosclerosis (the number one killer in the country). So with all of this on its plate, you can see why vitamin D has generated so much excitement in recent years.

Vitamin D is a family of many compounds. We can actually use cholesterol compounds in our skin to make vitamin D. This compound is called vitamin D3 (cholecalciferol). But the story does not end there. The activated vitamin D3 must now go to the liver and have a second process performed on it (D2-ergocalciferol) and then to the kidneys to have a third process performed on it before it is active vitamin D (calciferol-calcitriol). Obviously, anyone with significant liver or kidney disease may be at increased risk for vitamin D deficiencies. So what does vitamin D deficiency produce? In children a deficiency of vitamin D softens their bones and can cause rickets. In adults it causes osteoporosis and pathologic fractures.  Also, anyone taking antiseizure medicines for epilepsy destroys vitamin D more quickly.

The American Journal of Pediatrics said that 50% of African-American adolescents are vitamin D deficient.  Obesity also leads to vitamin D deficiencies. While it is a fat soluble vitamin, it is stored in fat tissue, but it is not released when it is needed. With two thirds of Americans being overweight or obese, you can see why this is our next biggest nutritional challenge. According to a recent analysis in Canada, 1.6% of the general female population is vitamin D deficient, and up to 76% of women have osteoporosis and pathologic fractures. It is also estimated that anywhere from 65 to 85% of nursing home residents are vitamin D deficient. Vitamin D is a fat-soluble vitamin and fat-soluble vitamins are more prone to possible toxicity from overdosing but that can only really happen with the fully activated form of vitamin D, which can only be obtained as a prescription. The over-the-counter vitamin D2 and D3 supplements can only be activated internally. There are feedback mechanisms in terms of your exposure to the sun as well as in the liver and kidneys which do not allow excessive vitamin D to be produced. What are our natural sources of vitamin D? Vitamin D2 is found in a very few plant-based foods with mushrooms being the best source. Most of our other plant-based sources of vitamin D are fortified milk and other dairy products as well as breakfast cereals and orange juice. Vitamin D3 can be found in animal sources such as oily fish particularly salmon and cod as well is in the yolks of eggs and butter. One needs to keep this in mind that when one changes to other sources of milk (such as soy, rice or almond milk), you should make sure that they are also fortified, if possible.

So what is the bottom line here? Should all of us be taking some form of vitamin D? If you have been reading my series of articles, you already know my opinion, which is that taking vitamin and mineral supplements without a deficiency state or a clear absence of a source in your diet is not helpful and may be harmful. Well, vitamin D can be measured in the blood and the current recommendation is that the level of 25OH-D should be greater than 32 ng/dl. There is also thought that levels between 20 to 32 ng/dl should be supplemented but that a level less than 20 ng/dl qualifies as a deficiency state. This vitamin is also more complicated in that there is some literature that say that the optimal level may be 80 ng/dl. What is currently recommended? In low-risk individuals under the age of 50, they should either have a dietary source of vitamin D from 400 to 1000 IU a day or take the balance as a supplement. Individuals who are at moderate risk and are over the age of 50, with or without osteoporosis, need 800 to 2000 IU a day and should have their vitamin D levels measured every 3 to 4 months until a normal level is obtained. High-risk individuals who have had recent fractures or osteoporosis may require at least 2000 IU a day, in some cases more, and should definitely have their vitamin D levels measured every three months until good levels are obtained. Visit the Jim Moran Heart and Vascular Blog for future posts from Dr. Charles Russo.

About Holy Cross Hospital

Holy Cross Hospital is a nonprofit, Catholic hospital in Fort Lauderdale, Florida, dedicated to innovative, high quality and compassionate care. For nearly six decades, Holy Cross has continuously expanded its services to provide leading-edge care for their patients in Florida and for those from elsewhere in the United States. Holy Cross also offers an International Services program to ensure that patients from outside the U.S. receive the care they need.

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