“I’m a very lucky person”
“I started having some stomach and bowel issues a few years ago and thought I had become lactose intolerant,” relates Sandra Hand of Indio. “I finally decided I was just too young to be having problems like this, and my boss recommended that I go see Dr. Tornay [Board Certified Gastroenterologist Anthony Tornay, MD].”
Hand was 51 at the time, a year past the age when most people should have their first screening colonoscopy.
“So I went to see him, and he recommended that I have a colonoscopy in order to see what was going on,” she continues. “My boss had just had one and told me that it was nothing and that I shouldn't be nervous.
“So I went and had it done, and I didn’t remember anything until I woke up afterward and heard someone telling me I was really lucky,” Hand says. “Then Dr. Tornay was there with a paper in his hand, and he jokingly tapped me with it and said, ‘You are really lucky.’”
Dr. Tornay had discovered a large polyp — 4.2 centimeters, or nearly two-and-a-half inches in diameter — in Hand’s colon. Because of its flat shape, he couldn’t “snare” and remove it using the colonoscope. And while a tissue sample revealed that the polyp was benign, Dr. Tornay said it still needed to come out. He referred her to Board Certified Colorectal Surgeon Scott Gering, MD.
Hand met with Dr. Gering and her surgery was scheduled for late August. He was able to perform a transanal microsurgical endoscopic resection using the da Vinci Xi® robotic surgical system.
A minimally invasive approach to surgery
“TAMIS — transanal minimally invasive surgery — enables us to go in through the rectal opening and scoop off the polyp or lesion on the lining of the colon or rectum without an abdominal incision,” Dr. Gering explains, noting that it’s a good option for treating early-stage or precancerous colorectal tumors. “We used to perform TAMIS laparoscopically, but there were technical constraints because you’d have to operate in a straight line.
“With the robotic platform, however, we have advanced instruments that are wristed — like the human hand — so we can maneuver them in tight spaces,” he continues. “This capability greatly enhances our ability to operate minimally invasively.” Hand’s procedure was performed on an outpatient basis — she went into Eisenhower Medical Center at 5:15 a.m., and was discharged at 11:30 a.m. She stayed home from work for seven days and took it easy for several weeks after that, avoiding stairs and any heavy lifting.
At her first postoperative visit with Dr. Gering, Hand was again reminded how lucky she had been.
“He told me that my polyp wasn’t cancerous, but it had a high level of dysplasia, which means it was precancerous,” she relates. “Had it stayed in, we’d be talking about cancer treatment instead of the preventive procedure I had.
“I also shared with him how I’d been having bowel problems, and they weren’t there anymore since I’d had the surgery,” she continues. “He agreed that the polyp had been causing the issues. I wasn’t lactose intolerant after all.” From now on, Hand will undergo periodic surveillance colonoscopies.
Moving from screening to surveillance
“When we find someone who ‘makes’ polyps, the person moves from the screening group into the surveillance group,” Dr. Gering explains. “The frequency depends on what the endoscopist finds. If you make polyps with malignant potential, you might need to have a colonoscopy every year or, if they’re not precancerous, every five years.
“Our goal is to prevent cancer from happening, and when you take out the precancerous polyps, you don’t get cancer,” he emphasizes. “It’s as simple as that.”
“If everyone understood how preventable colorectal cancer is, maybe more people would have colonoscopies done,” Hand says. “I am shouting it from the rooftops, telling everyone I know to have their screening colonoscopy.
“We also need to be really observant of our bodies,” she continues. “Sometimes things happen that tell us there’s a problem. We’re all different, but if something is going on that’s not normal for you, listen to it. Don’t assume it’s nothing and put off seeing the doctor. I thought I had lactose intolerance and, come to find out, I didn’t.
“My symptoms started when I was around 40, so had I gone then, this probably would have been detected earlier, since Dr. Tornay told me this type of polyp is very slow-growing,” she adds. Hand also urges people not to avoid seeing the doctor because of the cost involved.
“Figure it out,” she says. “They’ll work with you; you can make payments, negotiate. The most important thing is your life. If you wait too long, you may not have a choice about treatment. The decision may be made for you.
“I’m a very lucky person that I came in when I did,” she adds.
What can happen when you don’t follow up
Wayne Hooper’s experience illustrates what can happen when someone doesn’t heed the doctor’s advice about surveillance colonoscopies after polyps are discovered.
Hooper, who turned 66 in November 2017, is president of the publishing company that produces Healthy Living magazine. He had undergone a screening colonoscopy seven years ago. At that time, the endoscopist found a single polyp in his colon. It was removed and, because the pathology showed it to be benign (noncancerous), Hooper was instructed to return for a surveillance colonoscopy in five years.
“When the five-year mark rolled around, I didn’t have health insurance,” Hooper says. “Then, when I did get insurance, I was concerned that if they found anything, it would be expensive to deal with.
“So, I decided to wait until I was on Medicare,” he adds. “I wasn’t having any gastrointestinal symptoms, so I didn’t think waiting would be a problem.”
In the meantime, however, he began experiencing a worsening of symptoms related to a condition called restless leg syndrome (RLS), which is characterized by an uncontrollable urge to move the legs, typically at night.
“It was getting out of control,” Hooper relates. “I couldn’t sit for any length of time. I had terrible insomnia and was sleeping erratically. I lost interest in working out and had no energy. I didn’t want to travel anymore because I couldn’t sit still on planes. We couldn’t have guests stay over since I had to sleep in the guest room.
“I was working with my primary care physician, trying to treat my symptoms with various medications like the sleep drug Ambien®,” he continues, “but that would make me sleepwalk. I was having a hell of a time, and no one but my partner and close friends knew the misery I was in. I was at the end of my rope.”
At the same time, Hooper’s hemoglobin (red blood cell count) level began to drop, a potential indicator of anemia, which also was contributing to his fatigue.
In the midst of this health situation — and now covered by Medicare — Hooper finally scheduled his two-years-late follow-up colonoscopy in July 2017, at the urging of his primary care physician.
“We found a mass”
“We found a mass at the hepatic flexure that turned out to be stage 3 adenocarcinoma of the colon, the most common type of colon cancer,” says Christopher Flannery, MD, Board Certified in Internal Medicine, Fellowship Trained and Board Certified in Gastroenterology, who performed the procedure. The hepatic flexure is the right-angle bend in the colon on the right side of the body near the liver. “The next step was for him to see a surgeon and an oncologist.”
Hooper was referred to Scott Gering, MD, and underwent surgery in September.
“We did a robotic laparoscopic right colectomy,” Dr. Gering says, referring to a procedure in which about a foot of Hooper’s right colon was removed.
“The robotic platform has allowed us to do this operation in a less traumatic, more precise manner,” he continues. “It gives us better tools and high-definition visualization, which translates into more precision and accuracy, less trauma and fewer postoperative complications.”
In addition, he can use one of the specialized robotic tools to inject fluorescent dye to check the blood supply between the pieces that are sewn back together. “This new technology was introduced in just the past few years, and it gives us another level of safety and security that ensures good healing,” he notes.
Surgery, possibly chemotherapy
Dr. Gering also removed 16 of Hooper’s lymph nodes to determine if the cancer had spread beyond the tumor in his colon. One of the nodes tested positive.
“The mainstay of treatment is taking the tumor out with clean margins, and we achieved that,” Dr. Gering explains. “By removing the lymph nodes, we also cleared the basin that drains that section of the colon, so Mr. Hooper is hopefully clear of cancer.
“The question is, have any cancer cells escaped into the blood stream and gone elsewhere — like the liver, lungs or bone?” he continues. “We don’t have a tool today that’s precise enough to pick up one or two cells, so we have to wait and see if it shows up.” Chemotherapy to kill what Dr. Gering characterizes as “a couple of rogue cancer cells that might be out there” is a possible adjuvant treatment (“adjuvant” refers to therapy that’s applied after initial treatment for cancer, especially to suppress secondary tumor formation). At this writing, Hooper is scheduled to meet with an oncologist to discuss his options.
Hooper spent four nights in the hospital after surgery, and says his recovery since then has been “really good.” In fact, the troubling symptoms he was experiencing — insomnia, extreme RLS, fatigue — have subsided.
“It all ended when the tumor came out,” he relates. “My hemoglobin count had been dropping because the tumor was bleeding. I still have RLS, but it’s much milder and controlled with medication. Now I can get out and do things, like go to the movies or dinner, without my legs twitching.
What has he learned from this experience?
“Don’t miss your follow-up colonoscopy!” he replies. “I had no way of knowing what was going on; I’d noticed during my workout routine at the gym that I just couldn’t do things, and I wrote it off to getting older. You have to trust your instincts if you’re not performing as well as you think you should; ask questions.
“So many times, we treat symptoms but not the underlying cause,” he continues. “It’s important to find out what’s causing a problem. My RLS was way out of hand, making my life miserable, and that was a red flag that something else was going on.
“My outlook on life today is way better, even with my diagnosis,” he adds. “In fact, I’m thrilled that they diagnosed it and got right to work on treating it. I’m so impressed with the care I’ve received.”
“I almost didn’t go for another colonoscopy”
Gertrude Thomas takes good care of herself. The 81-year-old Palm Springs resident goes to the gym three days a week where she works out from 7:30 a.m. until her yoga class starts at 9 a.m. She also dances about three times a week — West Coast swing, ballroom and a little Argentine tango. And she does laps in the pool in the summer.
But last March, she considered foregoing a follow-up colonoscopy.
“I’d had my last colonoscopy in 2008 and they discovered two small polyps,” she relates. “I was due for a follow-up, but a friend in yoga who’s near my age said she wasn’t doing them anymore, and I thought maybe I wouldn’t either. But at the last minute, I decided I’d do one more.”
It was a good decision.
A rare tumor is discovered
“When we performed Mrs. Thomas’ surveillance colonoscopy, we discovered what we thought was another polyp, about a centimeter in size, so we removed it with what’s called a snare polypectomy,” explains Christopher Flannery, MD. “But when the pathology came back, it showed this was a leiomyosarcoma, a very rare smoothmuscle tumor that occurs in the colon and rectum.
“Since the leiomyosarcoma extended into the edges of the specimen we removed, we wanted to make sure we got all the cancer cells,” Dr. Flannery continues, “so we scheduled another procedure to perform an endoscopic mucosal resection [EMR].”
EMR is a minimally invasive technique used to remove cancerous or other abnormal lesions found in the digestive tract. Depending on the type of tumor, its location and stage, gastroenterologists can perform EMR and avoid a more invasive surgical procedure with an abdominal incision.
“Fortunately, the pathology came back negative, which means we got all the cancer the first time,” Dr. Flannery says. “What’s more, the margins were so clean that Mrs. Thomas didn’t even have to undergo adjuvant chemotherapy.”
This was excellent news, especially for an older person for whom chemotherapy could have been difficult.
“When I first heard the word ‘cancer,’ I was in shock,” Thomas says. “I had been feeling fine; I didn’t have any symptoms. Thankfully, they caught it at the beginning stages.
“Get a colonoscopy when you’re supposed to”
“And now I’m telling everyone I know to get a colonoscopy when you’re supposed to,” she says. “I’ve talked my neighbor and my son into getting one, and people from my yoga class. You just never know, and it’s definitely better to be safe than sorry.”
Dr. Flannery emphasizes that colon cancer screening — with colonoscopy being the gold standard test — doesn’t automatically stop at age 75, which many people, including doctors, believe.
“We recommend that everyone be screened starting at age 50, earlier if there are risk factors such as a family history of colon cancer, and continue until age 75,” he explains. “Between the ages of 76 and 85, the decision to screen is an individual one. Typically, at about age 75, if you’ve never had polyps, screening tends to stop.
“But today, especially here in the valley, we see very healthy people, like Mrs. Thomas, living well into their seventies, eighties and nineties,” Dr. Flannery continues. “So we continue to screen, and to schedule surveillance colonoscopies when appropriate.”
“It’s time for a paradigm shift”
“All these cases underscore how imperative regular screening is, as is surveillance if you’ve ever had polyps,” Dr. Gering says. “It’s time for a paradigm shift — to start calling colon polyps precancerous growths so people don’t get a false sense of security that they have a ‘benign’ polyp. While the term ‘benign’ may be correct, the fact is that, if left unchecked, that polyp can develop into a malignancy.”
“Once we find polyps, we need to educate folks that ‘you’re a polypmaker, so you need surveillance now,’” he stresses. “That’s very different from screening every ten years. Surveillance needs to happen every one to five years, depending on the individual patient.
“I can’t say this enough: colon cancer can be prevented, and appropriate screening and surveillance are the way to make it happen,” he adds. “If it’s time for your colonoscopy, either an initial screening procedure or a follow-up surveillance exam, talk to your doctor today about scheduling it.”
For more details on advances in the colonoscopy “prep” (often the number one reason people avoid having a colonoscopy), see sidebar on page 64. To find a physician at an Eisenhower Gastroenterology Specialty Clinic, visit EisenhowerHealth.org/GI.
“Colon cancer is one of those diseases that’s unique because we can almost 100 percent prevent it,” says Board certified colorectal Surgeon Scott Gering, MD. “With appropriate colonoscopy screening and follow-up surveillance if polyps are found, we could prevent 150,000 new cases of colon cancer each year and 50,000 deaths. those are incredible numbers.”
So why aren’t more people getting screened?
“The biggest excuse i hear is that they don’t like the prep,” Dr. Gering says, referring to the bowel cleansing that’s crucial to a successful colonoscopy exam. “But there have been some advances that make it more tolerable.”
One of these is a split-dose approach in which the recommended amount of bowel cleansing liquid (usually one of two packets dissolved in water) is taken the night before the exam, followed by eight glasses of water, and the remainder in the morning before the test.
Research has shown that the split-dose prep not only is more tolerable than a single dose (decreasing the intensity and duration of bowel movements), but it also does a better job of cleaning the colon — which leads to better results. one study, in fact, found that doctors detected more polyps (adenomas) in people who prepped with the split dose than those who prepped with the single dose.
Conversely, poor colonoscopy preparation can impede the examiner’s ability to detect polyps, tumors or other issues. it can also cause the exam to take longer and increase the risk of complications. in some cases, a colonoscopy must be repeated.
“Some newer preps have smaller volumes of liquid which also make it more tolerable,” Dr. Gering says, noting that he “speaks from experience.” not all of these newer preparations are currently covered by insurance, however, but if a patient is willing to pay out of pocket, they can be worth it, he adds.
“There’s also a test called cologuard® that looks for genetic material in a stool sample,” he says. “You collect a small sample in the privacy of your home, send it in for analysis, and the results are sent to your doctor. if something is found, you still have to undergo a colonoscopy.
“And we still recommend that your first screening be a colonoscopy to determine if you’re a polyp-maker,” he continues. “if you’re not, cologuard is a good option for subsequent screening, and it’s Medicare-approved for every five years.” Patients and physicians alike agree that the inconvenience of the prep is minor when compared to a diagnosis of colon cancer. And finding precancerous polyps is the first step toward preventing that diagnosis.
“That’s why we really need to educate patients that ‘benign’ polyps are still potentially premalignant lesions,” Dr. Gering says. “if we find them, you go from regular screening to regular surveillance. And that means regular colonoscopies.”