Dr. Kokenes is from Charlotte NC and practices at Charlotte Gastroenterology. He is a graduate of Duke University ’83 BS and UNC Chapel Hill ’87 MD. He did his internal medicine training at Boston University and gastroenterology fellowship at Emory University. He is a past board member of Hospice and Palliative Care Charlotte Region and past President of the NC Society of Gastroenterology. He is the UNC Chapel Hill School of Medicine Course Director for gastroenterology at the Novant Campus in Charlotte, NC
Colorectal Cancer (CRC)
I appreciate the opportunity from The After Care to explore the experiences of Colorectal Cancer (CRC) survivors. My work as a gastroenterologist typically focuses on diagnosing CRC and then referring patients to oncologists, surgeons, and back to their primary care providers. I do get to see them for the surveillance colonoscopies which is usually a joyous experience since it means they are through the shock of the diagnosis and the surgical and oncologic treatment. They can finally focus on a future without CRC.
Let’s begin with the good news! The incidence of CRC is declining thanks to robust population colon cancer screening (CCS) especially since the Affordable Care Act of 2010 which made CCS a mandated benefit of health insurance. Also, with earlier detection and improved therapies, two-thirds of CRC survivors are living well beyond 5 years after diagnosis. I will outline some basic strategies to anticipate potential short- and long-term issues related to CRC aftercare.
Before we review recognizing the symptoms of a recurrence it is important to be aware of the most current guidelines for CRC surveillance. Catching problems before symptoms develop is the real goal!
American Cancer Society CRC Survivorship Care Guidelines
1-2 Years post treatment:
History and Physical exam (H & P) every 3-6 months
Carcinoembryonic Antigen (CEA) every 3-6 months if a candidate for further intervention
CT scan of the chest/abdomen/pelvis every 12 months (Stages I-II if high risk and all Stage III)
Colonoscopy in 1 year; if advanced adenoma found, repeat in 1 year, otherwise in 3 years
3-5 Years post treatment:
H & P every 6 months
CEA every 6 months if a candidate for further intervention
CT scan of the chest/abdomen/pelvis every 12 months (Stages I-II if high risk and all Stage III)
Colonoscopy in year 4; if no advanced adenoma found, repeat every 5 years
> 5 Years post treatment:
CEA not recommended.
CT scan of the chest/abdomen/pelvis not recommended.
Colonoscopy every 5 years starting 9 years after resection if no advanced adenomas found.
Book a FREE call with a survivorship mentor to talk about your experience with colorectal cancer
Listening to Your Body and Knowing Your Poop
Surviving cancer gives one the opportunity to reevaluate their overall health and make important adjustments in behavior and lifestyle. To be able to identify potentially alarming GI symptoms one must first establish excellent bowel health and then from as healthy as possible a baseline it will be easier to recognize important deviations.
We only use unleaded gasoline in our cars, and we never give our pets food that we know can harm them. However, we are commonly ingesting foods with high concentrations of sugars and fats that are often overly processed and in greater than appropriate portions. Food is fuel. In essence, we take better care of our cars and pets than we do of our own bodies. As a result, many of us live with gas-bloat, abdominal cramps and discomfort, diarrhea and constipation which can lead to pathological hemorrhoids and bleeding. How can we identify pathologic symptoms of possible cancer recurrence when this is our norm?
Nutritionists are largely in agreement that the Mediterranean Diet is the overall healthiest diet. In a nutshell this means daily fruits, vegetables, grains, and lean protein in proper quantities. A healthy colon is populated with a wide variety of bacteria known as the colonic biome. A diet rich in fiber is the best first step to having soft, easy to pass, regular bowel movements. When achieved, it is easier to identify changes that should be investigated between the scheduled exams, x rays, and labs listed above.
It is important to note that there is no evidence-based research that indicates that a healthy diet will reduce one’s chances of recurrence. Furthermore, almost half of CRC survivors have some degree of chronic diarrhea independent of how well they eat because of post-surgical changes, chemotherapy side effects, and in cases of rectal cancer, chronic radiation injuries. Working with a gastroenterologist and nutritionist can help to optimize one’s quality of life and improve these symptoms so that the best possible baseline of digestive health can be achieved.
Colorectal Cancer Symptoms to Look For
Early-stage recurrence:
A change in bowel habits, such as more frequent diarrhea or constipation
Blood in stool
Abdominal pain or discomfort such as cramps, gas or bloating
The sensation of incomplete bowel movements
Late-stage recurrence:
Weakness, fatigue, shortness of breath, and dyspnea on exertion
Unintentional weight loss
Any of the above symptoms should warrant checking in with your physician for proper evaluation. This will allow for the earliest possible detection since even strict adherence to the CRC survivorship guidelines can miss things.
Genetics and Colorectal Cancer
Another way to enhance survival after CRC and any cancer is not just to listen to your body but to know your body all the way down to your DNA. Let me be clear, everyone with cancer does not need genetic testing. However, it can be critically important in many cases. Consider sharing your diagnosis with your family and creating a detailed family tree of other relatives with cancer. The more you know the more accurate genetic testing can be. Review this information with your physician and decide if you should see a genetic counselor. It is estimated that 20% of patients with CRC who are less than 50 years old have an inherited genetic defect that predisposes them to the disease. Knowledge of one’s genetics can modify the screening strategies for other malignancies and help guide the medical care of other relatives potentially at risk and otherwise unaware and asymptomatic.
We have come a long way in the understanding, early detection, and treatment of CRC. We need to stay vigilant even years after successful treatment and follow the survivorship care guidelines, take excellent care of ourselves, know our bodies and our poop, and alert our physicians when there has been an unexpected change. Only when we work together will have the best long-term outcomes.