At the Forefront Live: IBD and Colorectal Cancer
April 23, 2019
Coming up on At the Forefront Live, there is a connection between inflammatory bowel disease and an increased risk of colorectal cancer. Now if you suffer from one of the forms of IBD, what do you need to know, and how can you protect yourself? We'll have our experts on to discuss this and answer your questions. That's happening now on At the Forefront Live.
And welcome to the program. Today, we're discussing IBD and colorectal cancer. We want to remind everyone that today's program is not designed to take the place of a visit with your physician, but our experts are taking your questions, so start typing. We'll get to as many as possible. Now joining us today is Dr. David Rubin and Dr. Atsushi Sakuraba. Welcome to the program.
Well, thank you very much for having us.
Well, let's just dive right into this, because I imagine we'll get quite a few questions. It's an interesting topic, and I think people are certainly curious. So let's just start kind of with the basics, if you will. Tell us what IBD is and maybe the differences between ulcerative colitis and Crohn's disease.
Sure. Inflammatory bowel disease refers to a series of inflammatory conditions that involve the intestines. They are generally grouped into what we call Crohn's disease and ulcerative colitis. Both of these are often diagnosed in young people, but can be diagnosed at any age, and are considered chronic, meaning they last a lifetime or nearly one. They have characteristic features based on their location in the intestinal tract, as well as the fact that inflammation of the intestines is what causes symptoms.
Crohn's disease classically may involve any portion of the GI tract, but the most common location is the last part of the small intestine and the first part of the large intestine. And ulcerative colitis, by definition, only involves the large intestine and always starts in the rectum, the last six inches, and can work its way up to involve more of the large intestine. Both problems can cause more symptoms when they're active, as well as go into periods of what we call remission, which is when they're under very good control, and that's one of the goals we have to managing them.
Although Crohn's and colitis are rising around the world for reasons we don't quite know yet, there's a lot of good research going on, but we've made great progress in treating these conditions. And although today we're not talking about treatments, one of the goals of treatment is preventing complications. And one of the complications that we think a lot about is the risk of having intestinal cancer. Thankfully, it's rare, but it's an important one that we're going to speak a little bit more about today. And it's relevant not only because it's important, but also because March is Colorectal Cancer Awareness Month, and this is during March that we have the opportunity to have this conversation.
Very interesting. I do have a follow-up question for you, though, Dr. Rubin. And you've told me this before. It's a very fascinating history that we have here at U Chicago Medicine with IBD, and you're one of the pioneers in that field. But there are a lot of folks that came before you too, and this is work that's been happening for decades.
Sure. Well, the University of Chicago has a very long history and a proud history in taking care of people who suffer from these conditions. We have evidence and lots of stories that our inflammatory bowel disease center of many different types of experts working together started all the way back in 1935, when one of my mentors, who lived to the age of 102, actually took care of a patient with ulcerative colitis. And when he saw how this disease affected her, he decided he would devote his life to these conditions. In fact, it was his research that later showed the link between cancer and ulcerative colitis.
That's fascinating. And again, I think this is one of the true advantages of an academic medical center and a research facility, which is what we have here for patients. It's a tremendous advantage.
Well, I work with some wonderful colleagues, and it's really a team approach.
Absolutely. Dr. Sakuraba, a question for you. Why are people with IBD at greater risk of developing colon cancer?
Sure. So the main reason is because there is a lot of inflammation going on in the intestine, and not only in inflammatory bowel disease, but we learn from chronic hepatitis cirrhosis that-- from all of the different inflammatory-- chronic inflammatory conditions that we've learned that the chronic inflammation after a long period of time may lead to dysplasia, and then dysplasia is pre-cancer, and precancerous lesions, and then eventually into cancer.
In the setting of inflammatory bowel disease, the inflamed colon is going to cause a lot of inflammative process. And then after a period of 10, 20, 30 years, the chronic inflammation starts to develop precancerous lesions, and eventually, colon cancer.
So this is something that's really important for folks that do suffer from IBD to be aware of and take the proper steps to make sure that they-- first of all, they see their physician on a regular basis, and they're aware of this, but take proper steps to protect themselves. Dr. Rubin, what are some of the risk factors that are associated with developing colon cancer?
I'm glad you brought that up, because often, people are very nervous about this problem, and they may not even have any risks specifically for it. So we want to be very clear with our audience what the risks are for pre-cancer or cancerous changes of the large intestine. The first thing is you have to have inflammation of your large intestine.
As I mentioned, people with Crohn's disease, that may only involve the small bowel in some patients, doesn't have any inflammation of the large intestine. Therefore, their risk of colon cancer is the same as the general population. It doesn't mean they have a decreased risk than the general population, but their risk is less than what we would see if they have an inflammation of their large intestine.
People with ulcerative colitis or Crohn's disease that involves the large intestine should know that the major risks are how long you've had the disease-- we don't even worry about this until you've had the disease for more than eight years or so-- how much of the bowel is involved. The more intestine that's involved, the more the risk maybe over time. A major risk factor and one that we're proud to have done some research contributing to is the amount of inflammation, as my colleague Dr. Sakuraba mentioned. If you live with active inflammation, and the disease isn't under good control, the risk goes up.
And then the other risk factors that are very important and get into a little more detail-- if you have a family history of colon cancer-- even if you don't have a family history of IBD, but if a family member had colon cancer, if you have inflammation of your liver, a condition called primary sclerosing cholangitis, or PSC, that's an important risk factor. Thankfully, that's not common, but when you have that, we have to take some extra precautions. Those are our major risks, and there's some other discussions and debates about what might be risks, but we focus on those in order to customize the approach to prevention.
And the important thing to know and to reassure everybody is that the risk of cancer in colitis, although it's very important, has been going down and is now almost like the general population because of our efforts to treat the disease and to prevent with the other strategies that we're going to talk about.
It is good news.
That's great. So how important is diet in all of this?
Sure. So diet may be responsible for some of the symptoms that patients have, such as if you eat a greasy diet, spicy diet, not only patients with inflammatory bowel disease, but also anyone, even a healthy patient may develop symptoms-- more loose stools. And so diet may be responsible for some of those symptoms, but it hasn't been proven to show that any diet can reduce or decrease any of the inflammation that's actually going-- that's actually been caused in the colon.
And it's a great question. We also don't have data that show that diet increases or decreases the risk of cancer related to colitis. So certainly, we recognize the very important aspect of diet and how we think about these conditions, but that doesn't change the risks that we're talking about today.
Interesting, interesting. We do have a question from one of our viewers. And this one is, are people with RA prone to colon cancer?
So this question's about rheumatoid arthritis, another chronic inflammatory condition that involves the joints. And it's a great question. In fact, there's nothing specific about the inflammation of the joints that increases the risk for colon cancer. It's similar to the general population that you should be getting screened at age 45 or age 50, unless you have a family history. You might start earlier.
There are some older data with rheumatoid arthritis that actually suggest they may have a decreased risk of colon cancer, and that's because one of the medications that used to be used extensively to treat joint inflammation were the aspirin-like medicines or the non-steroidal anti-inflammatory drugs, which can actually reduce the risk of polyp formation. But none of those medicines, even if you're taking them for your RA-- and hopefully you're not taking them for your IBD, which makes the colitis worse-- have been shown to change the need to have your colonoscopies or other screening approaches.
That was actually another question that I had on my list as far as aspirin is concerned, because some folks think that aspirin might help. And you mentioned it does have an impact on the polyps.
Well, it does in the non-colitis population. In the colitis population, we don't use aspirin to reduce risk of cancer or polyps. It doesn't change our general recommendations. And in fact, there's been some nice work done-- Dr. Sakuraba was part of it-- that shows that those who need aspirin for their hearts who have colitis can take it, and it's safe, but it doesn't reduce the risk or the need for screening and surveillance of the colon cancer risks.
Dr. Sakuraba, what are some of the steps that can be taken to reduce the risks of colorectal cancer?
So the main-- like I mentioned before, the main issue that drives the risk of colon cancer is the chronic inflammation. So I would make sure that your symptoms are well-controlled, and also make sure you get the surveillance screening colonoscopies starting at age-- starting at eight years after the diagnosis, if you have pan colitis, if your entire colon is inflamed, and generally starting at 10 years after diagnosis if you have a condition called left sided colitis, which is the inflammation is mainly in the left part of the colon. And make sure you stay on those surveillance screening procedures every one to two years, which will be recommended by your treating physician.
Yeah, so unlike people who don't have colitis, where they have the options of having their stool tested for blood, or if everyone's seen the commercials now on TV where you can have genetic testing of your stool or DNA testing of your stool, or even some of the radiological procedures like what we used to call virtual colonoscopy or CT scans of the colon-- those are all options that have been considered available to people who don't have colitis.
If you have colitis, unfortunately, we still recommend and you need a colonoscopy. And the reason for that is that sometimes the pre-cancer or even cancer in colitis doesn't grow as polyps that are easy to see or detect. And there is a lot of overlap in the inflammation and in the precancerous changes that can look like the same DNA changes we see in people with polyps or cancer.
So colonoscopy is what you need when you have these conditions. And fortunately, we've gotten really good at doing that effectively, and we think that's what's driving down a lot of the cancer risk now.
And that's a tool that has changed pretty dramatically over the past couple of decades as far as your ability to screen and see things, and it's gotten much better, correct?
Yeah, so Dr. Sakuraba, maybe you can describe some of the new techniques that we use.
Sure. So until now about 20 years ago, the colonoscopes, the cameras that we were using was called standard definition colonoscopes, which had the low definition to visualize the colon.
Like your tube TV.
I was going to say we've got some cameras here, and we've changed our technology, the old TV.
Like the old TV, the resolution is not so good, and they break a lot.
And about 10 years ago, that evolved into a technique called high definition colonoscopes, so you can more visualize small minute findings on the surface of the colon. And also, Dr. Rubin was one of the pioneers in chromoendoscopy, where you spray a light blue dye into the surface of the colon, and then that shows up the small bumps on the colon, which would then-- which would allow you to see much easier the small dysplasic, small precancerous lesions in the colon.
So Dr. Sakuraba, when you spray that light blue dye, do you do that as you're doing the colonoscopy?
Yes, as we withdraw the scope from the deeper parts of the colon, we spray small amounts of the blue dye into the-- onto the surface of the colon, and then we can see the small, minute--
Well, let me ask you this, Dr. Rubin, since you helped pioneer this, how did you come up with that idea? What was the--
I don't claim credit for coming up with the idea.
But the general principle is looking for precancerous changes. In people who don't have colitis, the precancerous changes are easy. You're looking for essentially little mushrooms or cherries growing on the wall of the colon. That's not so hard to find in most patients.
However, in colitis, as I mentioned, they can be flat. They can be harder to see. So if we get better at looking at the lining of the colon, if we have high definition scopes, better optics, better monitors, and we can actually see the changes that are very subtle, it's like getting closer to the moon and realizing that it's not full of water and seas, all these different areas, but they're actually valleys, it's the same. When you can get closer, you can find lesions that were much harder to detect. And being able to see more has enabled us to approach this very differently.
It used to be that, because we couldn't see very well with these older technologies, and we were worried about this risk, if you happened to find any precancerous changes with just random biopsies-- you literally would do random biopsies-- you would then feel concerned enough that you'd recommend surgery. And now because we can see so much better with these new techniques, we often can tell a patient we've removed the lesion. We found it. We can bring you back. You may not need surgery.
Now that's not always the case, but we definitely have changed the way we approach this. And we've gone even further than the dye now. We've been able to use some of the electronic filters, where you flip a switch while you're doing a scope, and the entire imaging changes, and that has also been shown to be effective for some patients. So it is a really new world. We just haven't eliminated the prep yet, unfortunately.
Yeah, that's-- people don't enjoy that, usually. So let's talk another viewer question. They'd like to know a little bit more about treatment for IBD, how it's evolved with the time, and how that actually can reduce the risk for colon cancer.
Sure. So the history of treatment in IBD starts with sulfasalazine and mesalamines, which were avail-- became available like 50 years ago, and then the steroids, prednisone, became available. Then about 20, 30 years ago, a drug called immunomodulators became available. But that dramatically changed 20 years ago when the first drug called-- first biologic drug called infliximab became available. Infliximab-- the trade name is Remicade-- became available 20 years ago. And with the power of those biologics, literally, at that time, we gained the strength, we gained the power of getting the-- achieving a condition called mucosal healing, where the entire linings of the colon actually turns back to normal.
There's really a change, a paradigm shift in how we think about managing these conditions. Previously, and somewhat embarrassingly, but it was the limit of what we could, we focused only on symptom management. And symptoms are very important. We want people to feel better, but we learned that if you didn't also control the inflammation, you could not change the natural history or the outcomes of these patients. And some of that work happened here and by many of our colleagues around the world who worked very hard to move us from more of a reactive way of managing IBD, where people would call us after they were already sick or failing a medicine or having a complication, to a much more proactive approach.
And we've learned now that we can actually push the bowel into healing and into remission. And we suspect that that's why the cancer rates have gone down, and the message for viewers is really to understand that of course you should be feeling well, but the new paradigm and the new goal for managing your IBD is to make sure that it's one step further-- your inflammation is under control. It's not always possible, but it is definitely a goal you should be talking to your team about.
That's great. And this is truly-- and one of the things you had written I was reading the other day, and it was interesting, because you mentioned the team effort that goes into this and how critical that is, because this isn't just one physician that does this. It's a group effort to make people feel better.
That's absolutely true. I often say it takes a village to take care of people who have inflammatory bowel disease, and that includes not only, of course, all of our wonderful colleagues who are gastroenterologists, our surgeons, our pathologists, our radiologists, our dietitians, our psychologists, our social workers, our nurse associates, our advanced practice providers, and I could go on, and I hope I'm not forgetting anybody important who's going to yell at me in 10 minutes. But I just want to make it clear that we have to work together.
And when we do that, on the patient's side, it also includes all their family members and their support team and their network. That's how we can do this most effectively. And I'm really proud to be part of a community of colleagues all over the world who are doing this and are advancing the way we do. We take care of our patients.
Please don't yell at Dr. Rubin, because we'd like him to come on the show--
They yell at me anyway.
--again in the future.
And we actually-- I think U Chicago Medicine even has support groups that meet on a regular basis for folks.
So we do have a monthly support group downtown, in our downtown office in the Streeterville location. And we do a variety of other educational programs for patients quarterly in different geographic areas around the city. We rotate them to the suburbs into Northwest Indiana, and we're very proud to do that kind of outreach, not just for our patients, but for everybody, just like this program. And I think that that's really important. We're happy to have people reach out, but also many of our colleagues in other places are doing that too. And we want to empower people with the knowledge to ask the right questions.
So you should know, is your large intestine inflamed? Is it in remission? Is it healed? And what are your specific risks for cancer prevention so that you can take control of this situation and not be surprised?
Dr. Sakuraba, inherited gene mutations is something that's in the news a lot. Does it play much of a factor, and if so, what do people need to know?
In inflammatory bowel disease, it probably doesn't play much of a factor. I think the uncontrolled chronic inflammation is the biggest risk factor, like Dr. Rubin has mentioned. If your entire colon is inflamed, the risk is higher compared to when part of the colon is inflamed. So, yeah, mm-hm.
Interesting. So how can you tell the difference between symptoms of an IBD flare up and symptoms of colon cancer?
Well, that's a great question, because whenever someone sees blood in their stool, if they go online, of course, one of the first things you might read is that it could be a polyp or a cancer growing in your large intestine. And when people have inflammation of the large intestine, one of the cardinal symptoms is bleeding. So how do you know the difference?
Well, if you already have IBD, and you see blood, it's almost never going to be a cancer. That's just not what we're expecting to see. But it, of course, represents that your bowel may not be under the right control. So distinguishing between these requires a thoughtful clinician or nurse working with you to help you distinguish which one it might be.
And of course, you've got to make sure that you're up to date on your colon cancer screening. That means making sure you're getting your scopes when you need them, and if there's any doubt at all-- maybe you've had disease longer than you realize, and you're worried that the timing is off-- certainly taking another look could be very helpful in that situation.
But I want to reassure people that cancer and colitis, thankfully, has become a rare problem, not because it's rare overall, but because what we do is actually making a difference. So you've got to work with your doctor and with your doctor's team to make sure you've got the right plan in place.
Perfect. Couple of questions from our viewers-- is microscopic colitis at a higher risk for colon cancer like UC?
So micro-- so the answer is no. So--
First of all, can you explain to us what microscopic colitis is?
Sure, mm-hm. So microscopic colitis is a condition where your colon actually looks normal, so visually, you don't see much inflammation. But patients will suffer from profuse diarrhea, and when we take biopsies, and when the pathologist takes a look under the microscope, they will find inflammation only under the microscope. So that is why it's called microscopic colitis. And it's more common in older people and in female patients, and also, some studies suggest that if you take a medication called proton pump inhibitors, the risk can go up.
It's a great question though, because microscopic colitis, in some textbooks, is on the spectrum of our inflammatory bowel diseases. But Crohn's and colitis are macroscopic inflammation, where you see ulcers, and you see inflammation. But one of our colleagues, Dr. Eugene Yen, has done some nice work to show that there's not an increased risk of polyps or cancer in that population.
And again, I want to emphasize that doesn't mean there's a decreased risk. You still have to remember that if you're out there in the general population without IBD, we have very specific recommendations across the American Cancer Society and all the GI societies, as well as the US Preventative Health Services Task Force for cancer prevention and colon cancer prevention. So make sure you're getting that taken care of, and know your family history.
Another question from a viewer-- what are virtual colonoscopies, and are they as effective as the traditional approach?
Well, I mentioned that earlier. It was actually one of the first research projects I did here as a resident with a radiologist who is internationally known in this area called-- named Abraham Dachman. Virtual colonoscopies-- the name was sexy, because it made people realize that they weren't going to have a scope put in their body, and that sounded nice.
But it still required a prep, so there was no virtual prep. The virtual colonoscopy was essentially a CT scan of the large intestine, and then a computer that would use the data from that scan to recreate the colon and to show it in special views so that the radiologist, a trained expert, could look for polyps that way. So now the term we actually use is CT colonography. This turns to the CT scan of the colon to do this. And it has become an option for some patients without colitis. It's not available to our colitis population.
So the advantages of that-- you say there's still a prep, so there's-- that's not an advantage, but the overall advantages?
Well, it's-- for somebody as a screening option, if you've had a difficult colonoscopy, and they couldn't finish, this is a nice way to make sure you get the rest of it looked at. If you have other reasons where you're at higher risk, and you can't tolerate sedation for a colonoscopy, it offers that as an option. And in some places, the resources of having people who can do your colonoscopy may not be available.
So this is another area where you should talk to your physician and pick the right option for you. Our general approach to cancer screening across the entire population is do something. Don't ignore it.
So Sakuraba, you mentioned earlier, if someone's been diagnosed with IBD, is it eight years then afterwards that you need to get your screening?
Yes, so it depends on how much of your colon was inflamed. So for pan colitis, when your colon was entirely inflamed, the recommendation is to start doing surveillance colonoscopy at eight years after diagnosis. When about half of your colon was inflamed, which we call left-sided colitis, then the recommendation is start-- is to start after 10 years of diagnosis.
Most patients don't know how much of their large intestine's involved.
So one of the questions to ask your doctor-- and I think every patient should know-- is, where is my Crohn's disease? Where is miles, my ulcerative colitis? How much of my large intestine is inflamed? So when Dr. Sakuraba refers to left-sided colitis, he means that it's half the colon or a third of the colon is inflamed as opposed to all of it. And you know, as we're talking about this, we don't even understand the fundamental reason that some people have their entire large intestine inflamed and some people just have a little bit. And we have a lot of research that we're doing to try and figure out these questions.
So after they start the screenings, then how often? Is that something that they do for the rest of their lives?
It's individualized. There are lots of different ways to think about it, but one of them is that if your bowel's in complete remission, and there's no precancerous changes, and you don't have other compounded risk factors, you might be able to go a couple years or even three years between exams. If you had a poor prep or you have other risk factors, or perhaps there was a precancerous finding, you're going to come back more often.
Great. So if IBD has been in remission for a long time, do people still need to get a colonoscopy every couple of years?
That's a wonderful and important question.
Yes, we do recommend that you do continue to have surveillance colonoscopies every one to two years, even when your colitis has been in remission.
Especially when you've been in remission, because one of the things we haven't yet been able to show is the longer you're in remission, does that decrease your risk over time? We're working hard to figure that out, but we haven't answered that question yet. And one of the tragedies we sometimes see is somebody who's been doing so well-- maybe they're even off their medicine-- but they've been walking around with a colon that was mildly inflamed or was inflamed earlier in their life, and they didn't think they need any follow-up. And then by the time they present, they already have a cancer.
So this is all about prevention. I always tell my patients when we're doing these colonoscopies that the reason we're doing all this is to prevent them from having cancer and to prevent them from having, God forbid, death from cancer. This is about looking for things early and doing something proactive, so don't let this sneak up on you.
So we only have a couple of minutes left in the show, and this has been wonderful information. Tell us-- just people that do suffer from colon cancer, colorectal cancer, what do-- I mean how do they-- can they live a normal life? What are some of the things that can be done for them to help them through the process and really kind of regaining that normal lifestyle?
So like Dr. Rubin has been emphasizing, if you catch the colon cancer at an earlier stage, it is treatable, sometimes even resectable by the colonoscopy. And even if it was not removable by the colonoscopy, certainly the surgeon can help remove part of your colon, or in the setting of ulcerative colitis, your entire colon needs to come out. But after that surgical procedure, you can certainly live a normal life.
It's important for people to know we've also made advances in surgical techniques, and we have a wonderful team here, but there are many other wonderful, outstanding colorectal surgeons who can help. And removing part of the colon, or even when you have to have the whole colon removed, the truth is that you should still have a completely healthy life. It does not affect your nutritional state. And it is something that, when it happens and when we need to do it, people live a very vigorous life. And often, they're very happy not to have to worry about more colonoscopies or worry about some of the medicines that they've been on for many years trying to control the disease otherwise.
So as Dr. Sakuraba emphasized, when we look and we find cancer in its early stages, those are curable lesions. So that's all what this is about. That's the whole point of colon cancer prevention is we've understood what the risks are. We have an intervention that works, and we want to keep people healthy.
Wonderful information. We appreciate you gentlemen being part of this.
Well, thanks for the opportunity. This has been really great.
Yeah, we'll definitely do this again. Thank you. Hopefully, nobody yells at you after this.
That's all the time we have for the program. If you want more information about IBD and colorectal cancer, please visit our website site at uchicagomedicine.org, or you can call 888-824-0200 to schedule an appointment. Now join us for our next At the Forefront Live. That's next Thursday, April 4th, at noon, and then we're going to have a discussion on pelvic health. Also, make sure you check in on our Facebook page often to see the very latest in health care news and healthy living tips. Thanks again for watching. Hope you have a great week.
People with inflammatory bowel disease have a greater risk for developing colon cancer. David T. Rubin, MD, and Atsushi Sakuraba, MD, PhD, answer questions about IBD-associated colorectal cancer as well as what can be done to decrease this risk.
Why are people with IBD at greater risk of developing colon cancer?
The main reason is due to the inflammation in the intestine. The chronic inflammation in the colon starts to develop precancerous lesions, and eventually, colon cancer.
Do people with Crohn's disease have the same risk of colon cancer as people with ulcerative colitis?
The risk is related to inflammation of your large intestine. People with Crohn's disease may only have inflammation in the small bowel. Therefore, their risk of colon cancer is the same as the general population. It doesn't mean they have a decreased risk, but their risk is less than what we would see if they have inflammation of their large intestine.
People with ulcerative colitis or Crohn's disease that involves the large intestine should know that the major risks are how long you've had the disease and how much of the bowel is involved. The more intestine that's involved, the more the risk is over time. If you live with active inflammation, and the disease isn't under good control, your risk goes up.
What are other risk factors?
Other risk factors that are very important include a family history of colon cancer — even if you don't have a family history of IBD — or if you have inflammation of your liver due to a condition called primary sclerosing cholangitis (PSC).
The important thing to know is that the risk of cancer in colitis, although it's very important, has been going down and is now almost like the general population because of our efforts to prevent and treat the disease.