Those who talk about the health of the colon, talk first and foremost about the prevention of colon cancer, one of the most common cancers in Israel among men and women. And although it seems that this is fate, colon cancer can be prevented in high percentages. In Israel, there is a national screening program to detect bowel cancer among the population over the age of 50. The screening includes a fecal occult blood test once a year, and a colonoscopy for those with risk factors (family history, polyp in the past, inflammatory bowel disease) or those with a positive fecal occult blood test. In practice, the health insurance funds allow in many cases, even for those who do not have risk factors, to perform a colonoscopy which is considered a better test, which creates a considerable burden on the system.
So, what are we doing?
For the population without risk factors (no family history, smoking, obesity, diabetes) it is recommended to perform a occult blood test once a year, although it is a less accurate test, but if it is performed once a year its value is high and satisfactory. Therefore, for those who do not have risk factors, it is recommended to perform a latent blood test as a first line. On the other hand, for those who have risk factors - it is important that they perform a colonoscopy every ten years.
What are the risk factors for the disease?
The risk factors are divided into hereditary/familial, environmental, and medical factors - if there is a first-degree relative who has contracted bowel cancer or if there are two second-degree relatives who have, the recommendation is to perform an examination from age 40 every 5 years, although the age at which the family members contracted the disease is also important for determining the recommendations. For example, a relative who got sick at a young age (defined as under 50) confers more risk than a relative who got sick at an older age. It is important not to suppress a family history of cancer or significant polyps and go get recommendations for the right follow-up method for you.
A medical condition can also increase the risk - especially for those suffering from inflammatory bowel diseases such as Crohn's and colitis, a personal history of polyps or colon cancer.
Lifestyle and lifestyle can also increase the risk factors - this includes those who are overweight, smoke, consume large amounts of alcohol, and anyone who leads an unhealthy lifestyle that includes eating processed food, processed meat and red meat in large quantities. Also, the lack of physical activity and a sedentary lifestyle and a life with a lot of stress also contribute.
The real prevention of colon cancer
It includes the prevention of the morbidity of our age, the prevention begins with adherence to a healthy lifestyle, something that should be instilled in children starting with nutrition at the young ages and kindergarten. These measures, as mentioned, promote health and not only prevent bowel cancer but a host of other diseases related to the lifestyle prevalent today and include, in addition to various types of cancer, diabetes, obesity, heart disease and inflammatory diseases. Colon cancer develops over years. The time it takes for a polyp to develop into cancer is around ten years, therefore the recommendation to do a colonoscopy once every ten years for people without risk factors.
Several works were recently published in The New England Journal of Medicine describing advanced screening tests for bowel cancer from blood and stool samples based on advanced DNA sequencing technologies that show better efficiency than the occult blood tests that exist today. There is no doubt that in the age of advanced technologies and artificial intelligence, additional tools will soon appear Less invasive than colonoscopy which will allow us to make personalized recommendations for screening and prevention as well as to prioritize the colonoscopy tests in light of limited availability of the public systems.
What is proper nutrition?
The subject is complex and there are different versions, which are not always easy to apply in our busy lives. And of course the personal aspect is important - a diet that is right for one is not right for another. I like to stick to a simple sentence I once read in the New York Times - eat what your grandmother's grandmother would cook for you. This grandmother probably did not use processed food and most likely used fresh, local products and added a lot of love as well. If you try to maintain the principle of eating at home, rich in vegetables and unprocessed products, even if you occasionally sin, it's okay. It is recommended to add to the daily diet a boost of antioxidants such as astaxanthin.
What about genetics?
The State of Israel today makes available to the public an onco-genetic test (a genetic test that reveals genetic changes related to cancer) called the "Common Mutations Panel". This is a basic panel of mutations (defects in DNA) found to be common among the country's population, Jews and Arabs. The panel mainly includes common mutations in the 1-2BRCA genes which is mainly common in Ashkenazim but not only.
It is also possible to discover in the test mutations that cause the syndrome called "Linz", which is the most common hereditary syndrome that causes intestinal cancer (but also other large ones such as stomach, pancreas and endometrial).
There is an under diagnosis of this syndrome and other hereditary conditions that increase the risk of cancer and treatment with proper follow-up is certainly possible Contribute to the prevention of morbidity in those families.
Also, the genetic background can contribute to disease management and personalized treatment for those who have cancer. For example, in Lynch syndrome, advanced tumors will respond to immunotherapy treatments.
In families with a history of cancer cases at a young age or several family members who have had cancer, genetic counseling is required since sometimes more in-depth tests are needed to detect carriers. The discovery of a genetic finding in one of the family members will make it possible to test the other family members in a targeted manner and to adjust the optimal follow-up to prevent cancer.
There are quite a few people who come to us due to an accidental finding in an exome test, a genetic test that is done by those who want to get pregnant. They and others who come for genetic counseling are asked about their family history, up to the third generation, and receive recommendations for further follow-up. There are clinics in Israel called carrier clinics, located mainly in hospitals, where follow-up with the necessary tests and long-term accompaniment of the carriers as well as support is carried out.
It has been unequivocally proven that proper follow-up in carriers of various cancer syndromes lowers their chances of getting sick and dying from cancer.
Lynch syndrome, which, as mentioned, is the most common hereditary cause of bowel cancer, is an interesting syndrome that suffers, as mentioned, from significant under diagnosis in the population. In this syndrome, the genetic defect causes a problem in correcting errors in the genetic material during cell division. Because of this, the cells accumulate mutations (genetic changes) at an accelerated rate and the rate of development of a polyp into a tumor is faster than usual. Therefore, the recommendation is to perform a colonoscopy every two years, a gastroscopy every two years, as well as gynecological follow-up with experts in the field and follow-up of the urinary tract and more.
By the way, paradoxically, Linz carriers will develop tumors with a good prognosis (the prediction of the development of the disease) and this is because, due to the many errors in the genetic material, they have many "nonsense proteins" that activate the immune system, while normally, in cancer there is an evasion of the big ones from the immune system The vaccine in different mechanisms. This action causes the infiltration of inflammatory cells into the adults, which apparently cause a better course in them. Today, at the forefront of research, efforts are being made to develop a vaccine for Lynch syndrome. The Ministry of Health instructs to carry out a pathological examination of the large intestine for the syndrome to those who have already suffered from colon cancer in order to identify the cases.
Cancer as a chronic disease and a disease of young people
In our era, cancer is becoming a disease of younger people. Also, in light of early detection, advanced treatments and surgeries - more people are recovering from the disease. Young people who have had cancer and recovered will be able to live long lives and have children, and of course they will face difficult challenges. In addition, those in whom a genetic mutation was found (but not only those) will be troubled by the transmission of the genetic failure to the offspring.
In recent years, there has been evidence of an increase in the incidence of colon cancer in young people under the age of 50, which is the age at which prevention screening begins. Morbidity in young people is not always due to genetics, it is very possible that our lifestyle has a contribution. In the US, some of the professional organizations already recommend starting screening for bowel cancer at the age of 45. This recommendation does not yet exist in Israel, but there is definitely an increase in the awareness of the medical community about the symptoms even in young people and it is important that this is also the case on the part of the patients.
In severe hereditary syndromes such as familial polyposis, in which there are mutations in the APC gene, masses of polyps develop in the colon from the teenage years and sometimes surgery is required to remove the intestine at a young age. In these serious cases, for those interested, a procedure can be performed at our medical center called pre-implantation diagnosis: a process of artificial fertilization is performed and before the embryos are returned to the uterus, they are tested for the presence of the mutation so that only the healthy embryos are returned to the uterus. It is a problematic and expensive process that is approved by a dedicated committee. Additional options to prevent the transmission of identified genetic defects to the next generation include a placental cyst test, and of course an amniocentesis test, except where visible may already involve premature birth. There is no doubt that making decisions on the subject is difficult and complex and our medical center has teams in both the Gastroenterology Institute, the Genetic Institute and the Obstetrics, expert teams on the subject who will be happy to help.
The warning lights: the symptoms that raise the suspicion of the presence of an advanced polyp or tumor in the colon
Blood through the rectum, even if there are known hemorrhoids, should be examined by a gastroenterologist or proctologist to understand if an evaluation is necessary.
New unfamiliar abdominal pains, new changes in stools, significant weight loss, a decrease in iron stores or anemia - these are well-known "alarm signs" that require, as mentioned, medical consultation to decide on the course of action according to the patient's age, background and medical assessment.
Obviously, most people with abdominal pain or anemia will not have bowel cancer, but those who do should not be missed. Therefore, anyone who is at increased risk should have a colonoscopy, if not done recently. People with suspicious symptoms after medical advice from a specialist, people with family history, inflammatory bowel diseases and an unhealthy lifestyle. And since colonoscopy does not replace a healthy lifestyle, the recommendation is to adopt beneficial and enjoyable lifestyle and diet habits.
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