Clinical Considerations to Reduce Risk of Colon Cancer

Clinical Considerations to Reduce Risk of Colon Cancer

An interview with Editor-in-Chief Tina Kaczor, ND, FABNO

Colon cancer is one of the most preventable cancers, and yet it is the third leading cause of cancer deaths after lung cancer, and prostate for men and breast cancer for women. Natural Medicine Journal’s publisher, Karolyn Gazella, recently sat down with our editor-in-chief, Tina Kaczor, ND, FABNO, to discuss how clinicians can help patients reduce their risk of developing colon cancer. Kaczor has been working in oncology for 2 decades and is a Fellow of the American Board of Naturopathic Oncology.

This was an excerpt of our conversation. You can listen to our whole discussion here, on iTunes, or wherever you listen to our podcast.

Question: Colon cancer is considered a preventable cancer, and yet it’s still a leading cause of cancer death. Why is that?

Answer: Many of the risk factors for colon cancer are a product of our modern lifestyles—lifestyle habits, what we’re eating, how we’re sleeping, and our stress levels. Colon cancer rates are higher in Westernized societies in general.

How and when it’s diagnosed has a lot to do with why it’s a leading cause of cancer death. Ultimately, it’s not just the prevalence and the incidence of colorectal cancer, but at what stage it’s diagnosed. The higher the stage that it is found at, the more likely it will be to result in death.

Question: That brings us to an important topic, which is screening. Can you take us through the types of screening tests and recommendations?

Answer: Screening for colorectal cancer, just like any cancer, is really governed by the country. So what we do here in the United States is not the same in other countries. But the US Preventative Services Task Force recommendations include stool tests, endoscopy, and imaging.

There are three types of stool tests:

• Guaiac-based fecal occult blood test that’s sometimes done in office or at-home. It is looking for blood in the stool.

• The fecal immunochemical test (FIT) test is similar to the guaiac test, it just uses antibodies to detect blood in the stool. What I like about this test is that vitamin C doesn’t interfere with the results as it can with the guaiac-based test.

• The FIT test combined with a DNA test looks for blood as well as abnormal DNA, so it’s a more sensitive test. This one requires an entire bowel movement to be collected and sent out to a lab, so it’s more involved. But it does offer a little bit more specificity since blood in the stool can be from so many causes besides colorectal cancer.

Endoscopy includes flexible sigmoidoscopy, which looks at the rectum and the descending colon but not the transverse or ascending colon. That’s usually done every 5 years, unless it’s done with those stool tests for blood, in which case it can be done every 10 years.

The other type of endoscopy is colonoscopy, which scopes the entirety of the colon. It’s an intervention of sorts, because it will remove polyps, it’ll remove suspicious lesions, and it will biopsy suspicious areas.

There is one imaging that is approved and it’s a virtual colonoscopy. Sounds great, no invasion, but it involves the same prep as a colonoscopy. Then they insufflate, which is a fancy word of saying they pump air into your whole colon, which can be uncomfortable. After that they put you through a CT scanner, so there’s a mild amount of radiation involved. If they see a polyp or anything suspicious, they still have to go back and do a colonoscopy with a real scope to get a sample.

The other reason I’m not a huge fan of virtual colonoscopies is that they can miss one of the most likely polyps to become cancer, and that’s the sessile polyps.

The recommendation for which type of colonoscopy to get has to do with patient preference, other medical conditions they may have, and risks and benefits to each of these.

Question: When should people be tested? Answer: Someone with low to average risk should start testing at age 50 according to the Centers for Disease Control and Prevention (CDC). The American Cancer Society says to start at 45 years old, and that screening should also be done in people with low to average risk—those without any family history or people with symptoms. Both agree screening should end at 75 years old because of increased risk of perforation— which is still low, even in older adults. I find that interesting because your risk of colorectal cancer does not suddenly go down at that age. It actually keeps going up well into your late 70s and your 80s. For example, someone over 80 years old is at 10 times the risk of someone in their 50s. We can say with some level of confidence that regular coffee consumption reduces the incident risk of colorectal cancer between 26% to 50%. “ ”

So I don’t think we should stop thinking about colorectal cancer in our elderly patients. I do think we might want to turn to something less invasive like Cologuard, which is a stool test that can be done at home. It’s by no means as thorough or accurate as a colonoscopy, but it does find 94% of early-stage colorectal cancers. There is certainly a false negative rate and a false positive rate. So it has some drawbacks.

Question: Which risk factors do you feel clinicians may not be paying enough attention to in their practice?

Answer: The well-known risk factors are processed meat consumption, abdominal fat, body fat in general, smoking, height with taller people having higher risk, and age. Then there are lesser-known risk factors. One is occupation—sitting still for long periods of time is a risk factor, so if someone has a job that keeps them at a desk all day, that should be taken into account.

Hyperglycemia is also associated with colorectal cancer.

And then there’s dysbiosis, which has to do with the microbes in the gut. There should be a predominance of beneficial bacteria in the gut. There’ll always be a little bit of candida, just like there’s a little bit of dandelion in someone’s lawn. It’s not consequential unless there’s a lot of the bad or pathogenic organisms. But more and more we’re seeing that what inhabits the gut as far as organisms, and in particular bacteria, is associated with colorectal cancer. So if someone has gas, bloating, diarrhea, IBS, and other GI issues, those should be taken into consideration, since these symptoms can signal dysbiosis.

Question: What role does family history play in increasing one’s risk?

Answer: When someone has a family history, they may want to get screened at an earlier age. If you have a first-degree relative (parent, child, or full sibling) with colorectal cancer or advanced adenomas diagnosed before 60 years of age, or 2 first-degree relatives at any age, you have a a 3- to 4-fold increased risk of colorectal cancer and should be screened much earlier. A guideline is to get screened when you’re 10 years younger than the earliest diagnosis of a first-degree family member. If they were diagnosed at 60 years of age or older, then colonoscopy screenings should start at 40 instead of 50.

Question: What should clinicians tell their patients about diet?

Answer: Generally, I think the advice should be around creating the proper flora in the gut. People hear that and they think probiotics. But prebiotics are just as valuable if not more so. Prebiotic food—soluble fibers, legumes, fruits, veggies, and polyphenols found in colorful foods—leads to a diversity in the gut. And we want the most diverse array of good organisms we can possibly have.

I’m a fan of probiotics at times, but there are some times where a probiotic can actually lessen the diversity in the gut, which is the antithesis of what we want. It depends on the probiotic itself. So from a generic level I say, diversity of the gut. From a drill-down and specific level, things like a small amount of nuts on a daily basis is really important for gut health and has been associated with less colorectal cancer. Greens in general are important. Cruciferous vegetables, like kale, broccoli and cabbages are also key.

And it has to do with not just gut health and the microbiota, it has to do with getting rid of carcinogens as you take them in. Because whether we’re breathing them in or we’re eating them or they’re going through our skin, we are exposed to things that we need to break down. Those crucifers help us do that. And maybe some green tea, which has been associated with less colorectal cancer risk. And of course I should say very specifically legumes. Beans have been associated with less colorectal cancer risk, and I have some concern about long-term diets that omit legumes.

Question: What does the research tell us about coffee?

Answer: Thankfully as a coffee lover, I’m happy to report that coffee consumption is associated with lower rates of colorectal cancer incidence. We can say with some level of confidence that regular coffee consumption reduces the incident risk of colorectal cancer between 26% to 50%, depending on how much you drink. There’s a dose-response relationship, meaning the more you drink, the more you reduce your risk. I will put a caveat to that of course, and that is, at some point coffee’s not good for your other systems, so you do want to drink it in moderation.

Question: From a lifestyle standpoint, what are the top-3 things clinicians should focus on when talking to their patients?

Answer: I would say body composition, exercise at any size, and minding the microbes of the gut. Those are the 3 lifestyle things that one can do. Body composition has to do with fat deposition and muscle mass. There’s a fat-to-muscle ratio that we want to keep an eye on, but it’s not exact. And having been a clinician for 20 years, I can tell you there are some people whose bodies simply will not release their fat no matter what they do—whether it’s genetics, age, or some other factor. But we can still increase muscle mass under the fat. I tell people, “Lose as much fat as you can, get your BMI down below 25 if you possibly can and certainly below 30.” If you can’t, if you just hit a wall, build muscle. Because muscle is the antithesis of the fat, so they oppose each other, making opposing molecules. Fat makes molecules that increase inflammation. Muscle makes molecules that decrease inflammation.

Next is exercise at any size. It doesn’t matter what you do, just staying active, having movement. You don’t have to run a marathon, but exercise to whatever capacity makes you slightly breathless. Exercise is far more important than any piece of diet or other advice. It reduces risk of colorectal cancer by 24% to 50%, depending on the studies you look at.

Lastly, mind the microbes. Remember, colorectal cancer is happening right where the food and the bacteria are lying against the cells. More than in any other cancer, we affect risk directly by changing the environment of the inner colon.

Question: What’s the connection between hormone replacement therapy and colon cancer?

Answer: The rate of colorectal cancer incidence worldwide is 50% higher in men than it is in women. So there’s likely something going on with hormones. We assume it probably has something to do with estrogens. At this point it looks like estrogen itself prevents the incidence of colorectal cancer. But once colorectal cancer is present, it may be the opposite. It looks like while estrogen may prevent the initiation of cancer in the colon and rectum, it may actually cause more growth once cancer is present. So if somebody has a small amount of colorectal cancer, meaning it’s occult, it can’t be seen, it’s never been diagnosed, and they begin hormone replacement therapy, they may accelerate the growth of that cancer. (continued on page 30)

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Question: What does the research tell us about aspirin use and colon cancer?

Answer: This is interesting. Some of the first data looking at the protection from aspirin of colorectal cancer diagnosis was incidental. It was found in studies involving people who were on aspirin to prevent stroke, for example. Watching what happened to participants over 10 and 20 years, they noticed that people who took aspirin had a lot less colorectal cancer. Since then there’s been retrospective and prospective studies looking at aspirin use and colorectal cancer incidence. An aspirin dose between 75 and 100 mg a day reduces the risk of colorectal cancer by about 10%. If the dose goes up to 325 mg a day, it looks like 35% reduction. And that’s according to a meta analysis that came out just last year that looked at a couple of dozen plus studies on this. So it’s clear that it protects.

But we do have to remember that aspirin thins the blood. So if someone is young, active, accident-prone, likely to have a bleed for any reason, then we may not want to do full-dose aspirin because it’s hard to staunch a bleed if there is an injury.

ABOUT THE EXPERT TINA KACZOR, ND, FABNO, is editorin-chief of Natural Medicine Journal and a naturopathic physician, board certified in naturopathic oncology. She received her naturopathic doctorate from National University of Natural Medicine, and completed her residency in naturopathic oncology at Cancer Treatment Centers of America, Tulsa, Oklahoma. Kaczor received undergraduate degrees from the State University of New York at Buffalo. She is the past president and treasurer of the Oncology Association of Naturopathic Physicians and secretary of the American Board of Naturopathic Oncology. She is the editor of the Textbook of Naturopathic Oncology. She has been published in several peer-reviewed journals. Kaczor is based in Portland, Oregon.

Question: Are there any nutrient deficiencies that can increase risk of colon cancer?

Answer: Yes, clearly selenium deficiency, which is interesting because there’s a lot of selenium deficient soil in the United States. You could have selenium deficiency if you eat a standard American diet or if you happen to eat food grown in selenium-deficient soil. Vegetarians need to be mindful of this in particular because selenium is found in meat.

Vitamin D deficiency has been linked to colorectal cancer incidence and outcomes. And interestingly colorectal cancer was one of the first cancers that vitamin D was linked to back in 1980. So vitamin D needs to be corrected and usually with a supplement no matter where along the continuum of colorectal cancer from prevention all the way to metastatic disease. And vitamin C, perhaps. There’s a little less evidence, but it looks like that may be a nutrient deficiency that’s linked to colorectal cancer.

Not ingesting enough calcium is also likely linked to colorectal cancer. It’s not because people are deficient in calcium per se, they’re pulling it from their bone if they’re not ingesting enough. You’re never going to see it on a lab. It has to do with calcium as it passes through the lumen of the colon, because it binds certain bile acids. And it needs to bind those bile acids because they happen to promote colorectal cancer. So ingesting enough calcium is important not just for normalizing serum in the bloodstream without bone degradation, but also for gut health. So calcium would be on my list of things to take if somebody isn’t already eating dairy.

Question: In addition to correcting underlying nutrient deficiencies, are there nutrients or herbs that may be helpful when we’re talking about reducing risk?

Answer: Garlic is really high on the list and—this goes back to the biome—it has to do with compounds that are anticancer within the garlic sulfurous compounds. As far as supplements go, curcumin might be highest on the list because of its antiinflammatory activity.