Colorectal Cancer: A Complete Guide

Program Description:

On August 14, 2018 at 2:00 p.m. (ET), The TASA Group, in conjunction with colon and rectal surgeon Dr. Stephen Cohen presented a free, one-hour interactive webinar presentation, Colorectal Cancer: A Complete Guide, for all legal professionals.

During this presentation, Dr. Cohen discussed:

• Colon and rectal cancer
• GI signs and symptoms
• Standard of care - Guidelines
• Informed consent

About the Presenter:

Dr. Stephen Cohen is a board certified colon and rectal surgeon with over two decades of experience. Not only does he continue to practice evidence based medicine and surgery, but he has made teaching, training, and educating young surgeons his ultimate long term goals. Dr. Cohen has been involved in the field of forensic medicine since the early 90's, and will help guide you on both standard of care and potential causation in many aspects of colon and rectal surgery.

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Transcription:

Rochelle: Good afternoon and welcome to today's presentation, Colorectal Cancer: A Complete Guide. The information presented by the expert is not to be used as legal advice and does not indicate a working relationship with the expert. All materials obtained from this presentation are merely for educational purposes and should not be used in a court of law, sans the expert's consent, i.e., a business relationship where she or he is hired for your particular case.

In today's webinar, Dr. Cohen will discuss colon and rectal cancer, GI signs and symptoms, standard of care guidelines, informed consent. To give you a little background about our presenter, Dr. Stephen Cohen is a board-certified colon and rectal surgeon with over two decades of experience. Not only does he continue to practice evidence based medicine and surgery, but he has made teaching, training, and educating young surgeons his ultimate long term goals. Dr. Cohen has been involved in the field of forensic medicine since the early 90s, and will help guide you on both standard of care and possible causation in many aspects of colon and rectal surgery. 

Attendees who require a passcode, the word for today is Colorectal. During the Q&A session, we expect you enter this passcode into the Q&A widget for CLE reporting purposes. The Q&A is located to the left of your screen. Please remember that if you're applying for CLE credit, you must log on to your computer as yourself and stay for the full 60 minutes. You are also required to complete the survey at the end of the program. Please note that CLE credit cannot be given to those watching together on a single computer. Tomorrow morning, we will send out an email with a link to the archived recording of the webinar. The slides can be downloaded from the resource list located at the widget at the bottom of your screen. Thank you all for attending today. And Dr. Cohen, the presentation is now turned over to you.

Dr. Cohen: Thank you very much. And I appreciate you all taking the time to listen to something very near and dear to my heart, which is colorectal cancer. And many of the things that we're gonna talk about today may help you decide if a case is worth either accepting or certainly defending based on standard of care and what the evidence is showing. So, I certainly don't have any particular affiliation with anything. I'm gonna give you my background a little bit. So, I actually was raised in Southern California. Went to college in medical school at UCLA for those of you that know where California is located. I spent five years doing general surgery at Boston University and then a fellowship in colon and rectal surgery at the Cleveland Clinic in Fort Lauderdale mostly because the winters are much better than Cleveland, Ohio. I then spent the next 20 years in the private sector in a very large busy colorectal practice. And now has found my way to the VA Medical Center in Richmond, Virginia, again, teaching, training, educating medical students and residents in all aspects of colon and rectal surgery.

So, I actually stumbled upon the field of forensic medicine. After I received the subpoena as a third-year resident about explaining that this gunshot wound patient of mine, since I was the emergency room surgeon or resident, actually had brains on the bed, and how I knew what was actually brains. And I really thought that was kind of neat because as you know, medicine and law are two different things, and it was a whole different world. But as I became a specialist in colon and rectal surgery, I was asked by many different individuals to opine on standard of care, what's indicated, certainly, I was doing 10 times the amount of a particular operation like either hemorrhoid surgery, or anorectal surgery, or colon cancer, and if and when there was a problem, I was asked about, was it standard of care? Did the provider or organization meet the standard of care and why or why not? 

And I've always been involved in teaching, training, and educating. And I always seem to get this question, especially when I'm on the plaintiff side, why are you testifying against the doctor? Doctor, why would you do that? And real simply is that, you know, initially, I was asked a lot of defense side but, you know, the whole process of the medical legal arena cannot function without physicians, or nurses, or someone in the field of medicine to explain to the jury, to the judge, to attorneys because you all didn't go to medical school. So, my goal is to try to take very complex medical issues that sometimes we fight amongst ourselves as doctors because there's different ways of doing things and trying to explain it in a logical sequence about what happened, did somebody meet the standard of care, or did they not, and what the reasons are for that, and not only have I...I've been involved in the teaching, training, and educating but at each level along the way. And currently, what I'm doing now is on peer review committee. And peer review as you know is protected information, but we evaluate each other. And I really think that as the years have gone on, it has made me a better doctor to know who's looking over my shoulder, what's the right thing to do, because sometimes it's easy to get caught up at midnight to talk yourself out of getting out of bed to go evaluate the patient.

So, what I want to talk a little bit about today specifically is gonna be colon and rectal cancer, there has been a change in the guidelines of who we offer colonoscopy. And this will play into a particular case as we'll talk about. What are some of the different GI signs and symptoms that are important? When does it meet criteria? What is standard of care to performing a colonoscopy or some type of imaging study? What is the standard of care in colorectal issues and we'll talk about the guidelines as well as some of the informed consent.

So, let's talk about colorectal cancer. If we're talking about incidents of colon and rectal cancer, it is number three in men and women. So, in men and women, lung cancer is still number one, number two in men is prostate, and we're talking incidents. Women number two is breast. And in incidents, it's colorectal cancer across the board, men and women. The problem with colorectal cancer is that it is even though number three in incidents, it is the second leading cause of cancer death in both men and women. Listen, the older I get, the chance of me getting prostate cancer is gonna be a 100%. Most men die with prostate cancer, they don't die of prostate cancer very similar with the breast cancer. This country, 2017, over a 130,000 individuals will have a new diagnosis of colon cancer, and nearly 50,000 will die from colon cancer. Normally, we see it in those individuals that are older, and the older I get, that's not that old anymore. However, there has been a recent trend that we are seeing of younger individuals developing colorectal cancer, and that's why the guidelines in 2018 have changed. But you may have seen this in the New York Times, so, this is less than a year, a little more than a year ago, that talks about the higher incidents of younger individuals with colorectal cancer. And that's one of the reasons why we're really advocating for younger individuals.

The difference between colorectal cancer and some of the other cancers obviously is, number one, it's preventable. Most colorectal cancers start from an abnormal growth called a polyp. A polyp is an abnormal growth. We don't know why people get them. But if I can take your polyp about before it turns into a cancer, I have cured you. And that's very different than breast cancer, that's very different than lung cancer. Lung cancer could be early but you're going to have a...we don't have a precursor to it, unlike colorectal cancer. There's definitely the polyp to cancer sequence, and what I will show you is in terms of survivability of colorectal cancer, the earlier we can take out the cancer, the better the long-term chance of survival.

Every March is colorectal cancer awareness month. I certainly hope those individuals that are listening to me that are over the age of now 45 have had their colonoscopy. There is absolutely no excuse to not get this test. I will tell you, I had mine. I had mine when I was earlier than recommended because I got tired of patients asking me why I haven't done mine yet. So, you know, the worst part obviously is gonna be the prep. It's not that bad, it's probably the only way I can get a day off of work, so, that was very helpful. But certainly, this is an older slide, but now what we're talking about is a younger age of performing colonoscopy. And colonoscopy is a very straightforward, there's over 14 million colonoscopies done in this country every year by all of us, either colorectal surgeons, gastroenterologist, general surgeons. It is a relatively safe procedure. 

Those of you that don't know what a colonoscopy is, it's a way for me to look inside your colon. There is a big, long, black snake called a colonoscope. Through that channel, there's a light, so, it's fiber optic technology that was developed by actually the airline industry by looking at the big jumbo jets. So, this fiber optic technology, I can irrigate fluid, I can put an instrument to take a biopsy, I can take pictures, and it's a very good way that colonoscopy is not only diagnostic, meaning, I'm using it as a tool to see what's going on in your colon, but it's also therapeutic because if I see a polyp or an abnormal growth, it's something I can take right out. And this is a picture of a polyp. I mean, there's nothing special about this, this looks like a little tree with a stalk. Most polyps have a chance to turn into cancer. If I can take the polyp out at an early stage, I have cured the patient of that particular cancer. We have different technologies or techniques to remove the polyp, either a hot biopsy forceps technique or I put some heat and I burn the underlying tissue. Remember, if I just pull this off, it's gonna bleed. There's blood vessels in the lining of the colon. So, we use electrocautery, this is like a little lasso, you know, like you're lassoing an animal, you're wrapping around this thing, you put a little heat on it, it burns, that way when you take the polyp out, and you can suction it right out through the scope, it doesn't bleed behind it.

Certainly, some of the risk factors, we'll talk about bleeding, perforation doesn't happen often, but certainly a known complication of colonoscopy. The reason why we want to take those polyps out, is that if those two little polyps you just saw grew to a big daddy polyp, that now becomes a cancer. The time course of that, depending on what you read, is anywhere between about 5 to 10 years. So, if you have a polyp today, the chance of it being a cancer next month is zero. It just doesn't do that. There is a predictable growth from polyps, so, at some point, the self become abnormal, the polyp grows inside the wall of the colon. As it grows, it turns cancerous, cancer cells. It will then go through the wall of the colon and then spread to what's called the lymph nodes, and the lymph nodes drain the protein out of the blood, bring it back to the heart, most of the lymph nodes live along the bowel itself, and then as the cancer continues to grow, it can spread to other organs, liver, lung, brain, those are the three most common. And as I told you before, that's how we stage them. So, if the colon cancer is all inside the colon, I have a potential to cure you, and that's stage one. Stage two is through the wall of the colon. Stage three is any type of lymph node outside the bowel. And stage four is spread to another organ, but you can see what the survival rate is. The longer it's there, the more chance it's going to spread, you do not have a long term survival, and this is five-year survival data. So again, you don't want to wait for your polyp to become cancer. If you can take your polyp out before it becomes cancer, hey, you're not gonna get it. And if there's some cancer inside the polyp, I still can potentially cure you.

So, let's talk about some of the new guidelines, and let's talk about screening. So, what are the symptoms of a patient that I would want to screen? And those are all the symptoms you can see there on the slide. And I hope you're seeing a blank slide. Screening colonoscopy means the patient does not have symptoms, okay? That means no blood in the stool, no change in bowel habits, no abdominal pain, no weight loss, zero, screening. Screening needs no symptoms. The recent guidelines have changed. As we talked about, we are seeing younger individuals with colorectal cancer. We want to try to get it before it turns into cancer. And now, the current guidelines as of this year, men and women because actually colorectal cancer is a little bit higher in women than it is in men, it's about 51% or 49%, is age 45. The old guidelines used to be Caucasian, 50, men and women. African-American, 45. Now we're down to 45 for everybody across the board, okay? Who do we not screen? So, screening again means no symptoms. If you have a family history of colon cancer or polyps, and I wanna explain this for a second.

I have a lot of patients tell me, "Well, my dad had polyps but he didn't have cancer, so, that's not a risk factor for me, is it doctor?" That is a risk factor, okay? Let's think about this for a second. Very logical. Listen. Colorectal surgeons are not that smart. If your father had a polyp at age 60 and I'm making up the age, and the doctor takes out your father's polyp. And it's not cancer, it's a precancerous site, not cancer, congratulations, you're fine. Remember, if that precancerous polyp in your dad had been there for another 5 or 10 years, it turns into cancer. So, the American Cancer Society does not distinguish between a family history of colon cancer or a family history of colon polyps. It's probably a genetic disease. So, if you have a first line, first generation family member with colon cancer or polyps, that puts you as a positive family history. And I guarantee some of you are thinking that some of your parents probably have some polyps but nobody has cancer that you're safe, well, you're safe if you get your colonoscopy. So, family history, we're only talking about first-degree relative. I don't know what to tell you with second-degree. So, that always comes up too. My grandfather had it, what do I do? You're in really the regular screening pool. So, it's starting at age 45. But first-degree relative could mean mom, dad, brother, or sister, or offspring. I had a 22-year old patient with colon cancer, neither of her parents had been screened, one of them had precancerous polyps, the other one didn't. But it's the same first-degree. We don't understand perfectly the genetics, but that's where we decide who gets the colonoscopy.

Again, some of the other more uncommon things, family history or familial polyposis, there is an autosomal dominant disease where everybody gets polyps. Personal history of polyps. If you had polyps yourself, that's gonna be in every five-year screening or a look inside your colon. Any history of ulcerative colitis or inflammatory bowel disease, and the other thing that comes up a lot is blood in the stool is not normal, okay? I'm gonna say that again, blood in the stool is not normal. I cannot tell you the numbers of patients that come to me that are young, 30s. I have blood in my stool but I know it's my hemorrhoids. Really? How do you know that? Well, because it's bright red blood. Listen. Blood in the stool is not normal. Blood makes us all nervous. It is standard of care to investigate that source of blood. 

Do I have to do it right away? Absolutely not. Maybe I examine the 30-year old and they have some hemorrhoids and it sounds like hemorrhoidal bleeding. And I treat the hemorrhoidal bleeding and it goes away, and they're fine. That's okay. If that same hemorrhoidal bleeding patient does not improve, that now warrants investigation, okay? The timing of that, months. I don't have to do it right away. Again, to go from polyp to cancer doesn't happen overnight. Even if my hemorrhoidal patient that I'm thinking is hemorrhoidal bleeding, I don't feel anything on rectal exam, I don't see anything in the office. If I don't scope that patient because for persistent bleeding for three months, that there's no causation there, nothing changes in three months. Colorectal cancer in general, low growing, doesn't happen that quick, but certainly that particular patient, you need to make sure they have no other symptoms, your treatment was effective, and they're not having ongoing symptoms.

Change in bowel habits. Everybody has a different normal number of bowel movements, okay? I would like to go every day. I don't. I know my grandmother loves to go three times a day. The average number of bowel movements is different for everybody. The textbook says anywhere from three times a day to three times per week is normal. So, whatever is normal for you is gonna be normal. So, have you had a change? If you used to going every day and you stopped going, now you're once a week, that's a change in bowel habits, okay? So, that's important. 

Unexplained weight loss. Obviously, you can have a right-sided colon cancer that makes us nervous. Anemia. Anemia. Unexplained anemia, meaning low blood count in anybody over the age of 50 is a colon cancer until proven otherwise. Yeah, I'm gonna say that again. If a patient over the age of 50, says, "Look, I feel fine, but I'm anemic and my doctor gave me iron," and they're not seeing blood in their stool, or they're not having change in the bowel habits, and they don't have a family history, unexplained anemia is a right-sided colon cancer until proven otherwise, that particular patient need the colonoscopy. You could have extremely large growths in the right-side of your colon and you're not gonna have any symptoms. The right colon is very thin wall, the right colon can almost get the size of my head, and you're not gonna have symptoms. Unless it's blocking the ileocecal valve. The ileocecal valve is where your 23 feet of small bowel dump into that right colon. And if you're not blocking that, you could have an extremely large growth and not know it, and that's very important. I have seen tons of patient over the year that have anemia for a year and are on iron and maybe even blood transfusions, and they missed the right colon cancer. So, unexplained anemia over the age of 50, 45, needs a colonoscopy. I'd rather do the colonoscopy until you don't have colon cancer, let's get another explanation of the anemia.

The other question that always comes up is, how long does a patient have to undergo screening colonoscopy? So, I had a 95-year old patient walk into the office a couple years ago, with the diagnosis of colon cancer. So, I'm getting a history. She had normal colonoscopies throughout this whole time, she presented with some blood in her stool at...well, she got to age 88 and was told by her doctors, "You're too old, you've had all normal colonoscopies, you don't need this anymore. You're already 88, you're fine." She goes, "Okay." Age 95, blood in the stool, anemia, colonoscopy showed the right-sided colon cancer. So, the question is, you know, was she told the right advice, or did somebody miss it? And actually, the rule of thumb is and what the guidelines currently say is you can screen somebody in colonoscopy up to age 76. Between age 76 and 85, it really depends on what's going on with the patient. If they have a bad heart, if they have some other comorbidities, if they have a shortened life expectancy based on whatever is going on with that particular patient, you do not have to recommend screening anymore especially if you don't think they're well enough to undergo the procedure. 

I've had that conversation a lot. They bring in their 86-year-old, you know, family member, "Would you recommend a colonoscopy?" Well, if I find a colon cancer, what are you gonna do about it? Nothing, they're too sick for surgery. Then I'm not gonna do the test. And I try to emphasize that to the young doctors too, don't get a test if you're not gonna act on the result as long as everybody is in agreement of what we're doing. It used to drive me crazy when I was a surgery resident, where you'd have a patient come in with a ruptured triple aneurysm that was sick as can be. And the history was, six months before, they were told by the vascular surgeon, and everybody, the cardiologist, and everybody, "Listen, you have a big aneurysm, the chance of you surviving surgery is very low, we do not recommend an operation."

Now, they have their rupture, they're in the emergency room with no blood pressure, and we're supposed to whisk them to the operating room to do emergency surgery? Listen, if you're not gonna survive a lengthy surgery, I guarantee emergency surgery is not going to go well, and it never did. And I think as medicine is going along just this whole, and I'm getting off track a little bit, this whole palliative care, we need to be able to have these conversations. Listen, if you're 90 and if I find something, you're not gonna undergo treatment, that's fine. That's okay, but we all need to know that. So, the guidelines currently state, if you're over the age of 86, you do not need colonoscopy anymore. Some patients will want it just in case they find something they...you know, as we all get older, that may be an issue to do it. And that's really kind of patient preference, family preference needs to be documented. I don't need to tell this group that that's very important.

Well, part of the problem with colonoscopy is patients don't want it. I mean, I'm talking to patients almost on a daily basis. Now, listen, you're 65, you got some blood, you really need colonoscopy. Forty percent of patients in this country that need screening colonoscopy are not interested. Not at all. I don't want to do it. I'm healthy, doc. I don't need that. Okay, that's fine. You know, I can't make you do something but certainly, those are the recommendations. The other question that comes up is family history. We all talk about family history, okay? Family history is important. However, out of every colon cancer patient that walks into my office, only 20% of them actually have a first-degree relative with colorectal cancer or polyps. So, that's a scary statistic. Meaning, most patients that present with colorectal cancer, they're the index case. So, you can't, if you're listening to this thinking, "Well, it's nobody in my family. I'm not...I'm fine." That's not necessarily true. 

Eighty percent of patients with colorectal cancer are the index case. So, don't feel good about yourself just because you don't have a family history, doesn't really mean anything. And the other problem as I talked about before is that some of the symptoms occur late. You can have very large cancers on the right side of the colon. Usually right-sided colon cancers present with bleeding or anemia. Left-sided colon cancer is present with obstruction because the lumen, the opening, is smaller. Very big opening on the right, smaller opening on the left, smaller cancers on the left could lead to obstruction, nausea, vomiting, abdominal pain, bloating, those are the things we normally see with left-sided colon cancer.

Again, the screening updated, the things that we talked about, you don't have to do colonoscopy. Colonoscopy has become the gold standard because it's diagnostic and therapeutic, meaning I could look in your colon, I can see what's going on, I can take out a polyp. Some of these other things are out there. We're doing a big study here at the VA looking at annual fit, fecal immunochemical testing or fecal DNA testing. Meaning, are we able to identify early polyps or cancers looking at stool specimen? I think that's gonna eventually, not really take over colonoscopy because if you have a positive fecal stool card, now you need your colonoscopy. Well, if it's me personally, just give me my colonoscopy every 5 or 10 years and I don't want to deal with stool of the toilet bowl, or swabbing it, or sending it back. And a lot of patients say that as well.

Rochelle: Thank you Dr. Cohen. We have now entered the Q&A section and if all attendees can enter the passcode for today which is colorectal in any questions that you have for Dr. Cohen. Our first question is, are most insurance providers supporting an earlier colonoscopy before 45 if elected?

Dr. Cohen: Wait. I've missed that question again. Say that again. I'm sorry.

Rochelle: All right. Are most insurance providers supporting an earlier colonoscopy before 45 if elected?

Dr. Cohen: Yeah. That's a good question. Some are at this point and some are not. I just read an article that some of them are reviewing the data to see if that's being supported. So, right now, not 100%, but I think that's coming and I will tell you the American Cancer Society, the American Society of Gastroenterology, the Colorectal Societies, they are pushing some of these third-party payors, because in the long run, even though everybody thinks so short-term, that it's gonna cost them more money, I would rather do a colonoscopy and take out your polyp than a total abdominal colectomy because that's gonna be a whole downstream effect. So, the short answer is right now, not all of them, some are, hopefully that will change by the end of the year.

Rochelle: Next question. Please compare a colonoscopy and FIT as a diagnostic tool?

Dr. Cohen: Yeah, that's a good question. So, most individuals, say annual FIT test which, you know, the old stool guaiac cards, the problem with the old cards like I learned back in the 80s, is that there was a lot of false positives and false negatives because it looked at hemoglobin breakdown from anything, okay? So, if I ate a bunch of red meat, that would turn a false positive card, the red blood cells came from the meat, didn't come from my body. The other thing about the old guaiac cards is that there was a lot of false negatives. Most patients take a multivitamin. Vitamin C commonly will turn the old cards negative. So, a lot of false negatives from just taking a multivitamin because they all have vitamin C. FIT test is currently an accepted method for screening for colorectal polyps. But again, the difference is if that card is positive, the patient then needs a colonoscopy because it's a diagnostic tool not a therapeutic tool.

Rochelle: Next question. How often should young men with UC or Crohn's be screened?

Dr. Cohen: Yeah. That's a very good question. So, the incidence of colorectal cancer, and I don't know that I would call that screening. I would really call it because individuals with inflammatory bowel disease, Crohn's disease, ulcerative colitis, they are higher risk of colorectal cancer, that's thing number one. Its 1% to 2% additive every year once you get to 10 years. So, that's high, okay? Every year goes by, if you have inflammation in your colon, it's gonna increase your incidence of colorectal cancer. And the other problem is that when these individuals develop colorectal cancer, they're not garden-variety like I showed you that picture with a big fungating mass that's obvious to everybody. They grow in the wall of the colon. So, it really is very individualized if and when you have inflammatory bowel disease, every three to five years is a ballpark, but it depends on the responsiveness because remember, there's a lot of newer medications out for inflammatory bowel disease where we are seeing complete remission. And if you have no inflammation, it lowers your risk of colorectal cancer.

Rochelle: Next question. Do you have to be referred by a PCP to have a colonoscopy?

Dr. Cohen: Well, that's more of an insurance question. I mean, some insurance companies mandate that, but not all of them. So, I don't even know how to...again, that's also jurisdictional. I mean, Blue Cross in one State may be different than Blue Cross in another State. That's up to the insurance company, but, you know, again, once the guidelines are out there, and if that particular doctor, family practice OB, if they're practicing, you know, as the primary care, then it is really their obligation to order the screening colonoscopy. To order the mammogram, to do the PSA testing, whatever is indicated. So, that's really up to the insurance company and then maybe jurisdictional.

Rochelle: Next question. Does colorectal cancer show up in a blood test?

Dr. Cohen: It does not. So, the common test that we do after you have colon cancer is called a CEA level. CEA is a protein that can be secreted from the colon cancer cells but it can also be secreted from other cells. And we use it to monitor for recurrence, but not as an index. We don't use it as a screening test, it is not reliable, it can come from other things. And the poorly differentiated colon cancer, I mean, the cells are so undifferentiated, they don't secrete CEA. So, a normal CEA does not rule out you have something in your colon.

Rochelle: Next question. You said a polyp doesn't become cancerous quickly. Is neuro-endocrine carcinoma of rectum faster growing than normal?

Dr. Cohen: Usually not. I mean, something like a carcinoid tumor, they're even slower growing or a GISST tumor, GI stromal tumors used to be leiomyosarcomas in the old days. Now, those are generally lower growing than garden variety adenocarcinoma. The two main kind of polyps are adenoma, just what the cells look like or hyperplastic polyps. Hyperplastic polyps never, never, never turn into cancer, so, if you have a polyp and it's called hyperplastic, you only need to scope every 10 years if you don't have family history. Adenoma that's polyps and adenoma if left alone long enough turn into adenocarcinoma, and that's the cancer. Those are the precancerous ones, most polyps are adenoma. I cannot tell by looking at it, I have to take a biopsy, I have to take the polyp out, I have to send it to pathology. And the reason I'm emphasizing that is that I've had patients say, "My doctor looked, I had polyps, and they said they were benign and they just left them there." No, no, no, no, I don't have x-ray vision, I can't tell what they are. So, needs to come out, but these neuroendocrine are generally slower growing.

Rochelle: Next question. How effective is a colonoscopy to find the polyp?

Dr. Cohen: Yeah. I'm going to...let's punt on that because that leads into a very good lead into the next section.

Rochelle: Okay. Next question. How effective is the stool test to diagnose Stage 1 or Stage 2 of colorectal cancer?

Dr. Cohen: Yeah, it depends on the size of the polyp. Most of the stool tests, what we're saying now is those polyps have to be greater than a centimeter. Most cancers are greater than a centimeter but not all of them. So, 90% sensitive and, you know, maybe 90% specificity. Sensitivity is the chance of it actually being there, specific is that if the test is positive, do they really have it? Generally, those polyps have to be greater than a centimeter.

Rochelle: And our last question for this section. How do you treat an elderly patient who has a growth but cannot tolerate surgery?

Dr. Cohen: Well, it depends where their symptoms are. That's a very good question. I mean, if they're bleeding, it's a problem. And I don't know...you know, not to be flippant but generally, what I say is you're never too sick for the right operation. And I don't mean to be flippant about that. If you're bleeding and I can't stop the bleeding, you know, we at surgery look at risks and benefits. And if the risks outweigh the benefits, we don't do it. If the benefits outweigh the risk, then we do it. If they're obstructed and they're not bleeding, we can actually put colonic stents, there's actually through the colonoscope. We can put some stents in to open it up so they're not obstructive, but that's a tough problem.

Rochelle: Thanks, Dr. Cohen. You can continue with the presentation.

Dr. Cohen: So, those were actually great questions. So, let's talk about some of the litigation issues that come up in the field of colorectal surgery. So, some of the things that we talk about, the biggest one for a colorectal surgeon, or a gastroenterologist, or anybody dealing with colorectal cancer or colon issues is failure to diagnose. The second one is gonna be an injury. If I don't explain it to the patient, that's gonna be on complications. Sphincter injuries, I get asked to review a lot of cases of a routine hemorrhoidectomy, anal fistula, anal fissure, the patient then wakes up incontinent, that's a problem. And then lack of informed consent.

So, let's talk about a failure to diagnose case and how this plays in. And it'll really lead in very well to the question of how accurate a colonoscopy is. So, I saw a 65-year old patient came into my office with some rectal bleeding, been going on for about three months. No big deal. Except she told me that two years before, she had a colonoscopy, it was stone-cold normal, and she brought me the pictures to prove it. Not that I didn't believe her but she had the pictures with her. I did my typical exam, my rectal exam and lo and behold, she had a very distal rock-hard rectal mass that I knew right away wasn't gonna be good, lo and behold, the biopsy showed the rectal cancer. So, that case after I operated on her and we got her through the surgery obviously came as a medical malpractice case. And the claim from the plaintiff's side was that of a misdiagnosis. It went to a jury trial. The experts disagreed, right? Because what have I been telling you this whole time? The defense was saying, "Wait a second, I have a picture of her rectum, we had a picture of her rectum, there was nothing there," right? But what did I tell you? 

The plaintiff argued that, "Listen, to go from polyp to cancer," and this actually turned out to be a Stage 3 cancer, she had positive lymph nodes. So, what did I harp on you in the beginning of this talk, right? It takes 5 to 10 years to grow, it's very slow growing. The plaintiff argued, "Well, wait a second, two years ago with a normal colonoscopy and now you have Stage 3 colorectal or rectal cancer?" Obviously, there was a problem and the causation was, listen, if the doctor had performed an adequate colonoscopy and found this thing earlier, two years is a long time. And obviously on the plaintiff side, their expert, more likely than not, this is not in the lymph nodes and our survival is improved. Again, all those graphs that I just showed you. So, the question is, and this happens a lot, who is to blame in this case? You have a normal colonoscopy and a cancer develops one to four years later, you know that's gonna be a setup for a medical legal action. Again, what we talked about the plaintiff is inadequate performance was the proximate cause in the delay of the diagnosis. And that delay resulted in progression to cancer to an advanced stage.

So, I will tell you, so, to answer that question and that was perfect whoever is in the audience, is that colonoscopy is not 100%. I know everybody wants a guarantee, but as you know, this is medicine. And medicine, there is no guarantee. There is going to be an inherent miss rate of polyps inversely related to size. Meaning, the smaller the polyp, the more chance we're gonna miss it. The larger the polyp, probably not gonna miss it, and also, the higher number of polyps. Some patients on there for an hour taking out 15 little baby polyps that are small, but they all come back adenomatous. So, they've done some very good study. So, what does the literature show? So, they've done some very good tandem studies. So, what is a tandem study? Definitely something that you all do not want to sign up for. Tandem study is, in the morning, you go to doctor number one to do your colonoscopy. You wake up from the procedure. An hour later, you go into room two and doctor number two does a second colonoscopy to see if the first doctor missed any polyps. And what does that show? That this is the percentage of polyps that are actually missed. So, in the first study, they looked at almost a hundred patients. Polyps less than 5 millimeters, 16% at a time, they were missed. Six to 9 millimeters, 12% of the time they're missed. And you can see the other study down below, so, that's a problem.

The other problem is, as I told you, that there's a variable growth rate. It takes 5 to 10 years depending on what you read to go from cancer to polyp, but once the polyp turns into cancer, it's then got to go through the stages of through the wall of the colon, then to the lymph nodes, then to the spread. Well, so, let's go back for a second. So, if it takes that long to grow, we know that there's about a 6 to 8-month doubling time in colorectal polyps as they grow, that's standard. So, if you have a...let's go backwards, a six centimeter cancer diagnosed two years at index with the six to eight-month doubling time, that cancer two to three years earlier was less than a millimeter, right? 

So, what am I telling you? I'm telling you that about 10% at a time, you are going to...the individual physician is going to miss a small polyp that can turn into cancer in a 2 to 3-year time. This is a known inherent miss rate of colorectal polyps. The other question is does size matter? I mean, so, you know, I think tumors as big as my fist that have all been located inside the colon, have not spread the lymph nodes, have not spread, and I've seen colorectal cancers the size of a dime. But terrible pathology, all the lymph nodes are positive, so, size does not matter. It has no correlation to spread to liver, longer to the brain. 

And the other problem is that we're learning a little bit more about the genetics of colorectal cancer. Most colorectal cancers, and this is what I learned, you know, 10, 15 years ago, are from chromosomal instability which leads to that 5 to 10 year growth rate, but genetics have changed and that's why we're seeing this a little bit more in younger individuals. We can do some special DNA mismatch repair genes looking at the genetics of the individual cancer cells. And what we are finding is that there is a little bit faster growth rate in those colorectal cancers that have these mismatch repair genes. And that's something that can be done by the pathologist to determine if this happened to be a faster growing cancer. And that's important. So, the question is, are interval cancers, interval cancer meaning I do your colonoscopy today but two years you now have a cancer, are they based on negligence? And number two, you know, what is a colonoscopy? Is it standard of care or is it a guarantee that you're never going to have a problem?

The standard of care, you all know this definition, you know, what's a reasonable prudent provider, similar training, how they would take care of that patient under similar findings based on the way the presentation or based on the way the patient is presenting. And it's very important and I try to make this distinction. Standard of care doesn't really take into account what the outcome of the conclusion would be. I don't know that, right? I can only deal with facts as they come to me, and the standard of care really should be, what is the thought process? If I'm thinking DVT, am I ruling that out? If that test is normal, what's the next step? How is the patient progressing? So, standard of care really shouldn't be what the outcome is because sometimes, we have no control over the outcome even if our thought process is accurate. And as you know, poor outcome, I've had plenty of them over the last 20 plus years, can occur even if you're doing everything right, getting every test appropriately, and working the patient up the right way.

The other question that comes up a lot is judgment, right? Doctor, Dr. Cohen, doesn't a physician have judgment to make? Absolutely. Judgment is important. But judgment needs to fall within the standard of care. Listen, we argue amongst ourselves at our conferences every week, sometimes what the appropriate surgery could have been, or should have been, or what were the other options? There's options in everything. And if the provider, if the individual is acting within the standard of care, then they do have some judgment based on the certain signs of symptoms of the way the patient present. So, specifically for colonoscopy and some of these points I want to make at the end because they're important, what are the reasons that I get asked to review charts in terms of colonoscopy, specifically? Certainly perforation. Every perforation, everybody wants to sue, everybody...bleeding or medication reactions and also, you know, did the doctor do a complete colonoscopy? And that's very important. 

So, when I'm doing a colonoscopy, what are some of the standard of care items that need to be checked off the box to make sure I've done a complete exam? Because I will tell you, sometimes we can be fooled. So, an adequate colonoscopy, number one, you have to make sure that you get all the way to the cecum. The cecum is the very first part of the colon, it's way down by the right hip, it's where the appendix is attached, it's where the ileocecal valve is located. You need to intubate this area. So, if the cecum is not intubated, you can easily have a little colon cancer or polyp missed in this area. So, that's what it looks like. I mean, the ileocecal valve there, it's where the small bowel comes in, we see the appendiceal orifice. There is no polyp or tumor in that field of view but you need to be able to see that, okay?

The other question is, was the prep adequate? Listen, I didn't like drinking all that stuff. I was in the bathroom all night long, I mean, it was awful. But if a patient comes to me and I do a colonoscopy, and I can't adequately visualize all around the colon and there's liquid stool, I'm not gonna call that test negative, right? Because I carry all the liability. So, if the prep is not adequate, it has to be done again. Absolutely, I have some angry patient, trust me. But I tell them, if you're not clean, you were doing this again, right? I mean, I want someone to take some ownership. Listen, when I had my colonoscopy, I took an extra dose of the prep. I did not want my partner to see any kind of stool inside my colon at all. So, it needs to be adequately cleaned. 

And the other thing that is important is that, obviously, some of these little polyps are small, they can hide behind folds in the colon. And it has been determined really in the American Society of GI that the hardest part of a colonoscopy is getting all the way to the end. So, once you get all the way to the cecum, I then look for polyps coming out, as I'm withdrawing. It has been demonstrated that if the endoscopist with the total withdrawal time is less than six minutes, there's gonna be a higher incidence of missed polyps. So, if you're looking at a colonoscopy report and you want to see like, did this meet standard of care? How do I know it met standard of care? Did somebody fall below standard of care? Number one, did they intubate the cecum and document that? Number two, was there an adequate bowel prep? Because these polyps can hide behind fluid or stool. And number three, was there withdrawal time greater than or equal to six minutes? And most GI software systems, once I hit the cecum, the nurse hits the button and I get timed. And if I don't take shorter than six minutes because the more time you look around folds, you will find polyps.

The other thing I'll mention that I don't have a slide is, if I do a hundred colonoscopies, what percent of the time am I gonna find polyps? Am I finding them 2% of the time? Am I finding them 50% of the time? In general, it's about 20% to 25% of the time. So, one thing to think about if you're whatever side of defense you're on, plaintiff or defense, is look back at the particular endoscopist. Are they always finding polyps? Do they find polyps 100% of the time? No way. Are they not finding enough polyps? And everybody has that data. That data can be kept in the GI lab, they keep data on us for everything that we do. But you should be about 20% to 25% polyps, meaning you're finding enough and you're not taking out things that are not polyps. 

So, why do I say that? Remember I came from the private sector. I get paid one fee for a colonoscopy, and I get paid a higher fee if I take it a polyp. There are some occasions where I've looked at some charts where someone has taken out normal mucosa. So, if you have a doctor that's taking out a lot of normal mucosa, something is not right, okay? Sometimes, normal mucosa can look like a polyp. So, I got that because I've had that happen to me before. When you suction through the scope, you can get some mucosa sucked up. It can look like a polyp, and we call that a suction polyp. So, sometimes if you're not sure, just take it out because it's a lot easier. But those are some of the things that you need to look at, you should be able to tell by looking at a colonoscopy report if it was done within the standard of care.

And again, I'll briefly end up here a little bit with informed consent. You know, it's not possible that I can tell you all of the possible problems that can happen with a particular procedure. The one thing that drives me crazy however is...and a patient has said to me, you know, if they've had a complication, "But I didn't understand the informed consent." Wait, wait, wait, it's an informed consent. It's not an understanding test, right? I mean, I don't mean that mean, but I inform you, you consent. If not, did you understand what I'm talking about? Because sometimes it's hard for the medical students to understand, but that's why they're placed in there about did I ask questions? Did they explain everything to me? But it's not an understanding test, I informed you, and you consented. 

The other thing that I teach some of the young doctors and we only have a couple more minutes, is you can't possibly tell every patient from every surgery every potential complication. These six things I actually write on everything that I do. If I'm doing a hemorrhoidectomy, if I'm doing a total colectomy, if I'm doing a liver resection, these are the things I write. These are the things that can happen to you anytime you do surgery. Bleeding, infection, anesthesia complications, I can make you worse because there is a lot of rare complications out there that I would not have predicted, that I've never seen, that I made the patient worse. I can injure another organ or obviously death. Now, my anorectal patients that have to read that list are generally not happy with me, however, there's no such thing as a simple operation and anything can happen as you all know, and any of these things during surgery. And this tends to cover. Certainly informed consent doesn't prevent. Medical and legal action, we all get that. But certainly, these things, if you go over with them, it's a lot more helpful.

So, to conclude and wrap up here, obviously, it's very important to understand what the issues are, who gets the colonoscopy? When is colonoscopy indicated? What would be the standard for performing a colonoscopy? What are some of the things if somebody met or exceeded or fell below the standard of care in colonoscopy? Make sure...again, some of these things are debatable amongst us. Obviously, the reason that you're all looking at to get an expert is just to give you what's the bottom line? What should have been done? What is standard of care? Because things change, things are different, and it's very important that, you know, when we're explaining these things to each other or to a jury, you know, if you make it simple, then I think it's a lot easier to understand. That's my picture. And now we're back to the Q&A.

Rochelle: Thanks, Dr. Cohen. If everyone can insert their passcode for today which is colorectal in any questions that you have for Dr. Cohen. Our first question. If I had a clear colonoscopy at 50, doctor says, "You have a beautiful colon," but I'm now 58 and experiencing occasional bloody stool, should I request a colonoscopy now or wait until I'm 60?

Dr. Cohen: That is the best question I've heard and that is a...I hear that question every single day. And I laugh about it because yes, you absolutely need a colonoscopy. Because if you wait, the chances are you may have something two years from now or if you have a little polyp causing the bleeding, you're cured. So, that's very important distinction. And I say that to patients. Listen. You don't need another one of these for 10 years, but if you have any symptoms, please, tell me. Meaning blood in the stool, change in the bowel, anything different, so, absolutely, you need a colonoscopy.

Rochelle: Next question. Can you address whether perforation is ever a breach in the standard of care, and if so, what factors make that so? Conversely, is a perforation always deemed as unavoidable risk of the procedure?

Dr. Cohen: Well, so yeah, that's a very good question, that comes up a lot. So perforation is a known a risk factor of a colonoscopy. There's gonna be...you know, so there's two issues. Issue number one, there's a higher risk of perforation if you take a polyp out. Taking out a polyp weakens the wall a little bit. If I use heat or electrocautery, the way we're taught to do it is I grab the polyp, I pull it away from the wall, I burn the tissue, and take the polyp out. There's either early perforation or delayed perforation. My first perforation happened three days after I took the polyp out. So, that's thing number one. Thing number two, sometimes, the scope itself, if you push hard it up because it's flexible, the back end of the scope can bow up and tear the colon. But I will tell you that more often than that, if you have a perforation of the colon, that is a known complication, not below standard of care. The question is, when was it recognized? And that there's where the rub comes in because I've reviewed cases where the patient has a colonoscopy or polypectomy, they go home that night doing fine, they met discharge criteria, and no issues. Midnight, they start having abdominal pain. They call the doctor. The doctor says, "It's gas, no problem." That's a problem. That's a problem. 

It's not the perforation that bothers me, it's the failure to recognize the perforation. If a patient has a problem after a colonoscopy, that mandates evaluation. You don't get gas 8 hours, 10 hours after your colonoscopy, your gas is right away. So, we had a rule, if any...and this happened early in my career, it wasn't a medical legal thing but the nurse that took the call at 4:55 told my colonoscopy patient, "Morning, oh, that pain's normal, everybody has that." Seriously? No. No. If you have pain or some symptom after a colonoscopy, you need to be seen, you need to be evaluated. The perforation itself is not below standard of care where individual physicians, ER, you know, GI, medicine, gets into trouble is failure to recognize, failure to treat it. The earlier I can get to you, I can close the hole.

Rochelle: Next question. Regarding the standard of care, does the prevailing community standard warrant physical perianal examination and visualization with the report of blood in the stool?

Dr. Cohen: Can you put that up there?

Rochelle: It's up there.

Dr. Cohen: About failing community standard warrant physical perianal test? Oh, absolutely, 100%. Right. I mean, you know, this is what I tell the residents. There's only two reasons why you don't do a rectal exam especially having blood in the stool, okay? Number one, the patient doesn't have a rectum, it's something, let's take it out. And number two, if you don't have a finger. I mean, again, seriously, if you're gonna listen to the heart and lungs and you have a report of blood in the stool, that mandates a rectal exam. And not to do that is below standard of care.

Rochelle: Next question. Can someone just request a colonoscopy at any time?

Dr. Cohen: Well, there certainly have to be indications for the colonoscopy. It's funny the way that question is asked because another thing I tell the...I have all these things I tell the residents. Listen. You're gonna get complications in surgery, that's fine. If you do enough surgery, I've had every complication, that's fine. But if and when you get a complication, the first question anybody asks you is, did the patient need the procedure? So, you better be able to answer yes to that. So, if you have a patient that's requesting a colonoscopy that does not have an indication to have it and they have a complication, that's not defensible. So, yeah, I don't know why you requested at any time, and I don't know who's going to do it unless there's an indication for it.

Rochelle: And our last question. My gastroenterologist advised me that I didn't need any additional colonoscopies after age 68, even though I have had polyps removed. I'm now 75, should I insist on having them done anyway?

Dr. Cohen: Yeah. So, that's a very individual question. I mean, if you're 75 and you're healthy and you probably are, then absolutely. Because the guidelines usually it's about 76 to 85. Over 76, we don't recommend it any more. So, if you were told at 68 you don't need it, I don't know where that came from. That number to me was made up because I've never seen that before. The age is really above 75. But again, you know, we're all living older, so, I guarantee those numbers are gonna tweak up. I mean, I hope I'm spry at age 75 or 78 but, I tell you, if you're otherwise healthy, if God forbid they find the cancer and you would do okay with the right colectomy or a partial colectomy, then absolutely have it because if you've had polyps, you've gone now a long time without another colonoscopy, the chance of you having a precancerous polyp is high. So, absolutely. I tell you, if you were related to me and didn't have a lot of other comorbidities, I would definitely tell you to have it.

Rochelle: Thanks, Dr. Cohen. All unanswered questions will go directly to Dr. Cohen to answer them individually. In addition to being your best source for testifying and consulting experts for more than 60 years, TASA also offers free interactive webinars, expert-written articles, research reports on expert witnesses including the Challenge History Report 2.0 and Expert Profile 360. I would like to take this opportunity to thank everyone for attending, and most especially Dr. Stephen Cohen for his time and effort in creating this presentation.