I recently visited my primary care doctor after more than a year. At the end of the visit he gave me some encouraging feedback. My weight was stable, he may be right there but I know the weight is not everything since my belt has advanced about a hole since my last visit. He mentioned that my blood pressure was stable and normal in spite of a positive family history of hypertension. Then he asked about my next birthday and I knew he was moving on to the dreaded territory of colonoscopies because I turn 50 on my next birthday which comes in the early half of 2020. I would not bore you with the rest of the details all I would say about this is I have the phone number of a gastroenterologist sitting on my desk right now.
This situation though is not that easy for me because it reminds me very much of a conversation I had with a classmate from high school whose younger brother recently died of colon cancer at 45 years? When we all hear of such cases we always ask why? Because this is a situation where our best known medical science even when well applied fails us completely.
I do remember this brother but in my memory he is still the little 11 year old boy wearing orange shirts and Khakis. I cannot imagine him as a 40 ish young man. I am very sad for the life of this young man both as a personal loss but also disappointed at this obvious failure of modern medical science. Unfortunately that is the nature of medical science, whilst we consider it a science and attempt to rigorously apply the scientific method in our treatments and in research, we all know it is not an exact science.
Medical science at its best is an art guided by the best known scientific discoveries of the day. In my early days as a young physician full of myself with all the scientific knowledge acquired from my reading the latest research I had been frustrated by patients seeking more individualized care. I learned as time advanced that the patient was always right not in the hackneyed sense that the customer is always right but in a more nuanced way because every so often medical science fails. In these cases we usually identify these failures by listening to patients. The patients seeking a more individualized care are right but unfortunately are ahead of the science.
Today the science of genomics and proteomics is catching up with my patients who would say “doc this does not work with me.” When you listen to these individuals and veer out of the realm of known science in your attempt to co-manage these cases with some form of understanding that is when you start practicing the art of medicine.
In a few cases you may realize though that the patient is leading you down the garden path. I have learned to sometimes follow patiently with understanding being fully aware of where that is going to lead but having a plan to guide the patient out of there onto a carefully crafted plan. This is a totally different art which may take more time for most young doctors to perfect.
Good medicine is not for the fascist who says only by going my way would you do well because that is not true. Those of us who take the time to know patients learn that even our best patients do not follow our directions all the time. My friend died and would still have died of colon cancer if he followed all his doctor’s instructions. Unfortunately colon cancer at age 43 years is a red herring. Our guidelines recommend screening for anyone without a family history at age 45 years. Judging by the science that we know his process probably started out as a polyp at age 33 years.
The question though that one may ask is how could this have been prevented? I would start here from the simpler ones.
Most Colon Cancers are diagnosed in individuals older than 45 years. Thus for most of us a colonoscopy after age 45 years would suffice.
For those with a family history of cancer in a parent or sibling the colonoscopy must be scheduled 10 years before the age of their appropriate relative’s age of diagnosis. That means 33 years for the siblings of my friend.
For those who have a normal colonoscopy the procedure must be done every 10 years for as long as your doctor believes you have more than 10 years to live. In the United States most of our guidelines recommend to stop at age 75 years.
Now, what about if you hate having a tube shoved up your ass? Well tough luck with that, whilst there are other methods including Computed Tomographic Colonography and Fecal DNA testing as screening modalities there is not enough known about these for a strong recommendation on their benefits.
In the area of diets studies suggest that communities with lower protein and higher fibre diets have lower rates of colon cancer. One study that compared rural South Africans to African Americans suggested a more than tenfold increased risk in African Americans. Similar studies have found increased risk in Japanese American communities one generation after immigration to a western country.
For most of us therefore having a diet rich in vegetables and fruits and low in animal proteins changes the bacteria colonies in our intestines and this has been associated with a lower risk of colon cancer. So if you are an African living in the US do not be in a hurry to adopt American diets like some of us. For the Ghanaians the Abom and fresh boiled plantains still wins the day.
Unfortunately some families have genetic abnormalities that make them more prone to colon cancers. These are overall very rare though about 2-3% of all colon cancers. Such individuals depending on the type of gene abnormality would need to screen as early as 20 years and sometimes a prophylactic colectomy may be a reasonable treatment option. In my friends case it is most likely just run of the mill sporadic colon cancer which just started really early. In medicine always beware of the red herring.
Dr. Leonard Sowah is an Internal Medicine Physician in Baltimore, Maryland
Useful links for further reading
This post was written and published in the memory of a school mate Francis Kofi Asiedu of MOBA (Mfantsipim Old Boys Association) Class of 1990. A memorial and educational service will be held in his honor to support Cancer Prevention in Ghana.
Details to follow.