We are a primary care internist, a gastroenterologist, and a man diagnosed with colon cancer at age 32. Ask Us Anything.

to the colon cancer survivor, did one of your symptons include black tarry stool and severe stomach cramps? asking for my dad.

Those were pretty much my only symptoms, as well as a little bit of blood in stools as well. The stomach cramps were really what led me to seek medical attention, and they were only severe on one occasion. - David Siegel

Can you briefly talk about what black tarry stool looks like and how to tell the difference between that and regular color/consistency fluctuation in stool?

Like are talking the poop looks like it was dyed jet black? And what does tarry mean in this context?

This is a good question! I often say black, tarry stools to patients and they don’t often ask me to clarify. Digested blood can look dark and black like tar so bleeding for example from the stomach or small intestine could be dark/black vs. bleeding from a hemorrhoid which might be bright red. A regular stool is some spectrum of brown and solid. - Dr. Arefa Cassoobhoy

thank you David!! idk how old you are now but i hope you are well and have many years ahead of you.

I’m currently 33. Thank you, I hope I have many years ahead as well. - David Siegel

Why are colon cancer rates skyrocketing among young people? Also, what's the connection between Ashkenazi background and increased potentials for colon cancer?

We are unsure why rates of colorectal cancer in younger individuals are increasing. I suspect there is a dietary and weight element. There is no obvious connection between Ashkenazi Jewish heritage and colorectal cancer. - Marc Sonenshine, MD MBA

Is there a particular food you would advise people to avoid? Are there any food you wish you had incorporated into your diet before? Does the long term use of tablets to reduce stomach acid (e.g. lansoprazole/ omeprazole) cause stomach cancers?

I believe in a well balanced diet including all food groups. Weight management / control is critical for good health. Obesity is a risk factor for the development of many conditions, including various malignancies and atherosclerostic diseases like heart attacks and strokes.

As for colon cancer, red and processed meats may potentially increase the risk. However, the data is conflicting. Therefore, again, like all conditions, a well balanced approach is best.

New data is starting to emerge regarding risks from PPIs (proton pump inhibitors like Omeprazole / Esomeprazole / etc.), including a possible increase in stomach cancer. The risks associated with these medications seems limited, but, if one can come off the medicines, it is always best. I typically recommend finding the lowest, effective dosage as well as working with other measures that helps control reflux. - Marc Sonenshine, MD MBA

Mother had colorectal cancer.

I began having serious abdominal pain below and to the right of my belly button 2 years ago.

Had an armada of scans done, followed by colonoscopy. Doctor said I was clear.

Pain and flat stools remain. Pain never stops.

Is a colonoscopy fool proof? Is it possible they missed it, or could this be something else?

Colonoscopies are the best test for evaluation of the colon. Unfortunately, no test in medicine is 100%, including a colonoscopy, and, in very rare instances, things can be missed. Doctors often will look at all the various tests and symptoms to see if repeating a test is necessary. - Marc Sonenshine, MD MBA

I keep hearing about colon cancer in younger people and it's scary. Given that most insurers don't offer free colon cancer screenings as "preventative" medicine before age 50(?), when should someone consider shelling out the $$$$ (even with insurance) for these types of screenings which would almost certainly be considered "diagnostic"?

The American Cancer Society just changed their recommendation to screening all patients for colorectal cancer to age 45. There are various screening modalities, all of which have specific benefits and risks. Hopefully, the insurance payors will follow the ACS and allow the physician - patient relationship to guide which test is best for screening. While many of the screening tests need to be done annually to be effective, I favor a colonoscopy for screening, as they are only needed once every 10 years in average risk individuals. Whereas, if the other tests are positive, you will still need a colonoscopy. Higher risk individuals (family history of colon cancer or colon polyps) are typically covered by insurance at a younger age for screening. - Marc Sonenshine, MD MBA

Does taking antibiotics mess with gut health? If so, what are good ways to restore gut health after taking a course of antibiotics?

Also to follow on, are probiotic tablets worth taking to restore gut health?

Probiotics tabs are filled with so called good bacteria for your gut. These tabs are not FDA regulated so if you take them, you need to go with the brand your doctor recommends and follow the directions carefully. Some probiotics need to be refrigerated. While there’s a lot of researching about probiotics and there are certain conditions where doctors will recommend them, you don’t need to take probiotics as a preventive medicine -- like a multivitamin. I’d recommend instead a varied diet. Yogurt with active cultures have probiotics, as well as other foods like kimchi and sauerkraut. These are great to add your diet to give your gut a variety of foods that are part of a healthy diet. - Dr. Arefa Cassoobhoy

Antibiotics are critical to treating some infections, but unfortunately they can also have a side effect of messing with your gut health. It can be mild from irritating your stomach to more severe causing antibiotic associated diarrhea from an infection called c.diff. The best policy is to only take antibiotics when your doctor says you need it; wash your hands regularly; and as far as diet -- eat a variety of healthy foods. If you do feel like you’re having issues, talk to your doctor. - Dr. Arefa Cassoobhoy

I agree w/ Dr. Cassoobhoy. Unfortunately, the benefits of an antibiotic can also have associated downside consequences. Many antibiotics are very broad in nature; so, they will kill many bad bacteria, but also good bacteria. Good bacteria makes up a large portion of the GI flora (gut bacteria). So, antibiotics should only be taken when absolutely necessary. There is a lot of discussion about prebiotics and probiotics, and, in theory, one would expect significant improvement in gut health after antibiotics with taking them. However, the data is not strong, and, rather, only a few of the many probiotics on the market have scientific data to support their use. -Marc Sonenshine, MD MBA

I'm a 27 yo female andI have moderate Crohn's Disease, that has been in remission for the last 7 years, thanks to Remicade. I'm wondering if long term use of these immunosuppressive drugs has been studied in relation to Colo-rectal cancer risk? And if so, what are my chances of getting it, what kinds of questions should I be asking my GI moving forward?

Chronic, on-going, longstanding inflammation from inflammatory bowel seems to be the biggest risk for developing colorectal cancer in a patient with ulcerative colitis or Crohn’s disease. Therefore, treatment which controls the inflammation will not only improve your life through symptom control, but, actually, probably reduces risk of colorectal cancer. Now, various medicines do increase risk for various conditions, but, like all things, the ratio of benefit vs risk must be weighed with your physician. - Marc Sonenshine, MD MBA

To David....What were some of the earliest symptoms that you may have had? Was there anything that you really didn't think was in any way abnormal, but looking back was something that turned out to be an early indicator that you should get checked out?

Good question. The earliest symptom was probably dark stools and occasional blood in the stools. After a quick web search I brushed this off for a couple of months as nothing too serious, which looking back probably was an early indicator that I should have been checked out sooner. – David Siegel

Good question. The earliest symptom was probably dark stools and occasional blood in the stools. After a quick web search I brushed this off for a couple of months as nothing too serious, which looking back probably was an early indicator that I should have been checked out sooner. – David Siegel

Dark, black, tarry stools are more often from an upper GI bleeding source like the stomach or small intestine, while bright red blood is typically from a lower GI bleeding source like the colon. In approximately 10 of cases, the opposite is true. So, any bleeding from the GI tract, whether from black stools or bright red stools should be investigated. Other things that may look like blood, but are not, is taking bismuth-containing medicines or iron supplements (both turn stool black) or eating beets (turn stool red). - Marc Sonenshine, MD MBA

Is there an association between hemorrhoids (blood on toilet paper) and malignancy at a later age?

It would seem plausible that the constant turnover of epithelial cells could lead to carcinogenesis.

Hi, so there’s no association between hemorrhoids and cancer at a later age, but I think it’s important to note that you have to confirm that the blood on the toilet paper is from hemorrhoids and not from some other colon condition - like colon cancer. Plus, talk to your doctor about treating those hemorrhoids so you don’t have any further bleeding! - Dr. Arefa Cassoobhoy

Hemorrhoids are swollen blood vessels that close the rectum. Hemorrhoids and their associated bleeding do not lead to colorectal cancer. However, many patients will assume the blood is from hemorrhoids when rather it is a lesion in their colon. Therefore, it is important, with rectal bleeding, to seek medical advice and confirm the bleeding is in fact hemorrhoidal in nature. Hemorrhoids can be treated with improved toilet hygiene (no more than 2-3 minutes on a toilet bowl) with a high fiber diet to ensure your bowels are regular. - Marc Sonenshine, MD MBA

How can young people get screened for colon cancer, if colonoscopies are not part of preventative care?

Other options for colorectal cancer screening beyond a colonoscopy are certain stool tests for blood (i.e FIT stool test or Cologuard stool test) or various imaging modalities (i.e. CT colonography or barium enema). However, if a colonoscopy is not covered, then, it is unlikely these modalities will be covered either. Remember, all non-colonoscopy screening tests that are positive will require a colonoscopy. It is important to discuss with your physician which test is best for you. - Marc Sonenshine, MD MBA

What are some big leaps in medicine in how colitis/chrons is being treated or even cured in the last 5 years?

There has been significant pharmaceutical advancements in the treatment of inflammatory bowel disease. Beyond earlier diagnosis due to increased awareness, in the past 10 years, there have been 3 new classes of medicines for treatment of inflammatory bowel disease, all of which have data for increased efficacy compared to older therapies. These new classes work on various parts of the inflammatory cascade. - Marc Sonenshine, MD MBA

Another colon cancer survivor in their mid 30s here (diagnosed at 29) - if anyone has any questions feel free to send them my way!

To the patient from the OP, how do you deal with colonoscopy prep? Every time it's a nightmare since Trilyte and Moviprep both make me really ill.

Thanks for joining, and hope your journey wasn’t too difficult. After I was diagnosed, I was inundated with survivor stories which was a great comfort to me as I underwent treatment. I have signed up for pretty frequent colonoscopies for the rest of my life, or until they come up with a better diagnostic option, so I share your pain with the prep. I have tried 3 of them and have one that is bearable only with a heavy dose of anti-nausea medicine. - David Siegel

At 27 years old, I was recently diagnosed with mild UC. Is there any truth to the idea that UC can be an early predictor of Colon cancer, and also, what is the end-game for UC? Medication for life once it becomes worse?

Ulcerative colitis is defined by the severity of the inflammation and the extent of the inflammation in the colon. The more limited and less active the inflammation, the lower the risk. Getting the disease in remission through effective treatment to resolve the inflammation will reduce the risk of a patient with ulcerative colitis developing colon cancer. Furthermore, patients with IBD (Crohn’s or UC) are monitored more frequently through surveillance colonoscopy to catch it early. - Marc Sonenshine, MD MBA

To what extent can colon cancer be attributed to controllable factors (e.g. diet & exercise) vs. uncontrollable factors (genetics, etc.)?

Great question. It all plays a role. No way to attribute a percentage of one risk factor to another. Obviously, one can’t alter their age, race, nor genetic profile. However, one can be monitored and screened more closely based on those factors. The modifiable risk factors one can control, and should work to control. Modifiable risk factors include weight (i.e. obesity), tobacco use, and diet (limiting red and processed meats). -- Marc Sonenshine, MD MBA

My paternal uncle died of colon cancer. My brother, who is 39 (only 2 years older than me), recently had blood in his stool and had precancerous polyps removed on a colonoscopy. I am female. What's my risk here of also having issues? My insurance denied noninvasive colon cancer screening (fecal DNA) because they consider it experimental and I'm too young to get a colonoscopy covered. I have no symptoms but I'd like to get some sort of screening done. What are my options and how important is it? I am hoping my risk is much less than his because I am female, not overweight (he is), and eat a much healthier diet including fiber (he rarely eats a vegetable)

I’m not sure that I can speak to your risk of colon cancer. But I do think it’s good you’re asking questions. Do you know how old your uncle was when he was diagnosed with colon cancer? That’s information your doctor will want to know along with your brother’s medical history. If you ever notice blood in your stool, or have other GI issues, let your doctor know. It may be that you’d benefit from testing like getting a colonoscopy to diagnose those symptoms and thereby get screened for colon cancer. I’m happy to hear you’re taking care of your health - not overweight and eating a fiber-filled diet. Good luck. - Dr. Arefa Cassoobhoy

Do you think probiotics are an effective means of treating certain GI issues? Do you believe that the intestinal flora is another organ often overlooked by MDs?

The data for use of probiotics is small, but evolving. In the future, I believe we will be using more gut flora (bacteria) related therapy. I do recommend trials of specific probiotics with continuation if there is symptomatic improvement in symptoms. There are relatively few conditions that I recommend probiotics as the lone treatment. - Marc Sonenshine, MD MBA

What should you do to start colon rectal screening? Should you just go to your GP or set up an appointment with a Gastro? What are the screenings like and when should you start your regularly scheduled ones?

A primary doctor can absolutely help and steer you in right direction, but, ultimately, you will be seeing a gastroenterologist. Colon cancer screening for average risk individuals should start at age 45. I favor a colonoscopy over the other screening tests, especially due to its ability to detect certain precancerous lesions. Furthermore, a negative colonoscopy provides a certain level of protection for a longer period of time -- 5 to 10 years. Whereas, the other testing options currently require more frequent testing. - Marc Sonenshine, MD MBA

What can you do to prevent colon and gastric diseases?

also

How bad/what damage does instant food (aka 5 min cooked food from a bag) do to your stomack and colon?

There is no simple answer. Prevention of all diseases comes from a broad approach -- maintaining a healthy lifestyle is the place to start. Eating a diverse, well balanced diet, exercising 3-4 times per week, avoiding tobacco, limiting alcohol, and developing coping mechanisms for stress / mental health wellbeing will go a long way.

Also, annual physicals with your primary care physician will also help, as certain recommendations based on age will help keep one healthy.

Instant food is probably not the healthiest, but, unlikely to cause a problem if only eaten on rare occasions. The best diet -- fresh and frozen, lean and green! - Marc Sonenshine, MD MBA

Why don't they check the prostate at the same time they do the colon scope? Seems like a good time to take care of the business in that area.

The prostate sits outside the colon. So, when a provider does a digital rectal exam for prostate evaluation, they are actually feeling the prostate through the rectal well. During a colonoscopy, the colonoscope should not be outside the colon. Some endoscopists, however, will do a rectal exam +/- prostate evaluation before inserting the colonoscope in the rectum. However, endoscopists do no typically specialize in prostate evaluation, and, thus, prostate cancer screening is usually covered with a primary care provider or urologist. - Marc Sonenshine, MD MBA

What symptoms should one be aware of?

Can IBS lead to cancer if not properly taken care off?

First off, irritable bowel syndrome is not associated with colon cancer, but inflammatory bowel disease like ulcerative colitis and Crohns can be associated with a higher risk of colon cancer. In terms of symptoms to be aware of -- a change in bowel movements like new diarrhea or constipation, bright red or black tarry stools, belly pain or gas pain, as well as general symptoms like weakness or weight loss. All of these could be from other gut issues, but it’s worth sorting through it with your doctor and deciding what diagnostic tests might be needed and what treatments to try. If you have irritable bowel syndrome it may take a conversation with your doctor to understand what changes to your symptoms would warrant a further testing or a change in your treatment plan. Dr. Arefa Cassoobhoy

IBS does not lead to cancer. IBS (or irritable bowel syndrome) is a constellation of symptoms with a normal appearing colon seen on colonoscopy. In rare cases, a patient’s symptoms attributed to IBS can be a malignancy or some other diagnosis, but, IBS won’t cause colon cancer.

Some frequent symptoms of colon cancer include rectal bleeding, abdominal pain, change in bowel habits, weight loss, and abnormal blood work (new anemia with iron deficiency). - Marc Sonenshine MD MBA

Is it possible to put something in to replace the colon so you wouldn't have to have a bag? Serious question because if i ever had to use a bag, i'd just put down 20 shots and go fight a rhino,.

Hi, there are surgical options for patients who need their colon removed, so a permanent ostomy bag isn’t always necessary. You could speak to a colorectal surgeon to get more information. But I do want to say -- I’ve heard from patients that the ostomy bag is not as bad as they expected. There are a few folks on Instagram that are breaking down stereotypes and the stigma surrounding ostomy bags. Search ostomy bags/colostomy bags. - Dr. Arefa Cassoobhoy

As someone who has a very strong family history of CC, what age do you recommend to start screening? My grandpa and uncle died from it, another uncle has had it, and they have found precancerous polyps on my dad.

You should start screening for colon cancer 10 years before the age your first degree relatives got colon cancer, or at age 40 -- whichever is younger. You’ll need to get a colonoscopy for screening. And if you notice any concerning symptoms with your bowel movements like blood or black tarry stools; or a change in your bowel movements get checked out, and let your doctor know your family history and any other health changes - Dr. Arefa Cassoobhoy

David- colon cancer check ups at your age arent the norm, so what lead you to seek evaluation? What symptoms did you have, and how long did the persist before seeing a doctor?

You are correct, most doctors don’t recommend screening at my age. Based on my family history, my primary care physician was going to start me on colonoscopies around age 35. As mentioned earlier, I had some dark stools / blood in stools and some abdominal pain which led me to discuss with my primary care physician who then referred me to Dr. Sonenshine. I reached out to my primary care physician the same day the abdominal pain started to occur, which was a couple months after the dark stools / blood in stools. The combination of the two was what led me to reach out to my doctor. - David Siegel

How accurate are colonoscopies?

Colonoscopy is the best test on the market for evaluating the colon. It is considered the current gold standard. All of the other tests on the market evaluate surrogates for a problem in the colon. Unfortunately, like all tests in medicine, it is not perfect, with a small false-negative rate.

Remember, the colon holds stool. So, a good cleanse is critical and reduces the risks of missing lesions. Furthermore, the colon has folds, so things can hide between and behind a colonic fold. The most important part of a colonoscopy is cleaning oneself out. Many patients will say “I can only drink ¾ of the stuff” or “ I can’t eat just clear liquids the day before” -- following a doctor’s recommended protocol for getting empty is not the doctor’s way of torturing a patient, but getting them clean so lesions are not missed.

Making sure your endoscopist (person performing your procedure) is following his quality metrics will lend to a better outcome too. Physicians follow certain indicators to ensure they are performing the highest quality procedure to reduce missed lesions.

Finally, newer scopes with HD imaging are improving outcomes and increasing detection rates.

-Marc Sonenshine, MD MBA

Did you have a strong family history of colon cancer or other malignancies? Anyone diagnosed at a young age?

Did you have a strong family history of colon cancer or other malignancies? Anyone diagnosed at a young age?

My maternal Grandmother passed away from colon cancer in her 40s (about 50 years ago), but no other family history of colon cancer. I had an aunt that passed away from breast cancer (other side of the family) in her late 50s or early 60s. I have undergone a panel of DNA testing to see if there is a genetic link and thus far nothing that is proven to be a genetic link, however some of my doctors do suspect a genetic link. - David Siegel

What does the typical treatment for colorectal cancer entail? What is the prognosis if caught early? Are there significant changes in how the patient has to live post-treatment?

Treatment depends on the location of the tumor and stage of the cancer and presence or absence of associated symptoms. Surgery is the primary treatment. Chemotherapy and occasional radiation is performed based on stage, location, and overall physical fitness. The earlier the cancer is found, the less therapy and better prognosis. Close follow-up surveillance is performed upon diagnosis. - Marc Sonenshine, MD MBA

There is currently an age difference recommended for your first screening colonoscopy. If high risk, why won't insurance pay for the younger age (45) group to have a screening done sooner?

Most insurance payors will pay for a colonoscopy in high risk individuals. Occasionally, if a physician recommends a procedure, a letter explaining the reasoning to the payor or prior authorization will be required. - Marc Sonenshine, MD MBA

Do you feel Okay David? Also, best Wishes to you man!

Thank you. I’m starting to feel better. - David Siegel

Hey there!

I was just curious about this, but are colon cleanses helpful/harmful?

Colon cleanses are not helpful and could potentially be harmful. Your gut is filled with good bacteria and you don’t want to flush those out. Leave it to your body to digest your food and move it through your colon, out your body like it’s meant to do. One of the only appropriate times to do a colon cleanse is before a colonoscopy. Your gastroenterologist will prescribe the liquid prep needed. - Dr. Arefa Cassoobhoy