Innovations and barriers in colorectal cancer screening strategies [PODCAST]

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Nurse practitioner Elisabeth Evans discusses her article “The critical role of nurse practitioners in colorectal cancer screening.” Elisabeth shares why colorectal cancer is the second-deadliest cancer in the U.S. yet remains under-screened, and why early detection can mean the difference between a 14 percent survival rate and over 90 percent. She highlights the lowered screening age, the role of public figures in raising awareness, and how nurse practitioners and physician associates can normalize conversations, provide multiple screening options, and ease patient fears. Elisabeth also discusses environmental risk factors, the importance of family history, and the potential of emerging technologies like blood-based screening. Listeners will take away strategies to better support patients, improve screening rates, and save lives through prevention and timely intervention.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Elisabeth Evans. She’s a nurse practitioner. Today’s KevinMD article is “The critical role of nurse practitioners in colorectal cancer screening.” Elisabeth, welcome to the show.

Elisabeth Evans: Thank you so much for having me.

Kevin Pho: Let’s start by briefly sharing your story and then jumping into your KevinMD article.

Elisabeth Evans: Sure. I am a nurse practitioner, believe it or not, for 20 years. My background is emergency medicine, family medicine, and for the most part, gastroenterology.

Kevin Pho: Excellent. And tell me about some of the typical cases that you see as a nurse practitioner in a gastroenterology practice.

Elisabeth Evans: Sure. For about 15 years, I specialized in inflammatory bowel disease at a tertiary care center, so I saw patients with Crohn’s disease and ulcerative colitis. I retired from the University of California, San Diego, and I’m now at a community practice looking at general gastroenterology cases, working with constipation, the brain-gut axis, acid reflux, diarrhea, and all those fun gut things.

Kevin Pho: And as a nurse practitioner, tell me about your role on the health care team in relation to the other members, like the physicians, the nurses, and the other medical staff.

Elisabeth Evans: In California, I practice pretty much on my own. I do have a physician that I will call if I’m stuck on a case or if I need help referring a patient out. I manage the patients pretty much on my own. I have a nurse that answers a lot of my questions and interacts with the patients. I have medical assistants that see patients and may call them with labs, but I really manage the patients pretty much on my own with my background and experience.

Kevin Pho: And in terms of procedures, if a patient that you see in a clinic requires a procedure, do you do those on your own or do you refer those out?

Elisabeth Evans: No, I refer those out. In California, that’s beyond our scope to be able to do colonoscopies or upper endoscopies.

Kevin Pho: All right, so let’s talk about your KevinMD article. You talk about colorectal cancer screening. Tell us what it’s about for those who didn’t get a chance to read it.

Elisabeth Evans: Sure. So my passion is really cancer awareness. In my practice, I’ve seen so many young people in their forties diagnosed with colorectal cancer. What’s so devastating about colorectal cancer is that there aren’t really signs like rectal bleeding, constipation, and weight loss until a patient already has late-stage cancer, and at that point, the prognosis is not great. We certainly have celebrities that have brought awareness to colorectal cancer in the younger generation.

This is really about how nurse practitioners and physician assistants, because we are in the trenches managing those patients while the physicians may be doing procedures, are having those day-to-day conversations with patients. How can we have that conversation even before the screening age of 45? When a patient comes in at 40, we can give them some advice about, “Hey, your screening for colorectal cancer is coming up. There are options.” There are just ways that we can place that in the meeting in our office visit, not just at that 45-year-old annual visit, because a lot of our patients are otherwise healthy. They don’t necessarily come in every year for their physical like maybe pediatric patients do.

Kevin Pho: And for those who aren’t familiar with the colorectal cancer screening guidelines, you mentioned age 45. So go into more detail in terms of what the current guidelines are.

Elisabeth Evans: The USPSTF did make a recommendation to lower the colorectal cancer screening age from 50. The new age is 45, and that’s for average-risk patients. If someone has a first-degree family relative (mother, father, brother, sister) that has had colon cancer, then we screen ten years before that family member was diagnosed with colorectal cancer. But for average general screening, it starts at 45.

Kevin Pho: When you approach colorectal cancer screening with patients in the exam room, just tell us your approach and how you share the different modalities and options that are available to them.

Elisabeth Evans: I think when we just ask patients, “Have you had your colonoscopy?” there’s an inherent sort of anxiety and fear. We’ve all seen those comics about the prep and how horrible that can be, and there is certainly a little bit of anxiety over that unknown of having to have a colonoscopy. So I try to approach it as, “Hey, have you had your colorectal cancer screening?” And when a patient says, “Oh, what’s that?” I say, “Well, at 45 we see a risk of colon cancer.” I don’t label it just as a colonoscopy. I try to let them know that there are options, there are stool-based options, and in the future, there might be blood-based options. I try to take some of the anxiety and the intensity away from just saying “colonoscopy.”

Kevin Pho: And you mentioned stool-based options. I hear commercials about Cologuard all the time. So going to those other options as well.

Elisabeth Evans: Sure. By lowering the age to 45, we’ve expanded colorectal cancer screening to hundreds of thousands of people. There are simply not enough endoscopists that can give everyone a colonoscopy. So again, if you have a family history, then you absolutely need to have a colonoscopy. What a colonoscopy does is it takes a look at the inside of the colon, finds a polyp, and removes the polyp. So it’s not just looking for cancer; it’s possibly removing a pre-cancer. That’s really our gold standard.

But for someone that just needs screening, a stool-based test like Cologuard looks for genetic material in the colon that’s produced by early cancers, and it also looks for blood in the stool. That really is a good enough test for patients as an initial screening, and they have that test repeated every three years. It is a test that’s mailed to the patient’s home. They are able to have a sample in the privacy of their home and then it’s shipped off. I tell patients that this is a screening test; if the test is negative, then 99.99 percent of the time, you do not have colon cancer. Now, if the test is positive, that doesn’t necessarily mean you have colon cancer. It might mean that you have an early polyp, but it means you do have to get a colonoscopy so that way we see why the test was positive. It’s not a test for someone who can’t undergo a colonoscopy. It’s not a test for someone who says, “On my deathbed, I will never do a colonoscopy.” It’s one of our tools that we have in our toolbox for patients to get them screened.

Kevin Pho: And just to be clear, if they do have that family history of colon cancer, then you strongly suggest the colonoscopy.

Elisabeth Evans: Absolutely. In fact, Cologuard is contraindicated for patients that have a family history of colon cancer. Cologuard is really just meant for patients of average risk.

Kevin Pho: What about those virtual colonoscopy options? CT scan-based colonoscopies? I have patients in my exam room asking me about those options. What do you think about that?

Elisabeth Evans: Sure. We think that a CT scan might give us more information, but what patients don’t realize is that with a CT scan, they still need to do the prep. Also, it can be quite uncomfortable to have contrast instilled rectally. A CT scan is not that sensitive for early cancers, and what we want, the purpose of a colorectal cancer screening, is to detect early cancers or pre-cancers. So a CT scan, I don’t usually make that recommendation because it’s not that sensitive to early cancers, it still requires a prep, and if we find something, a patient needs a colonoscopy anyway. If they’re open to it, I find that a stool-based test is just easier for a patient overall.

Kevin Pho: Tell us the types of questions that you get in the exam room where patients can have some reservations about colon cancer screening and how do you address some of those concerns?

Elisabeth Evans: Working in gastroenterology, I talk poop all the time. I have two boys at home; we talk poop all the time, so there’s nothing off-limits. But understandably, a lot of patients get a little sensitive when we start talking about diarrhea and bloody bowel movements. So patients are just naturally a little uneasy talking about their bowels. This isn’t a cancer that we share very openly with our family members. For some reason, maybe grandpa had a bag, but we don’t know why. There can be a lot of hesitancy and a lot of unknown. Most people don’t know their family history.

A lot of questions that I get are, “Well, why do I need this? I don’t have any symptoms. I don’t have this disease in my family that I know of.” So a lot of questions are just about “why?” That leads to the discussion of how we’re finding early-onset colon cancers and how screening is really about doing this test when you’re healthy to prevent cancer. Just like a mammogram for a woman will detect a cancer, a colorectal cancer screening test looks for early cancer so you never have to go through that.

It also leads the discussion, and I really want to emphasize, that a colonoscopy is not the only colorectal cancer screening test. Once patients hear there are options, they seem a little bit more open to it. You mentioned the commercials for Cologuard. I have to say in the last five years, a stool-based test isn’t as hard a sell as it used to be. About five years ago, it was a little harder back in the day to get patients comfortable with the stool-based test, but now we have commercials with the Super Bowl on it, so it seems to be a lot more familiar.

Some advice that I give to patients that do choose Cologuard is when the kit gets mailed to their home, to put it in the bathroom. It doesn’t do you any good if it’s in the hall and you’re ready to give a sample. Just some tips: when it comes to your house, bring it into the bathroom, have it ready. That way, it’s there and you’re not looking at it for the next year.

Kevin Pho: You mentioned earlier about the prep and sometimes that could be an obstacle in itself. What are some misperceptions we have about colonoscopy preps and what kind of options do patients have?

Elisabeth Evans: This idea of a prep that takes all day and is very painful with cramping is probably not the norm. There are large volume preps that are a gallon and taste terrible. I tell patients that there are smaller volume preps. They may cost a little more, but it’s worth it. There’s also a pill prep for patients, and these are for patients that have healthy kidney function, which are most of our 45- to 50-year-old patients. But there are low-volume preps available that make it much more tolerable.

It is an ordeal. It does take a whole day of clear liquids. It takes a whole day and night, and sometimes the morning of, to prep, but it doesn’t have to be that big gallon of nasty stuff. We can make the prep process a little bit easier. Something that patients don’t always consider is that they need to have a driver for a colonoscopy, and sometimes that can be a little embarrassing to have to ask a coworker or a neighbor. So again, emphasizing that a stool-based test might be easier for them and it may eliminate the need for a driver or taking a day off for a prep, etc.

Kevin Pho: We are hearing things in mainstream media about colon cancer being diagnosed in younger populations. What do you think some of the reasons behind that are?

Elisabeth Evans: That is the million-dollar question. There is something about this cohort that was born between 1970 and 1980. You can imagine, is it the addition of diet? What changed in our diet? It was TV dinners, it was aspartame, it was additives. Possibly. It is so hard to study diet as causation. We can see a correlation. Certainly, smoking increases your risk. Not being active increases your risk. We’re seeing a generation that may not be as fit, may not be as healthy, and may have been exposed to chemicals that earlier generations may not have been. What we do know is that there isn’t always a genetic factor. Most cases of colon cancer just happen, and it’s not genetic, it’s not family-based.

We don’t know why that’s happening, but typically because we believe we’re younger and healthier, the cancer is caught at a later stage where, again, like I mentioned, the prognosis is not as good in later-stage cancers as it is when we can catch it early. Thank you for the opportunity just to get the word out about colorectal cancer screening and hopefully your young audience listeners will take this advice.

Kevin Pho: In your article, you talk about some emerging concerns such as microplastics and their potential link to colon cancer. What’s the current thinking and data behind that link?

Elisabeth Evans: We’re seeing a link to all cancers, not just colon cancers. Again, it’s so hard to study something like diet or chemicals or microcosms, but we’re seeing an uptick in all cancers at an earlier age, and so it’s certainly worth the research.

Kevin Pho: In terms of the foreseeable future, what do you see in terms of any emerging technology? You mentioned blood-based potential options that could be screened for colon cancer. Where are we with that?

Elisabeth Evans: There are a few tests that at this time are not covered by insurance and are not on formal guidelines. To detect cancer in the blood, there needs to be circulating tumor cells. To detect cancer or pre-cancer in the stool is much easier because it’s sloughed off and it’s measured in the stool. A blood test needs to have more circulating tumor cells, which is correlated to a larger tumor. Right now, blood tests are not very sensitive for early cancers. They’re not sensitive at all for pre-cancers.

I think of the anti-cancer early detection test as a last resort. If somebody says, “I absolutely won’t do this, never ever will I ever,” and they’re willing to pay out of pocket, a blood test is an option. It’s meeting the patient where they’re at; it’s not forcing my will onto them. Colon cancer screening rates haven’t really changed, so we need to change. By just enforcing “colonoscopy only,” we’re not making a dent. I feel it’s important to meet the patient where they’re at, give them all of their options, and if they choose a colonoscopy, that’s fine. If they choose a stool-based test, that’s fine. Even if they choose to pay out of pocket for a blood test, at the end of the day, they’re getting screened.

Kevin Pho: We’re talking to Elisabeth Evans. She’s a nurse practitioner. Today’s KevinMD article is “The critical role of nurse practitioners in colorectal cancer screening.” Elisabeth, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Elisabeth Evans: Thank you. I just want to end with: colon cancer is prevalent, it’s rising in our younger population, and we don’t have symptoms of early-stage colon cancer. This is a cancer that can be treated early and it can be detected early. There are easier modalities. There are low-volume preps if we need to go that route. So don’t be scared. Engage in that conversation with your nurse practitioner and your PA. Ask questions. Don’t be afraid to speak up. If you do happen to have symptoms, it doesn’t mean it’s a cancer diagnosis. We can work together and we can figure this out.

Kevin Pho: Elisabeth, thank you so much for sharing your perspective and insight and thanks again for coming on the show.

Elisabeth Evans: Oh, thank you so much.