Month: October 2021

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States, and rates are rising, particularly in adults ages 20 to 49. Unfortunately, approximately 30% of eligible people in the US still have not been screened for CRC.

Colon cancer may be prevented with screening tests that look for cancer or precancerous growths called colon polyps.

When should you start screening?

The United States Preventative Services Task Force recommends starting screening for CRC at age 45 for average-risk patients. These guidelines reflect the most up-to-date research on when risk for colon cancer begins to increase.

Average-risk patients are those with no personal or family history of colon cancer or a genetic condition that increases the risk of developing CRC. For this reason, it is important for patients to share their family history, including all cancer diagnoses in blood relatives, with their primary care doctor, who can help decide the right time to begin colon cancer screening.

High-risk patients are advised to begin screening before age 45. A primary care physician can help determine when and how a patient who is concerned about their risk level should be screened for CRC. Patients who have a history of CRC or polyps; a first-degree family member with CRC or advanced polyps (those that would have gone on to become CRC if they had not been removed); a family history of certain genetic syndromes; or a history of inflammatory bowel disease (like Crohn’s disease or ulcerative colitis) are some examples of high-risk factors.

What are the options for CRC screening?

Colonoscopy: Colonoscopy is the gold standard of screening tests, and identifies approximately 95% of CRC. It is also the only method that allows a gastroenterologist to both detect and remove potentially precancerous colon polyps. Colonoscopies are considered low-risk procedures, but they do have a small risk of bleeding and perforation that increases in older age groups.

Patients need to clean out their colon prior to the procedure by drinking a colonoscopy prep, which washes stool out of the colon so that it can be properly assessed during the procedure. The prescription instructions for the prep are provided by the gastroenterologist’s office.

In most cases, the procedure will be performed under sedation to ensure the patient is as comfortable as possible. It is important to note that patients are not placed under general anesthesia, but most remain sleepy and comfortable throughout their colonoscopy.

During the colonoscopy, a gastroenterologist will insert a flexible tube with a camera at the end, called a colonoscope, into the rectum. The entire colon is then carefully examined. If no polyps are detected and the preparation (cleanout) of the colon is adequate, a repeat a colonoscopy is suggested in 10 years. If polyps are detected, or the patient’s risk level or symptoms change, this interval will be shorter.

FIT testing: The fecal immunochemical test (FIT) is a lab test that looks for hidden blood in the stool. Patients use a kit to collect their stool and then use a probe to scrape the stool, which is then placed into a tube and mailed to the lab. FIT testing is repeated every year. A drawback of FIT testing is that it has a false positive rate of approximately 5%. It can effectively rule out CRC with 79% accuracy. FIT testing is noninvasive, convenient, and cost-effective, making it an acceptable alternative to a colonoscopy for many people. If a stool test is positive, a colonoscopy is needed to evaluate the reason for the positive test.

Flexible sigmoidoscopy: A flexible tube with a camera is used to look at the rectum and the lower part of the colon. The advantages of this procedure are that it is faster than a colonoscopy (only 5 to 15 minutes) and requires less aggressive laxative medications. Typically, patients receive a flexible sigmoidoscopy every five years if no polyps are detected. As this test does not examine the whole colon, it cannot detect cancers or polyps in the unexamined portion. At best, it can detect 70% of cancers and polyps. If an abnormality is detected, a follow-up colonoscopy is needed to look at the entire colon.

CT colonography: A CT scan is used to visualize your rectum and entire colon. Just like with a colonoscopy, patients need to take laxative medications the night before to empty the colon. A small tube is placed in the rectum to expand the colon to get clear pictures. This test may be useful for patients who cannot tolerate anesthesia or have other medical conditions that prevent them from having a colonoscopy. A drawback of CT colonography is radiation exposure, and finding unrelated abnormalities outside the colon that can lead to unnecessary tests. While CT colonography is about 88.7% accurate at finding certain polyps, it is less accurate than colonoscopy overall. If the CT colonography result is abnormal, a colonoscopy is required for full evaluation of the colon.

Cologuard: This is a test where patients collect their stool, scrape it with a probe, insert it into a container with preservative, and mail it to the lab. This test looks for atypical DNA, or traces of blood in the collected stool that may be suggestive of precancerous polyps or CRC. Typically, patients repeat the test every three years. If the Cologuard test is positive, a colonoscopy is necessary for further evaluation. However, Cologuard’s accuracy is still limited; 13% of the time the test indicates the patient may have cancer when they do not. In 2019, a study showed that annual FIT testing or colonoscopy may be more effective and less costly than Cologuard. Further research is ongoing to evaluate how accurate (and thus how useful) this test is at detecting CRC.

Which screening option should you choose?

The most important part of colon cancer screening is to have a screening test performed. For most patients, colonoscopy or FIT testing are the most common ways to screen for colon cancer. However, there are other options to consider if you are unable to undergo or are uncomfortable with colonoscopy or FIT testing. Ultimately, this is an important and personalized decision, and a discussion for a patient to have with their healthcare provider, so that the right test can be done at the right time.

About the Authors

Nisa Desai, MD, Contributor

Dr. Nisa Desai is a practicing hospitalist physician at Beth Israel Deaconess Medical Center, and an instructor in medicine at Harvard Medical School. She completed undergraduate education at Northwestern University, followed by medical school at the … See Full Bio View all posts by Nisa Desai, MD

Loren Rabinowitz, MD, Contributor

Dr. Loren Rabinowitz is an instructor in medicine Beth Israel Deaconess Medical Center and Harvard Medical School, and an attending physician in the Inflammatory Bowel Disease Center at BIDMC. Her clinical research is focused on the … See Full Bio View all posts by Loren Rabinowitz, MD

In the spring of 2020, the pandemic catapulted many of us into shock and fear — our lives upended, our routines unmoored. Great uncertainty at the onset evolved into hope that, a year later, a semblance of normalcy might return. Yet not only do people continue to face uncertainty, but many of us have also reached a plateau of fatigue, resignation, and grief.

We are living through a time of widespread illness, social and political unrest, economic fractures, and broken safety nets. Whether each of us experiences the ravages of this time close to home or as part of a larger circle, the symptoms of collective trauma are widespread. Many of these symptoms — feeling overwhelmed, anxious, fatigued — may be familiar. One deserves special mention: numbness. As a psychiatrist who has considerable experience treating refugees suffering from trauma, and an author and teacher who works with collective trauma, we have learned a great deal about how numbness affects us all.

Newsfeeds: Friend or foe?

Compounding our challenges are our news viewing habits. During times of uncertainty, we are each, in our own way, experiencing vulnerability. Fears that had lain dormant for years may be activated, causing low-grade stress or full-blown anxiety. These fears are exacerbated by what might be called the “toxic trauma story” churned out by mainstream news channels.

The formula is simple: brutal facts associated with high emotion attract viewers. As the old adage says, “If it bleeds, it leads.” Negative news around vaccine reactions or political unrest provides the ultimate sensational content for viewers. But for most Americans, this daily onslaught of negativity exerts a toll on mind, body, and emotions.

Numbness is one possible response to trauma

When a situation is overwhelming, your body protects itself by entering a “fight, flight, or freeze” mode. Our responses to the pandemic and continuous uncertainty, fueled by doomscrolling and newsfeeds, range from hyperactivation (fight or flight) to numbness (freeze). While the three Fs refer to the body’s stress response in the moment, these reactions can continue long after exposure to trauma.

In medical terms, numbness occurs when nerves are damaged, leading to partial or total loss of sensation in the body. We can also describe numbness related to our psychological well-being: a lack of enthusiasm and interest in life, a sense of apathy and indifference. The spectrum ranges from mild apathy to disassociation to a heavy, weighty lethargy, which is often a symptom of severe depression. “Freeze” refers to a paralyzed or frozen state associated with post-traumatic stress disorder (PTSD) and major depression. We have each worked with thousands of people — some refugees, some not — who have experienced this level of trauma.

The numbness many people are experiencing and describing these days didn’t necessarily begin with the pandemic, nor is a toxic stream of trauma stories the only source feeding it. It may have been there for many years, only to be triggered by recent personal and societal challenges.

This numbness is not just a lack of feeling; its symptoms vary. You might feel a low level of anxiety operating in the background, much like an operating system running our computers silently. You may feel no emotion or a sense of frozenness during the day, followed at night by insomnia or nightmares. Some people who are refugees cannot watch the daily news, since it is a terrifying trigger that floods them with memories of their past traumas.

How does numbness affect us collectively?

Millions of people turn to their phones and devices for daily notifications of traumatic news. These instantaneous alerts offer little space for digestion and reflection. That harmful combination of speed and trauma can strike at our nervous systems, overwhelming us until we are too numb to comprehend the complex range of experiences flooding in over the last days, weeks, and years. What happens to us as a culture, grappling with this cumulative phenomenon?

Where collective trauma now exists, we need to seek ways to facilitate dialogue and restoration. The numbness following traumatization reduces our capacity to witness suffering. We lose our reflective capacity to be self-aware, which reduces empathy and compassion. Indifference and disconnection can contribute to further atrocities, fueling a feedback loop that makes new traumas more likely to occur.

Collective numbness can surface as epidemic substance misuse; food, sex, or entertainment addiction; media overuse; or in other ways. It reveals itself as a collective shutting-down to crisis, which can derail healing.

How can you counter numbness and feeling overwhelmed?

As individuals, we can spend more time practicing self-care, as outlined in the Harvard Program in Refugee Trauma toolkit. For example, take time to reflect on the resources and sources of support you have in your life. Spend quality time with family, and if possible, in nature. Set boundaries on news devices to give your nervous system a chance to relax. Turn off your notifications, leave your phone far from your bedroom at night, and consider periodic news fasts to give your system a full recharge.

Developing a mindfulness practice can help reduce stress, allowing people to digest and integrate hidden emotions or experiences buried under numbness. One option is a practice called 3-sync: imagine a journey of witnessing yourself, moving deliberately as you notice the state of your body first, then your mind, and finally, your emotions. Following this during meditation can help you become aware of imbalances within yourself, as well as areas of strength and vitality. Another practice, global social witnessing, is a conscious process of witnessing the news, and digesting it with our minds, bodies, and emotions fully present.

By working together to be with whatever is present, acknowledging and feeling our discomfort, resistance, and pain, we may move closer to integration and a sense of healing during this time of upheaval.

About the Authors

Richard F. Mollica, MD, Contributor

Dr. Richard F. Mollica is a professor of psychiatry at Harvard Medical School, and director of the Harvard Program in Refugee Trauma (HPRT) at Massachusetts General Hospital. A pioneer in international research on refugee trauma, he … See Full Bio View all posts by Richard F. Mollica, MD

Thomas Hübl, Guest Contributor

Thomas Hübl is a renowned teacher, and author of Healing Collective Trauma: A Process for Integrating Our Intergenerational and Cultural Wounds. Since 2002, he has led dialogue and restoration processes around collective trauma with more than … See Full Bio View all posts by Thomas Hübl