Jolanta Gore-Booth, the CEO of Digestive Cancers Europe, discusses the value of colonoscopy in diagnosing and preventing colorectal cancer.
In a recent survey by specialist pharma company Norgine, close to 90% of participants across five major EU countries said they expect to drink two litres or fewer of bowel preparation liquid before undergoing a colonoscopy – well short of the three litres or more that is typically required in the clinic. The results, which were presented at United European Gastroenterology Week 2018, are perhaps indicative of a wider lack of awareness around colorectal cancer and the importance of screening, which is central to early diagnosis and survival.
Health Europa spoke to Digestive Cancers Europe CEO Jolanta Gore-Booth to learn more about what can be done to improve bowel preparation adherence and ensure that colonoscopies are available to those who need them.
Why is bowel preparation liquid so important prior to a colonoscopy?
Without a clear bowel you cannot do a colonoscopy – it is that simple. You have to cleanse the bowel to the point where there is absolutely nothing left in it, and the cleaner the bowel, the better the results. The most important things to remember before having a colonoscopy are, firstly, to drink all of the cleanser, even though you may not want to, and, secondly, you have got to be absolutely clean inside the bowel so that the endoscopist can get the best view.
What can be done to improve bowel preparation adherence?
I think the problem lies in the taste of the cleanser – it’s not the nicest. Up until now, as well, you have had to drink four litres of fluid, which is an enormous amount, especially for older generations who are not used to drinking much water. It is a struggle for a lot of people. However, there is a new product out now which is only one litre, which does make the journey a bit easier, but as far as the taste goes, I think hints and tips are being currently prepared to make it easier to tolerate the cleanser such as keeping the fluid in the fridge so it’s cold, or drinking it through a straw. After I drank mine, I gargled to get the aftertaste out of my mouth.
To put it into perspective, though, it is an unpleasant few hours that can save your life – it did in my case.
What are the key advantages of colorectal cancer screening and how can people be motivated to take part?
We as an organisation are in the process of developing a pan-European awareness campaign for screening called #MyBestTenSeconds. It takes ten seconds to do the faecal immunochemical test (FIT), which checks for the presence of blood in the stool. This then tells you whether or not you are at risk of colorectal cancer. It is not a diagnostic test in itself, so if your results are positive, you should not immediately panic and assume the worst. There are other reasons why blood might be present in your stool.
The next step following a positive test result has to be a colonoscopy, because only that can confirm whether or not you have colorectal cancer. If you do, then it is likely to have been diagnosed early and can therefore be treated.
People still fear the word cancer, and they do not realise that in some cases it can be cured and that there are many people in the world today living with cancer. We have to educate people to understand how important it is that they do the screening test and then, if it is positive, that they need to do a colonoscopy.
I have been working in colorectal cancer for 20 years and – though I hate to admit it – I had never done a test let alone a colonoscopy until last year when I did not feel very well, which is ridiculous because I should have done it ages ago. The reason I didn’t was that I too feared the word cancer and, stupid as it may sound, I was worried it might hurt. In fact, it did not. I was semi-conscious, and because my bowel was very clean and because I had a very experienced endoscopist, I probably could have done it with no anaesthetic at all.
I was not diagnosed with cancer, but I was on the way there; a few years down the line and I could have had colorectal cancer since my polyps were transitioning. Thankfully, because it was caught extremely early, I could have my polyps removed during the colonoscopy, and now I just need to repeat the procedure in a year’s time. That’s the enormous benefit of colonoscopies – if anything untoward is discovered it can be removed straightaway. I cannot promote adherence enough both to screening and to follow-up colonoscopy.
More widely, what can be done to improve early diagnosis of colorectal cancer?
Improving early diagnosis and outcomes is the job of many stakeholders – the public, patients, clinicians, health ministries, industry. We need to ensure that the public better understands the importance of screening and when needed follow-up colonoscopy, we need to ensure that the people that are doing them are well trained, and we need to ensure that enough funding and resources are available to scope people quickly. That latter point is terribly important. When I began working in colorectal cancer in the UK, there was a nine-month wait for a colonoscopy. Can you imagine waiting for nine months, thinking you might have cancer?
Over the years, things improved and colonoscopy waiting times became much shorter. Unfortunately, in the UK now it appears that we are moving backwards and waiting times for colonoscopies are once again falling behind. We face a dilemma: the more screening that is being done, the more colonoscopies that are being done. That requires more endoscopists and more beds – more capacity. We have to be very careful to make sure that the people who are actually symptomatic are being scoped quickly and that the system is not being clogged up by potential false positives. I would encourage triaging as a potential solution. There are different tests being developed now which could identify whether a screening result is a false positive or not, or another solution would be just to do another test under much tighter conditions and see whether it comes up positive again. These are issues that need to be addressed because if the capacity is not there, then you have to limit what you can do.
This article will appear in issue 8 of Health Europa Quarterly, which will be published in February 2019.