Ep. 30: Chadwick Boseman and Colon Cancer Prevention
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In the movies, few people seemed healthier than Black Panther—which is what made the recent death of the actor who played the superhero, Chadwick Boseman, so surprising. Boseman was only 43. What can you do to prevent colon cancer? What’s the future of colon cancer treatment? Guest host Dr. Peter Nord, Medcan’s chief medical officer, interviews gastroenterologist Dr. Jeff Axler to get the answers.
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LINKS AND HIGHLIGHTS
Dr. Jeff Axler bio: A gastroenterologist working in Ontario for the past 43 years, Dr. Jeff Axler graduated from the University of Toronto in 1977 and has practiced in the specialty of gastroenterology in Toronto since 1984. He was the head of his local hospital gastroenterology division for more than 25 years. A past president of the Ontario Gastroenterology Association, Dr. Axler serves as a lecturer in gastroenterology for the University of Toronto, teaching 4th and 5th year fellowship trainees in gastroenterology and is a frequent principal investigator in clinical trials, mostly in inflammatory bowel disease. His studies have been published in some of the top peer-reviewed gastroenterology journals, including the New England Journal of Medicine and the Journal of Crohn’s and Colitis. He is presently on staff and associated with William Osler Health Center, North York General and Mt Sinai Hospital, and is the head of gastroenterology and the medical director of the endoscopy clinic at Medcan.
Facts about colon cancer, according to Dr. Axler:
Colon cancer incidence for those in Chadwick Boseman’s age group is 13 per 100,000 people. Rates have climbed in recent years from 8 per 100,000.
Your risk of getting colon cancer is 5% and if you have a first-degree relative who has been diagnosed, your risk doubles.
The colon is the lower intestine. It’s like a trash compactor and dehumidifier all in one, Dr. Axler says. It’s the fourth most frequently diagnosed cancer diagnosed in Canada after lung, prostate and breast cancer.
Colon cancer is very survivable and treatable if you catch it early. Screening is more convenient and easier than it’s been in the past. For most people, screening begins at 50. However, 10% of colon cancer cases begin under the age of 50. The American Cancer Society is suggesting screening of average risk people starting at age 45.
Our episode 30 guest, Dr. Jeff Axler, at left with a colleague before an endoscopy clinic.
Please subscribe and rate us on your favourite podcast platform. Eat Move Think host Shaun Francis is Medcan’s CEO and chair. Follow him on Twitter @shauncfrancis. Connect with him on LinkedIn. And follow him on Instagram @shauncfrancis. Eat Move Think is produced by Ghost Bureau. Executive producer is Chris Shulgan. Senior producer is Russell Gragg.
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Chadwick Boseman and Colon Cancer Prevention final web transcript
CHRISTOPHER SHULGAN
Black Panther made more money than any other superhero film to feature an individual protagonist. It’s number five in the highest-ever grossing superhero movies ever. Its success came, in part because of the charisma of the person who played Black Panther, Chadwick Boseman. So the news that the actor had died at the age of 43 of colon cancer, was one of those events that underscored the fragility of life—and the importance of following a healthy lifestyle. But exactly what kind of a healthy lifestyle is required to minimize the risk of developing colon cancer? How prevalent is colon cancer? And what does the colon do, anyway?
CHRIS
I’m Christopher Shulgan, executive producer of Eat Move Think, and this week’s episode amounts to an explainer of colon cancer and how to prevent it. Our guest host is Dr. Peter Nord. He’s the chief medical officer of Medcan, and he’s interviewing gastroenterologist Dr. Jeff Axler, who specializes in treating and preventing colon cancer. Here’s that interview.
DR. PETER NORD
So Dr. Axler, welcome first of all. Great to have you here. Super experienced clinician, especially with this particular topic of colon cancer. And we bring it forward today because of specifically Chadwick Boseman's recent death, which was pretty shocking to everybody for a couple of reasons. Number one, his age being 43. And the fact that he was able to really keep this so private and out of the public spotlight, and frankly be able to do the work that he was doing—very demanding, physically demanding work, while having gone through surgery and chemotherapy. I mean, such a tremendous actor and a real inspiration for young people of all colour.
DR. NORD
And so, you know, the kind of work that he was doing, I mean, Martin Luther King III said, you know, he brought history to life on the silver screen by his portrayal of Black leaders. You know, he played James Brown most recently, and then Jackie Robinson in the movie 42. And then the role that most young people would know him in King T'Challa in Black Panther. And so I think it came especially as a shock to younger people thinking well, colon cancer's a disease of my grandparents, and here's this guy who was in his 30s when it must have been first diagnosed. And so all the challenges that he went through. And so it's really brought this topic to light. So we thought we would focus on that today. And so, you know, specifically the age factor, so how common is colon cancer at that age? Age of 43?
DR. JEFF AXLER
You're right, the issues are A) that he was young, and B) that he's Black. So when you just look at overall, the statistics on colon cancer in the United States in that age group, it's still exceptionally unusual. It's 13 per 100,000 in 2016 had colon cancer at that age. So while it's tragic, and you look at the numbers, you say, "Gee, that's not that common." Although, in the last 10 years, it's gone from 8 per 100,000, up to 13 per 100,000. So, when you look at those numbers, it's gone up, but it hasn't really gone up to the point that I think people should worry. But still, it's an issue. And it's certainly an issue for me.
DR. AXLER
I work in a part of Toronto, that is, I'd say about 30 to 40 percent of my patients are Black. And we see the same thing here in Toronto that has been reported across Canada, across the United States, in that we're seeing colon cancer more in our Black community and also more in younger patients. You know, I was just telling Peter, this morning I was scoping patients, we found a patient actually who had colon cancer. She happened to be an elderly woman, 81, who hadn't been screened before. But as I was speaking to my surgeon next to me explaining the case to be done, he said, yeah, he just had a guy in his 30s who's from our community who's Black, who has extensive colon cancer already. So that is something that we're seeing. But I think if you look at the numbers, 13 per 100,000, I think that should put things in perspective, that it's come to our attention because he was such a fantastic actor, he's well known, he was really an icon and a role model, and it's tragic. But the numbers still are low. I think that's the other thing we should keep in mind.
DR. NORD
Yeah. And maybe we should start by going right back to first principles in terms of colon cancer. Maybe just give us a few seconds in terms of what's the colon? And, you know, how does cancer most commonly manifest in the colon?
DR. AXLER
Well, if you think of your digestive system as this long tube, there are certain parts of the tube, like the upper part people know is their stomach. And then the middle part is the small bowel, which actually doesn't get cancer generally. And then there's the lower intestinal system called the colon. The colon basically is, if I can use an interesting term, it's like a trash compactor and a dehumidifier all in one. It sort of takes what's going through your digestive system and sort of compacts it and takes the water out of it. And what comes out of it is stool, but that's essentially all the colon really does. It takes out some liquid part of the stool and compacts it in a way that we can manage our life. But unfortunately for reasons aren't totally clear, it has a higher rate of cancer than nearly any other part of the body after lung and after prostate and breast, it's the most common cause where cancer will occur in your body.
DR. NORD
Yes, so any hypotheses around why that happens? Why does cancer appear in the colon? And especially now we're seeing a bit of an upsurge in rectal and anal cancer as well, is there any hypotheses around those?
DR. AXLER
You know, you wonder why—like, when I scope people and I find the cancer, I always wonder, like, why did it happen there? Like, what was happening there in the colon? Like, did they have a different microbiome? Was the bacteria different there? You know, is it the food that's reacting differently there? Is there something going up or something going down? It's really not clear why that cancers occur at certain spots. It's generally felt that what's going on is at a cellular level, the DNA gets damaged and it gets repaired, in most cases. But in some cases, if it doesn't get repaired, the cell starts making abnormal proteins and starts changing, it forms a cancer. But really, in terms of the reason for it, I can't really say there's one universal reason. We can associate colon cancer with lots of things like red meat, animal fat, other issues like smoking, obesity, but there's many other things that really come into play here. Like, I have patients who are vegetarians, and they got colon cancer. They go, "How's this possible?" So I've got to give the answer that all the doctors say now during the pandemic: I don't know. I don't really know why people are getting colon cancer.
DR. NORD
But there are those associations. I know some of my patients will ask about fibre and transit time and that sort of thing. Has there been any association with individuals that might be on the less regular side to the more regular, and density of stool and fibre content and that sort of thing? Transit time through the colon? Anything around those theories?
DR. AXLER
Well, you've got to remember the theory of fibre was brought on by this guy Dr. Burkitt in Africa. What he noticed in Africa was, he was seeing people with very large bowel movements, and very low rates of colon cancer and diverticular diseases and said, "Ah! It must be all the fibre in their diet." And while that's a nice idea, in fact, what we're finding now is people eat more fibre are getting more polyps, which are sometimes pre-malignant conditions, which sort of totally is opposite to what we thought. But we do find generally that people who have lower fibre diets do have higher rates of colon cancer, but we haven't really been able to show that adding more fibre really makes a difference. So nonetheless, I eat a lot of fibre every day, I have a nice cereal every day. So I still believe that, even though the data isn't there, I think it's probably a good idea.
DR. NORD
Yeah, so most of the things are by association, not sort of cause and effect.
DR. AXLER
Correct.
DR. NORD
Great. And how about colon cancer in the various age groups? So we touched on that. How typical—you know, obviously, this is in younger individuals, it's less common. Where's the peak of that curve in terms of the prevalence of colon cancer? And is there a gender difference between males and females?
DR. AXLER
What happens is, as you get older the chance of you getting colon cancer rises. And it starts to rise really once you get into your 70s and 80s. And it really starts going up exponentially. Below that it's there but it's low. As I said, you can talk about that number of 13 per 100,000 in that age group between 20 and 49, but it starts to rise so that overall, the chance of you getting colon cancer in your life is about 5 percent. It's about 1 in 20 chance you're going to get colon cancer. But if you live to age 60 or 70, then your chances start to rise after that. And that's why when they look at screening, like, checking for people, they don't start screening early on, they start and they say, "Gee, if you're going to get colon cancer in your 60s or your 70s, let's start 10 years beforehand." And arbitrarily, we choose the age of 50. So if you look at the curve, when it starts to rise, it really starts to rise in your 60s and 70s. And they try and pick it up at starting at age 50. But we can talk about why that may not be the right number.
DR. NORD
Well, let's go there. I mean, in terms of screening, that's so important, and maybe one of the reasons why we're seeing some more cancers, hopefully at an earlier stage. What's the best kind of screening at the end of the day?
DR. AXLER
Well, there's all different types of screening techniques. And in the end, the best screening test is the one that you're going to go for. So some people will prefer a stool test that checks for blood, some people would choose for a colonoscopy. I feel badly for example, today when I scoped this 81-year-old lady and she'd never been scoped before because she was too afraid. I think that outlines the real social stigma that people have. They're just afraid to go or they just don't want to be tested. And this is really a very preventable disease. We know colon cancer is a very slow-growing cancer. It doesn't happen over a period of weeks or months, it takes years for these to develop, often through a polyp formation. the most common two types of tests for screening, that means testing people who don't have anything wrong with them but checking for things, is either a stool test, or a scope test called a colonoscopy.
DR. NORD
And this stool testing has changed a little bit over the last couple of years as well. What about this FIT test that we've heard about?
DR. AXLER
Okay, for sure. I mean, we used to have a test called FOBT, which was a test for the iron part of blood, whereas the newer test, the FIT test, actually tests for the heme or the hemoglobin part of blood. So the newer test is way better. The old test, believe it or not, missed 49 percent of cases. Which meant that if you had colon cancer, the old test would miss 49 percent. The new test, the FIT test is much better, but it still misses about 19 percent of cases. So you could if you actually have a colon cancer, that FIT test will be on one test, miss 19 percent. But if you keep testing every couple of years, the pickup rate is better. Now colonoscopy, which I always suggest, still has its own miss rate. We miss about two to three percent of cases. So there's nothing really perfect. You got to go into the screening concept understanding that nothing's perfect, but if you wanted the most accurate test, it would be a colonoscopy.
DR. NORD
So that's the gold standard, really, at this point.
DR. AXLER
Yeah. But for people who say, "I don't want to be scoped," the Fit test is really a great second alternative, bearing in mind that you could miss it in about 19 percent of cases.
DR. NORD
Yeah, and plus, there's other reasons why blood could be coming down the GI tract, and so there's a false positive read associated with those as well.
DR. AXLER
Yeah, I get that all the time when I get referred a FIT-positive test and the patient goes, "I've got hemorrhoids, they're bleeding all the time." And of course, the stool test is going to show positivity. So that's probably not the best way of doing that test. The test is best done on a patient who has no symptoms, is just going for a screening test. And so the significance of that is much more important. So screening really, we've been trying to get screening as a modality. But it's interesting, people still don't get screened. Like, screening rates across Canada are about 55 percent. And believe it or not, in the United States, screening rates are better. Screening rates are about 60, 65 percent. And we still need to get the message out, and maybe that's going to be the one thing that with this gentleman who passed away, I think people started to realize maybe I should be checked, you know? And I think if anything comes out of this story, this unfortunate story, that maybe they'll consider getting checked by going to their doctor and having either a FIT test or a colonoscopy.
DR. NORD
Yeah. And maybe a word of reassurance around the prep. I know a lot of my patients, they don't mind the colonoscopy, but they hate the prep. And that prep has also been changed significantly over the last couple of years.
DR. AXLER
This is the bane of my existence, explaining to people what's a good prep. Now the prep's better, but it's still not great because it involves, you know, going to the bathroom and drinking a fair amount of fluid. Right now we've cut down on the amount of fluid that people have to drink. But what we're finding is we do what's called the same-day prep, meaning the same day of your colonoscopy you're supposed to take prep early in the morning. And the reason we do that, not that we want to drive people crazy, but we find that you get a much better prep so we can see better. So if we can see better, we're not going to miss things. So while people may not like getting up two, three in the morning to take that prep, just think of it as taking an early-morning flight and you got to go to the airport early that morning. You know, take it, it's worth it, you'll get to the airport early, your doctor will have a better look at your colon and it's not going to have that two percent miss rate, he's going to have a zero percent miss rate. So that's become standard across the world now of doing—it's called the same-day prep.
DR. NORD
Yeah. And I mean, it wasn't too long ago that the prep would take two or three days sometimes. You know, just more and more and more fluid diet. And so compacting this into a very short period of time, it certainly makes it more convenient for everybody, for sure.
DR. AXLER
But there's lots of cultural issues too. Some people, like, talk about the colon, they're not interested. So we still got to get over that social stigma of talking about the colon. It's sort of like where we were about 20 years ago with breast cancer. You know, no one wanted to talk about it. Now we're into self-examination, mammography, awareness. And screening for breast cancer is much more prevalent and much more organized across most countries now.
DR. NORD
Yeah. Well, let's move to treatments then. So we've got screening, and let's say you're scoping somebody and you're seeing either something that looks very suspicious, a polypoid lesion comes back and it's showing that, in fact, as you biopsy that it's coming back as cancer. What is the next step in terms of staging? And based on the staging, what are the kind of treatments that we can offer people, especially if early detection is there?
DR. AXLER
Well, I'll take that case today. I saw a patient, this 81-year-old lady, she's got a rectal mass, which I'm sure is a cancer. We have a discussion. So what I explain to her, the first thing we have to do is stage this. And the way we do that is by imaging. And we would involve a CAT scan of both the chest, abdomen and pelvis, to really see the extent of the disease. Then once we get back the pathology report, which takes about a week, then the next appointment would be with a surgeon. The surgeon would then say, "Okay, is this lesion resectable? Or is it not resectable?" If it's resectable, it would mean that it has not extended too far beyond the lining of the bowel. And that it's not extensive, meaning stage four, and it's not obstructive. If it's an obstructing, meaning it's totally blocked off the colon, there's a different type of surgery involved.
DR. AXLER
But if we're looking at curative surgery, we're hoping that it's going to be early, what's called stage A or B where it just goes locally. We make sure that it has not spread to other organs like the liver or the lung, because those may have to be treated as well. Occasionally, patients may need, before they get surgery, what's called neoadjunctive chemotherapy and sometimes even radiation, but it's usually chemotherapy beforehand. Every case now doesn't just go up to a surgeon's idea of what he wants to do, it has to go before a tumour board. And they go through the standard protocols as to what they're going to do. They look at the staging, they see if it's potentially resectable and curable. And if it is, they will do it. So at least in Toronto, not every hospital will do cancer surgery, because it's a specialized type of thing. But that would be the approach: stage it, get the biopsy reports, make sure there's nothing else spread. And often, the best treatment is a localized resection, meaning you take out that piece of colon cancer, you put the two pieces together, and further treatment might be dependent on what they find. In other words, if they find there's no cancer in the local regional nodes, there's no other treatment necessary.
DR. NORD
That's great. And the surgical if caught early and it is resectable or able to be cut out and it's a fairly standard approach to bowel surgery, the results are extraordinary in terms of survivability and longevity. Those numbers haven't really changed there. They've always been quite good. I think that's another way to think about, you know, early detection means no chemo, surgery, chemo may not be needed, and the outcome is very optimistic.
DR. AXLER
Yeah. I've got to tell you, every time we scope and we find cancer, there's like a hush that comes over the operating room because it's like, oh God, we feel badly for the patient. We sort of feel, how did we fail this person? Why didn't we get that message out? You know, we know there's a difficult discussion, we know what they're going to go through, and there's a possibility they're going to die if it's too far. So we sort of feel like if it's caught early, like you say, Peter, this is a really completely curable, 100 percent curable condition if it's caught in the early stage, where it's called stage A.
DR. NORD
Yeah. And that's, I think, a really important message for our listeners, that not just that the screening is more convenient than it was in the past, but it's really important to get this early, because catching it late, we come back to the Chadwick Boseman situation. You know, and just in terms of understanding, have we had any changes in the overall colon cancer understanding to that end?
DR. AXLER
There's more and more genetic analysis and looking at the genes for colon cancer. So in some cases, there is a gene for colon cancer, there's a condition called familial polyposis, where if you have that gene you're going to get colon cancer. However, that's a little simplistic for the vast majority. That's like less than one percent of people have that condition. The vast majority of other people have multiple genes, I think you have to look at it like a deck of cards, that some cards will give you the risk, some won't. So if you're dealt—if you got a bad hand, some bad genes, you're going to get it, but it's not necessarily one card that's going to do it. It's going to be that pattern of genes and the other genes that you have. So you can do more genetic analysis about which genes are promoters and which genes are not promoters, and we're going to get better at that. We're going to be able to say, probably in the next 10 years with genomic studies, that your risk is way more than somebody else based on what we know, the way you're built. It doesn't mean that you're going to get it, but it's like a risk assessment.
DR. NORD
And so family history would be one of those things that every physician should be asking their patients.
DR. AXLER
Yeah. So what happens is, overall, your risk of getting colon cancer is five percent. But if you have a first-degree relative like a parent, brother or sister, your risk already doubles up to 10 percent. But it also depends when that family member got it. If your family member got it under the age of 65, it's a much more significant risk factor than if the family member had it in their 70s or 80s.
DR. NORD
For sure. And that's one of the reasons that at Medcan we have a very robust genetics program looking at all these things. We're convinced that the future of medicine is really taking a really good look at a person's genetic makeup. There's a lot of research going on, a lot of science is showing we can certainly tell people that you're at higher risk, you should definitely be screened on maybe a more frequent basis, more aggressive screening, so that we're picking up things early.
DR. AXLER
By the way, Peter, we find that if someone in the family is found to have colon cancer at a young age, the first thing we look at is their genetics. We look for something called the Lynch syndrome. And what the Lynch syndrome is, is a condition that actually the colon cancer forms directly without going through a polyp form. It's called hereditary nonpolyposis colorectal cancer. That's the Lynch syndrome. And I mean, I just had a phone call yesterday from a guy who's in his 30s. He's at a local hospital having actually a liver resection because he had metastatic disease diagnosed, and he's calling me from his hospital bed saying, "You got to get my mother and my brothers screened." Because—and the other irony is, this is a guy who's a vegetarian. So again, another tragic story. Someone in their 30s got it, would not normally have been screened. But however, it was looked and checked for Lynch syndrome because if they do have Lynch syndrome, we know that is something that's more common in their family and then we can screen those people and more regular basis.
DR. NORD
So maybe a final question, and I guess this is where it all comes down to. What can a person do to prevent colon cancer?
DR. AXLER
You got to be born right.
DR. NORD
Choose good parents.
DR. AXLER
Choose good parents. Okay. The question is, and what can you do? Well, you can make sure that you don't smoke, you can make sure that you're not fat, you've got to make sure that you eat right, that you make good lifestyle decisions. And I would still say eating fibre is a good thing. I don't think you have to be fanatic, but I think that food selection is important. And I think you should start talking about screening, I think you should take control of your screening. And considering that there's good screening, make sure that your family doctor screens you. And he may choose—or to have a discussion about the FIT test, or he may have a discussion about a colonoscopy. So I think either way, you should be screened at a certain age. And I think starting at age 50 is still the recommended age. However, when I look at the numbers, we know in Ontario where I work, 10 percent of cases of colon cancer occur under the age of 50. So before we even started screening, we've sort of lost 10 percent of the people. So if someone comes to me under the age of 50 and says, "Gee, what do you think?" I don't think it's such a bad idea. Already now in America, the American Cancer Society has suggested screening average risk people at age 45. That's not the standard in most professional associations, but that's what the decision was in the States. And we know that certain groups, for example, American Blacks have higher colon cancer rates and earlier. So there, if you're American Black it's suggested is already starting at age 45.
DR. NORD
Which makes a lot of sense. And that brings us back to again, Chadwick Boseman. You know, the ability of him to have access to and take advantage of excellent health care. So I think we'll wrap it up there. Thank you so much, Dr. Axler. This has been fantastic, great learnings. We're certainly doubling down in terms of our interest in colon cancer, not just because of Chadwick Boseman, but we're seeing a lot in the media of other individuals having colon cancer. And so it's been great just to be able to tap into your wisdom on this particular topic. Something that everyone has a significant interest in these days. So thank you very much for your time.
DR. AXLER
My pleasure, Peter.
CHRIS
That’s a wrap for this episode of Eat Move Think. We’ll post links and highlights on the website at Eatmovethinkpodcast.com, where you can also find later the same week as the episode debut the transcript for the episode. Eat Move Think is produced by Ghost Bureau. Senior producer is Russell Gragg. Remember to rate and subscribe to Eat Move Think on your favourite podcast platform. Follow Shaun on Twitter and Instagram @ShaunCFrancis—that's Shaun with a U—and Medcan @medcanlivewell. We'll be back soon with a new episode examining the latest in health and wellness.