M&D Clinical Corner: Community Pharmacist’s Guide to Colorectal Cancer Awareness

The Clinical Corner is a monthly feature that highlights a variety of important pharmacist topics that is written by Morris & Dickson’s staff pharmacist, Paula Belle (RPh).

This month’s Clinical Corner will provide information on Colorectal Cancer Awareness:

• The Need for Colorectal Cancer Awareness
• The Pharmacist’s Role
• Identify Patients
• Educate Patients
• Refer/Follow Up with Patients
• Resources for Pharmacists

The Need for Colorectal Cancer Awareness

• Colorectal cancer (CRC) is the fourth most commonly diagnosed cancer and the second leading cause of cancer-related deaths in the United States. [1]
• The median age at CRC diagnosis is 66 years, and the median age of death from CRC is 72 years. [1]
• It was estimated that 153,020 adults would be diagnosed with CRC in 2023, and 52,550 would die as a result of CRC. [1]
• The incidence of CRC in young adults (CRCYAs) is increasing globally, and it is now the third leading cause of cancer death among young adults under 50 years old. [2]
• Delayed diagnosis and more advanced disease presentation in young adults contribute to worse outcomes. [2]
• Effective, reliable screening has led to a substantial (>30%) decrease in CRC incidence and mortality among adults aged >50 years over the past 15 years. [1]

The Pharmacist’s Role

• Pharmacists have the opportunity to educate patients about the significance of CRC, help promote lifestyle changes, and provide recommendations for CRC screenings. [3]

Identify Patients

• Pharmacists are in a prime position to identify patients who are candidates for screening, referring them to their healthcare provider. [3]
• The CDC recommends that patients aged 45 to 75 years old get screened regularly for CRC. [4]
• Patients under age 45 who feel they may be at increased risk for CRC should consult with a physician. [4]
• Positive family history remains the most significant known risk factor for adults younger than 50, contributing to approximately 20% of cases. [2]
• A recent 2021 systematic review found that potential causal factors for early‐onset CRC include processed meat, sugary drinks, excessive alcohol intake, physical inactivity, and smoking. [2]
• Patients at increased risk for developing CRC include those with [5]:
  Inflammatory bowel diseases such as Chron’s or ulcerative colitis.
  Personal or family history of colorectal cancer or colorectal polyps.
  Certain genetic syndromes.

Educate Patients

• Counseling About CRC Risk
  • Patients can be coached to make lifestyle changes that will reduce their CRC risk such as [5]:
  • Increasing regular physical activity.
  • Eating a diet high in fruits and vegetables.
  • Eating a high-fiber, low-fat diet including reducing processed meats.
  • Losing weight.
  • Reducing alcohol consumption.
  • Discontinuing tobacco use.
• Pharmacists can emphasize that colorectal polyps and CRC don’t always cause symptoms, especially at first. [4]
• If patients do have symptoms, they may include [6] :
  • A change in bowel habits.
  • Blood in or on the stool.
  • Diarrhea, constipation, or feeling that the bowel does not empty all the way.
  • Abdominal pain, aches, or cramps that don’t go away.
  • Unexplained weight loss.

• Counseling on CRC Screening
  • A screening test is used to look for a disease when a person doesn’t have symptoms. [7]
  • Screening tests can find precancerous polyps, so that they can be removed before they turn into cancer. Screening tests can also find CRC early, when treatment works best. [7]
  • The U.S. Preventive Services Task Force recommends several CRC screening strategies, including [7]: Stool tests.
    • Direct visualization tests including:
    • Flexible sigmoidoscopy.
    • Colonoscopy.
    • CT colonography (virtual colonoscopy).

• Stool Tests for CRC
  • Stool-based exams are quick and noninvasive, can be done at home, and do not require bowel preparation. [3
  • However, their usefulness is limited by their inability to detect nonbleeding polyps or cancers. [3]
  • If any of these tests return a positive result, follow-up with a colonoscopy may be required. [3]
  • Guaiac-based fecal occult blood test (gFOBT) :
    • This test uses the chemical guaiac to detect blood in the stool. [8]
    • It is done once a year. [8]
    • For this test, patients receive a test kit from their health care provider.[8]
    • The patient performs the test at home, using a stick or brush to obtain a small amount of stool. [8]
    • Three stool samples obtained at home on different days should be submitted. [3]
    • Patients should also avoid ingesting certain foods and medications, including red meat, NSAIDs, iron products, or vitamin C before the test to avoid false positives. [3]
    • The test is returned to the doctor or a lab, and the samples are checked for blood. [8]
    • gFOBT is the most commonly used stool-based exam, but it is considered to be less accurate when compared with others. [3]
  • The fecal immunochemical test (FIT) :
    • The FIT test uses antibodies to detect blood in the stool. [8]
    • It is also done once a year in the same way as a gFOBT. [8]
    • This test has been found to be more sensitive and specific for detecting CRC when compared to gFOBT. [3]
    • It is more convenient compared with gFOBT because it only requires one stool sample and has no dietary restrictions. [3]
  • The FIT-DNA test (also referred to as the stool DNA test) [8]:
    • This test combines the FIT with a test that detects altered DNA in the stool.
    • For this test, patients collect an entire bowel movement and send it to a lab, where it is checked for altered DNA and for the presence of blood.
    • It is done once every three years.
• Direct Visualization Tests
  • Direct visualization tests include colonoscopy, flexible sigmoidoscopy, and computed tomographic colonography. [3]
  • These tests have greater sensitivity compared with stool-based tests and allow for the early identification of adenomatous polyps before they progress to CRC. [3]
  • They do require the patient to complete a bowel preparation prior to testing; however, because of their increased sensitivity, they are recommended to be performed less often. [3]
  • Colonoscopy is the most widely used screening test for colorectal cancer and is considered the gold standard. [3]
  • Flexible Sigmoidoscopy
    • For this test, the doctor puts a short, thin, flexible, lighted tube into the patient’s rectum [8]
    • The doctor checks for polyps or cancer inside the rectum and lower third of the colon [8]
  • Colonoscopy
    • This is similar to flexible sigmoidoscopy, except the doctor uses a longer, thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon. [8]
    • During the test, the doctor can find and remove most polyps and some cancers. [8]
    • Colonoscopy also is used as a follow-up test if anything unusual is found during one of the other screening tests. [8]
    • Colonoscopy is recommended every 10 years (for people who do not have an increased risk of CRC). [8]
  • CT Colonography (Virtual Colonoscopy)
    • Computed tomography (CT) colonography, also called a virtual colonoscopy, uses X-rays and computers to produce images of the entire colon, which are displayed on a computer screen for the doctor to analyze [8]
    • A complete bowel preparation is required but sedation is not necessary [3]
    • It is recommended that virtual colonoscopy be performed every 5 years. [8]
  • Pharmacists can help patients understand the advantages and disadvantages of each testing type and recommend that they consult a physician as the type of test to select depends on [8]:
    • The patient’s preferences.
    • The patient’s medical conditions.
    • The patient’s personal of family history of CRC or polyps.
    • Whether the patient has certain genetic syndromes that increase risk.
    • The likelihood that the patient will get the test completed.
    • The testing resources available to the patient.
• For patients who will be undergoing a colonoscopy, pharmacists can ensure the patient’s understanding regarding the importance of the bowel preparation and promote the safe use of these products. [3]

Resources for Pharmacists

• A Final Recommendation Statement from the U.S. Preventive Services Task Force regarding colorectal cancer screening is available at: FINAL USPSTF RECOMMENDATIONS
• Pharmacists can learn more about each recommended colorectal screening test at: BASIC SCREENING TEST INFORMATION
• Images suitable for social media that promote screening are available at: CDC COLORECTAL CANCER SOCIAL MEDIA IMAGES
• Posts that promote colorectal cancer screening are available at: CDC COLORECTAL CANCER SUGGESTED POSTS
• The CDC provides videos that explain why it’s important for men and women who are 45 years old or older to get screened for colorectal cancer regularly. These are available at: CDC VIDEOS
• A handout suitable for patients is available at : COLORECTAL CANCER SCREENING
• The American College of Gastroenterologists offers patient material for download at: CRC COMMUNITY EDUCATION KIT

Sources

1. Olga Hilas, P., MPH, BCPS, BCGP, FASCP Professor, Department of Pharmacy Practice St. John’s University College of Pharmacy & Health Sciences Queens, New York. Colorectal Cancer Screening in the United States. 2024 [cited 2024 February]; Available from: https://www.uspharmacist.com/article/colorectal-cancer-screening-in-the-united-states.
2. Kim, B.J. and M.H. Hanna, Colorectal cancer in young adults. Journal of Surgical Oncology, 2023. 127(8): p. 1247-1251.
3. Emily M. Ambizas, P., MPH, BCGP Associate Clinical Professor St. John’s University, College of Pharmacy & Health Sciences Queens, New York Clinical Specialist, Walgreens Pharmacy Whitestone, New York. The Pharmacist’s Role in Colorectal Cancer Screening. 2024 [cited 2024 February]; Available from: https://www.uspharmacist.com/article/the-pharmacists-role-in-colorectal-cancer-screening.
4. Centers for Disease Control and Prevention. Colorectal Cancer Awareness Feature | CDC. 2023 2023-11-27T07:20:49Z [cited 2024 February]; Available from: https://www.cdc.gov/cancer/dcpc/resources/features/colorectalawareness/.
5. Centers for Disease Control and Prevention. What Are the Risk Factors for Colorectal Cancer? | CDC. 2023 2023-07-31T12:58:21Z [cited 2024 February]; Available from: https://www.cdc.gov/cancer/colorectal/basic_info/risk_factors.htm.
6. Centers for Disease Control and Prevention. What Are the Symptoms of Colorectal Cancer? | CDC. 2023 2023-02-23T09:19:41Z [cited 2024 February]; Available from: https://www.cdc.gov/cancer/colorectal/basic_info/symptoms.htm.
7. Centers for Disease Control and Prevention. What Should I Know About Screening for Colorectal Cancer? | CDC. 2023 2023-02-23T09:20:09Z [cited 2024 February]; Available from: https://www.cdc.gov/cancer/colorectal/basic_info/screening/index.htm.