Q: I saw a Colorectal Cancer Awareness poster that said to look out for blood in my stools. What exactly am I looking for?

A: A person’s stool (poop) is a window into their health and a precious warning sign of a problem, so look at it before you flush it. Keeping an eye on your stools is an important step in being aware of colorectal cancer and identifying early signs of the disease.

The topic of what one’s stool says about their health is very extensive and I won’t get into it all here, but let’s talk about seeing blood.

Firstly, blood in your poop is not normal. All blood passed in the stool, around the stool or after the stool is abnormal and represents a problem of varying severity.

So to answer the question, you are just looking for blood. And if you see it, you need to report it to your family physician for investigation. It’s just that simple. Having said that, there are certainly more worrisome characteristics of the blood in one’s stool and certain features that you should be aware of in order to report them to your physician. To understand these characteristics, one must imagine where this blood is coming from.

Colorectal cancer is a disease of the cells of the inner lining of the colon or rectum. The cells begin to grow out of control, first forming a cluster of cells called a polyp and eventually becoming a cancer as the cells burrow deeper into the wall. Because these polyps and eventual cancers are growing on the inner lining of the bowel, they ooze or bleed into the bowel and that blood then becomes incorporated with the stool as it passes through.

With that background, one can begin to imagine just how blood in the stool might look if it is coming from a colorectal cancer. If the cancer is in the right side of the colon (the beginning of the colon and furthest from the anus) then the blood might be undetectable by the eye by the time it reaches the toilet. If there is lots of blood coming from a cancer in the right colon, it may no longer look like red blood by the time it reaches the toilet but rather like black tar mixed in with the stool.

If the cancer is further along in the colon or even in the rectum, the blood will still be red smeared along the stool as it hits the toilet or the blood will be mixed in with the stool but still bright red in appearance.

Finally, if the cancer that is bleeding is in the rectum, just before the exit, you might see only blood coming into the toilet either prior to or after the stool as it is bleeding directly out of the anus rather than mixing with stool.

So by understanding how blood in the stool could be a warning sign of a cancer, it also becomes clearer why we use a fecal immunochemical test (FIT) to look at the stool microscopically (and why it’s so important!) This test checks for occult (hidden) blood in the stool as a screening test for colorectal cancer — it can find blood that isn’t visible to the eye when you look in the toilet.

The test isn’t specific — many other things can lead to hidden blood in the stool and the test can’t tell which it is causing the blood. But it is very sensitive, which means that almost all colorectal cancer patients would be positive if the test was done. That means very few false negatives, which is ideal for a screening test.

It is obviously very important to understand that many different colorectal problems can lead to blood in the stools, not just cancer. But do remember that regardless of the cause, blood in your poop it is not normal and needs discussion and investigation by your primary care physician. The characteristics of the blood will offer clues but by no means will it make a diagnosis and almost certainly the next step will be a colonoscopy to definitively sort out what’s going on.

In very simple terms, please do this for me: Turn and look at your stool before flushing. It could save your life.

(This post was updated in August 2020 to reflect a change in Ontario’s colorectal screening test from the fecal occult blood test to the FIT)

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Answer: Let me start by saying that you being aware that your grandfather had colon cancer is a very important first step. The new national guidelines released this week specifically target high-risk patients, and without knowing your family history, you don’t know whether you’re at risk!

What we do know is that if you have a first-degree relative with colorectal cancer, your chance of developing this disease is doubled, making you high risk. That means we need to be more vigilant with your colorectal cancer screening.

Before we dive into this, it’s important to remind you that the definition of ‘screening’ is someone with no signs or symptoms of colorectal cancer. If there are any signs or symptoms, like changes in your bowel habits or blood in your stool as outlined in another post here, then the term ‘screening’ does not apply and you need diagnostic tests regardless of age or family history. In this post, we are talking specifically about people with absolutely no symptoms. In the general population, these people can be divided into high risk and normal risk of developing colorectal cancer.

So let’s look at these new guidelines for screening in high-risk people.

Firstly, what is a first-degree relative? A first-degree relative is a sibling, mother, father or child. A second-degree relative would be an uncle, aunt, cousin or grandparent. These new guidelines differentiate the intensity of colorectal screening based on either a first-degree or a second-degree relative diagnosed with colorectal cancer, and at what age the diagnosis was made. The guidelines state that if you have a first-degree relative diagnosed with colorectal cancer, you should be screened with a colonoscopy at the age of 40-50 (40 in my opinion!) or 10 years prior to that person’s diagnosis. If that colonoscopy is normal, you should have another in five-year intervals.

So what does that timeline look like?

Here’s an example. Let’s say Peter is diagnosed with colon cancer at age 75. His first-degree relatives (his kids) should start being screened at age 40-50. Peter should speak to his siblings about getting screened if they haven’t already taken part in a screening program.

Here’s another example. Say Gina, aged 35, has three small children. She has been diagnosed with colon cancer. When those kids hit age 25 (10 years prior to her age at diagnosis) they should begin their colonoscopy screening. Let’s say Gina has a younger brother who just turned 29. He should start his screening now. Maybe Gina’s Mom and Dad haven’t taken part in colonoscopy screening before. They should start. Now that a first-degree relative has been diagnosed, the whole family moves into the high-risk category.

One day last week, I conducted colon cancer removals in three patients all in their 30s. For those patients, it means all of their first-degree relatives — any siblings, and current or future children — should have colonoscopies when they are in their 20s (or for their siblings and parents already passed that age, screening should start now.)

This means a lot of people will now need colonoscopies starting in their 20s and for me, that raises a lot of questions: Do they all know about being screened? Will they all do it? Will their primary care physicians or nurse practitioners identify this need in time? You can help spread the word by telling people about the new guidelines!

And so what about your grandfather’s diagnosis? The guidelines state that if you have a second-degree relative with colorectal cancer, you should begin screening with either a stool test or a colonoscopy at the age of 50. For your mom – his first-degree relative – she should have (and hopefully has) already started being screened, and should continue to do so every five years.

So you can see why knowing your family history, and knowing your risk, can save your life. I can’t stress that enough: when caught early, colorectal cancer is treatable. But it often has no symptoms in its early stages, so screening can help us catch it early. And screening if you are high-risk is extremely important. Talk to your family about your family history.

See the entire new guidelines here (it’s a PDF from the Canadian Association of Gastroenterology) and if you have questions, talk to your doctor.

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Everybody Poops.

How to S*** in the Woods.

All great books about bowel movements. (Or BMs, or number twos, or poop. Or stool.)

And all just merely a way to get us all in the headspace to talk about this month’s health topic: colorectal cancer.

Colorectal cancer is when cancer cells begin to grow in the colon or rectum, parts of the digestive system. The colon takes in water and nutrients from the food we eat and then passes the waste to the rectum (and voila – poop).

Because of its location in the body, colorectal cancer is an oft-shied away from topic. It’s certainly not the first thing people want to talk about at a dinner party, but it should be, says Dr. Shady Ashamalla, surgical oncologist at Sunnybrook and head of the colorectal program.

“We know that early detection is key,” Dr. Ashamalla says. “So, talking to your family and friends about this disease – and the screening program that’s in place for it – could help save a life.”

Who is at risk?

“Familial risk depends on what age the immediate family member was diagnosed,” Dr. Ashamalla says. “The Ontario screening program starts at age 50. So if your immediate family member was diagnosed before age 60 it’s important to tell your doctor.”

If your immediate family member was diagnosed at age 54, for example, your screening should start when you are 10 years younger than that. You should start getting screened at age 44.

“We know there are genetic/hereditary disorders that put people at increased risk of colon cancer,” Dr. Ashamalla says. “But the majority of cases are sporadic, meaning there’s no specific genetic association.”

What’s the cause?

“It’s important to remember there’s no good evidence for cause,” Dr. Ashamalla says. “There is evidence of association, but that’s not the same as cause.”

So, alcohol-use, obesity, red meat consumption, low fitness levels have all been found to be associated to an increase in risk. But that doesn’t mean those things cause colon cancer.

You can make healthy lifestyle choices to help reduce your risk, he adds.

“Eat a healthy diet with lots of fruits and vegetables and not too much red meat, be physically active, don’t drink too much – they can make a difference in your risk,” he says. “That said, you could check off all those lifestyle boxes and still get colon cancer.”

Also important to remember, Dr. Ashamalla says, is that there’s no scientific evidence that probiotics or colonic cleanses do anything to reduce your risk.

You can check your risk at mycanceriq.ca – it’s a site run by Cancer Care Ontario.

Get screened.

Cancer cells in the colon and rectum can be present long before you have any symptoms. The symptoms don’t present themselves until the disease is advanced.

“That’s why it’s important to get screened starting at age 50 – or earlier if you have immediate family history,” Dr. Ashamalla says.

In Ontario, you can actually do a FIT screen for colorectal cancer from the comfort of your own bathroom. Talk to your family doctor or call TeleHealth at 1-866-828-9213.

Screening doesn’t prevent colon cancer. But it catches it early, before you would notice any symptoms. And catching it early means better outcomes.

What to watch for?

There are some symptoms to watch out for:

• Changes in bowel habits, including changes in frequency or in the shape of the stool
• Black stool
• Blood in your stool
• Unexplained fatigue, or a feeling of unwellness that can’t be explained
• Unexplained weight loss.

If you have any of those, go see your family doctor. Don’t be shy or delay – early diagnosis is key to better treatment outcomes.

Explore your options

Dr. Ashamalla says treatments for colorectal cancer have come a long way in the past few years, meaning less treatment side effects and better outcomes for patients.

“The treatments for colon cancer can have effects that last a whole lifetime, even if your disease is cured. But there are a lot of new minimally invasive techniques that really are better for patients. It’s not a one-size-fits-all treatment approach anymore.”

Be sure to talk to your specialist about all your options.

And talk to your family and friends about getting screened. (C’mon you can do it!)

(This column also appears in the March edition of Toronto’s Streeter Newspaper)

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