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In the field: Doctors urge patients to get screened for colorectal cancer

Drs. Bryan Butler and Brian Matier, born and raised outside the U.S., both followed opportunity to Buffalo.

Butler, 53, from the Dominican Republic, and Matier, 40, from Oakville, Ont., put down roots in Western New York after taking fellowships in colorectal surgery at the University at Buffalo School of Medicine and Biomedical Sciences.

Both became associate professors at the school afterward. Both operate in Catholic Health and Kaleida Health hospitals, mostly at Sisters Hospital.

And both wish they weren’t so busy when it came to colorectal cancer cases.

“I just cringe every time I get a patient with colorectal cancer who hasn’t been screened because I know it could have been prevented,” said Butler, who also heads the UB colorectal residency program and chairs the Buffalo Medical Group Board of Directors.

The doctors sat down this week to talk about their jobs. They focused mostly on the number of cancer cases they would like to reduce. They are part of an ambitious national effort that looks to raise the percentage of colorectal cancer screenings to 80 percent for those 50 and older or at greatest risk for a cancer that is the third most diagnosed in the U.S. and the second leading cause of cancer death. Erie County’s screening rate is 72 percent. More than 90,000 Americans will be diagnosed with colon cancer and another 40,000 with rectal cancer this year; more than 50,000 will die from the disease, according to the American Cancer Society.

Q. What conditions do you treat and what tend to be the most common?

Matier: Colon cancer and colon polyps is a common one. Diverticulitis is a common one. Inflammatory Bowel Disease. Then there’s a wide range of anal/rectal problems like hemorrhoids, which is probably the most common things we treat. There’s other functional disorders, like fecal incontinence, constipation and other pelvic floor disorders.

Q. How common are colorectal conditions in the general public?

Matier: Very common, and family history is rooted to many problems, whether it’s diverticulitis, cancer or Inflammatory Bowel Disease.

Butler: As patients get older, they tend to develop diverticulitis. About 60 percent of patients 80 years old or older have diverticular disease. That doesn’t mean they’re symptomatic, but they have pockets (in their lower intestine). About 85 percent will have no symptoms or problems.

Q. Who should be tested for colorectal cancer?

Butler: Anyone age 50 or over who hasn’t had one, with two exceptions. One is the African-American population. African-Americans tend to have colorectal cancer at a younger age and the likelihood of African-Americans getting screenings is lower than the general population. They tend to show up in the later stages of cancer, which translates into them having a worse prognosis and outcome. So the recommendation is that they start screening five years earlier, at age 45. The other exception is family history of colorectal cancer, and it depends on if it’s a direct family member or indirect family member, the number of family members and the age of the family member diagnosed. We take all of those things into consideration.

Matier: Without question, if you’re having any signs of anal or rectal symptoms, such as bleeding, or blood in the stool, dark-colored stools, a change in the quality of your stools and how often you go. If it persists over a few weeks, those sorts of things definitely warrant a colonoscopy.

Butler: The polyps that really concern us are called adenomatous polyps. Those are the ones that have a malignant potential. About 25 to 50 percent of people over 50 would have that type of polyp. ... We always say, “Any screening is better than no screening, but every other screening compares to the gold standard, which is colonoscopy.” It’s a reasonable starting point to talk with your primary care doctor about what type of test to take.

Q. What excuses do you tend to hear from those who avoid a colonoscopy?

Matier: What I hear is that when their father, mother or grandfather had one 10 or 15 years ago, they felt everything during the procedure, or that the bowel prep involved drinking a gallon of stuff that made them nauseated. Now, our prep is much easier. We also use sedation, so everyone is very comfortable and most people don’t even remember the procedure afterward.

Butler: I think fear. Some people are afraid we will find something. But if we find something earlier, it usually prevents a problem.

Q. How long can these potentially cancerous polyps grow without being detected?

Matier: Most cancers occur in people over 60 but we know that at that point, it’s probably been there for eight to 10 years, which is why we recommend starting the screening at age 50 – so you can find these things before they turn into cancer.

Butler: As the rate of cancer screening has gone up, the rates of colon cancer in the older population has gone down. ... The youngest person I’ve operated on with colon cancer was 28. That’s rare. Those are exceptions but they can happen. Many times, when you get patients at a younger age, it’s because of a family history.

Q. What sort of colorectal screenings are available?

Butler: The colonoscopy is the gold standard. It’s the only screening test that you can find a precancerous polyp, remove it and prevent a person from developing cancer. Any other screening test doesn’t do it. If you do a fecal occult blood test, it’s the cheapest and most convenient, but if it turns out positive you need a colonoscopy. The blood test detects blood in the stool, so you could have an ulcer and it would be positive. Or hemorrhoids. So it’s relatively nonspecific. You need to follow a specific diet for three days before and during the test, or you could have a false positive or false negative. A fecal immunochemical test is more accurate, but if it’s positive you need to have a colonoscopy. The sigmoidoscopy looks roughly at about half of the colon, the left side, so you could miss any polyps on the right side of the colon. You could always do a double contrast barium enema. That’s basically an X-ray that can find cancers and polyps, but if they find anything, you have to get a colonoscopy to confirm the diagnosis. They have a so-called virtual colonoscopy, which is a CT Scan that’s pretty good about detecting larger polyps but can miss smaller polyps. And again, if something is found, a colonoscopy needs to confirm the diagnosis and do the biopsies. There’s always a fecal DNA test. When people hear DNA test, people always think about high tech and that’s it’s probably the best. It is better than the fecal occult test but it’s considerably more expensive. It’s not as good as a colonoscopy and is significantly less effective at finding precancerous polyps.

Q. Is colorectal cancer more common in men and something women should be less concerned about?

Butler: The lifetime risk for male patients is 4.7 percent and the risk for female patients is 4.3 percent. There is a difference but it’s really small.

Q. How far has colon cancer treatment come in the U.S. during the last decade?

Matier: Dramatically. The biggest change in colorectal surgery has been minimally invasive surgery. The traditional way colon surgery was done was through large incisions. Now it can be done with robotic surgery or laparoscopic surgery.

Butler: If the tumor is larger than the small incision that we make (for laparoscopic) surgery, then we do the surgery open.

Q. Talk about the standard treatment protocol once a colorectal cancerous tumor is found.

Matier: The first step is to stage a tumor, determine how advanced it is. Everybody gets a CT scan to determine that the cancer hasn’t spread, for example to the liver or the lungs, which can change the treatment plan. As long as it’s not spread, or sometimes when it has, it usually requires surgery to remove the part of the colon that has the tumor in it. After the tumor is out, we look at it under a microscope to see if there are any nodes that have cancer in them, indicating the cancer has spread from the colon into the lymph nodes – the first step on the highway to spreading to other organs. Usually in those cases, the patients will do chemotherapy as well.

Q. How much better do patients who discover cancer early do?

Butler: Stage 1, the survival rate is about 90 percent. Stage 4 is less than 10 percent.

Matier: This is where the advantage comes from coming in to do a screening.

Q. Why did you choose colorectal surgery?

Matier: It was more about a couple of mentors while I was in my general surgical training. Both of them were colorectal surgeons. They seemed to be very happy in their careers and had a great mix of major surgeries, minor surgeries and nonsurgical stuff. They had similar personalities as mine and I gravitated toward that.

Butler: Colorectal surgery offers a wide variety of surgeries, from major abdominal open surgery to laparoscopic – or minimally invasive surgery – to robotic surgery, to minor rectal cases, to endoscopy. We treat benign disease, malignant disease and we have the opportunity to establish long-term relationships with many of our patients. I’ve been here 16 years and have patients who’ve been with me that long.


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