Daily Archives: July 28, 2016

COLORECTAL CANCER IN YOUNGER PATIENTS NOT AS UNCOMMON AS THOUGHT DON’T IGNORE SYMPTOMS

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“Don’t forget about the possibility of a colorectal cancer diagnosis in young patients.” Elena Stoffel, MD

Clinicians should consider colorectal cancer as a possible diagnosis when a younger patient presents with symptoms of intestinal bleeding, anemia, or a change in bowel habits.

Research spearheaded at the University of Michigan Comprehensive Cancer Center (UMCCC) found that 10 percent of patients with colorectal cancer were under age 50, and young individuals were more likely to be diagnosed at advanced stages compared with older patients. The results that Samantha Hendren, MD, associate professor of surgery at the University of Michigan Medical School, and her team culled from the Surveillance, Epidemiology, and End Results (SEER) database and published in the journal Cancer (2016;122:929-934) suggest clinicians should consider colon cancer as a possible diagnosis when a patient presents with symptoms of intestinal bleeding, anemia, or a change in bowel habits.

“While colorectal cancer incidence is decreasing overall, thanks to routine screening in individuals age 50 and older, it’s on the rise in younger patients,” said Elena Stoffel, MD, assistant professor of internal medicine and a gastroenterologist at the UMCCC, who was not involved in the Cancer paper.

The SEER findings are important for gastroenterolo­gists and other clinicians to remember: “Don’t forget about the possibility of a colorectal cancer diagnosis in young patients,” she added. “It’s important to keep colon cancer on the radar rather than dismissing bleeding or other symptoms as hemorrhoids.”

IDENTIFYING HIGHER-RISK PATIENTS

Samantha Hendren, MD

The reasons for the increase in colorectal cancer cases among young people are unknown. Incidence is highest among blacks who develop tumors at younger ages, when compared with non-Hispanic whites. In a paper under review, Dr. Stoffel and her colleagues examined the SEER data on outcomes for colorectal cancer patients under 50, and found the survival rate for blacks was lower at every stage of the disease and partic­ularly striking among individuals with stage II cancers.

“While differences in treatment may play a role in racial disparities of outcomes, we have to consider there may be genetic factors that influence cancer risk and outcomes that haven’t been accounted for,” said Dr. Stoffel, who also runs the University of Michigan’s Cancer Genetics Clinic. “The current algorithms used for colorectal cancer risk assess­ment don’t account for race. So, we’re working to find a better way to assess people’s cancer risk.

“There’s also an observable trend that the rise in colon cancer in young people has tracked alongside the rise in obesity, but we haven’t identified specific mechanisms to explain how obesity might increase risk for polyps or colon cancer,” said Dr. Stoffel.

“There are a number of genetic conditions associated with inherited predisposition to colon cancer, including familial adenomatous polyposis, MYH-associated polyp­osis, and Lynch syndrome,” Dr. Stoffel said. “Individuals who carry germline mutations associated with hereditary cancer syndromes tend to develop colorectal polyps at young ages, so they should be screened early.”

It is important to remember that 70 percent of colorectal cancers occur in people with no known predisposition or obvious risk factors. Thus, there may be genetic and environmental components to colorectal cancer risk that researchers have yet to identify.

Lowering the recommended age for colorectal cancer screening for everyone is not the answer; however, University of Michigan researchers continue to research ways of identifying patients at higher risk who would benefit from early screening.

SOLVING THE PUZZLE OF IBS: A NEW STANDARD OF CARE EMERGES

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“ I think most physicians right now are trying to manage diet by giving patients a sheet of paper with a list of foods to eliminate, and that’s simply inadequate.” —WILLIAM D. CHEY, MD

Successful management of irritable bowel syndrome (IBS) requires a comprehensive approach to care that combines the expertise of multiple health care professionals who specialize in dietary and behavioral counseling, in addition to medical treatments and pharmaceutical therapies.

“Over the last five years, we have identified and assembled the puzzle pieces that allow us to offer a more holistic approach to patients with IBS,” said William D. Chey, MD, who is a widely known expert on IBS.

That means thinking critically about how diet, lifestyle, and behavior might interact to bring about the symptoms of IBS. “We consider how we might offer interventions for each of those components of care to really maximize the benefit of medical treatments for patients with IBS,” he said.

“If you asked any of the gastroenterologists at the University of Michigan five years ago, diet and behavior would have been very low on their list of priorities,” Dr. Chey said. “Now, our gastroenterologists say they can’t imagine how we did it before we had these assets in place. It has really been a transformation in care over the past five years, and we’re extremely proud of that.”

Successful long-term management of IBS, it turns out, is a multidisciplinary affair.

PUZZLE PIECE A: EXPERT DIETARY COUNSELING

For many patients, symptoms of IBS are triggered by what they eat, and increasingly, physicians are recognizing the critical role of diet in managing the symptoms of IBS. Unfortunately, few physicians are trained to provide nutri­tional counseling.

“The reality is most gastroenterologists receive little to no training in nutrition or the practical elements of adminis­tering diet therapies for patients with IBS,” Dr. Chey said.

Emerging evidence suggests diets free of gluten and diets low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols—commonly known as the low-FODMAP diet—can be beneficial for patients with IBS. The low-FODMAP diet, in particular, is a fairly complicated diet, Dr. Chey noted. Patients following this diet require the assistance of professional nutrition specialists.

“I think most physicians right now are trying to manage diet by giving patients a sheet of paper with a list of foods to eliminate, and that’s simply inadequate,” he said. “Diets are definitely more comprehensive and complicated than can be conveyed with a sheet of paper—even potentially dangerous if not administered in a medically responsible way.”

As a result, many diets do not work as well in clinical practice as evidence from clinical trials might suggest, he noted. In order to achieve similar results, diets need to be administered by experts who understand gastrointestinal (GI) nutrition and know how to help patients incorporate dietary changes into their daily routines, he said.

“One of the problems right now is there aren’t that many trained GI dietitians around. There are dietitians, but they’re not specially trained in gastroenterology,” Dr. Chey said.

“One of the things that needs to happen on a national level to improve the quality of care for patients with IBS is to train a population of dietitians that have expertise in GI disorders, and to have them work closely with gastroenterologists to administer dietary interventions in a medically responsible way,” he added.

This is just one of the many areas where the University of Michigan sets itself apart: the Division of Gastroenterology has the equivalent of four GI dietitians—two full-time GI dieti­tians at University Hospital and others who assist in caring for patients at offsite facilities that are part of the University of Michigan Health System.

PUZZLE PIECE B: FOCUSED BEHAVIORAL THERAPY

Just as diet has come into focus as an essential aspect of treatment for IBS, so have behavior and lifestyle. The way in which an individual responds to stress can greatly affect symptoms of IBS.

“There are certainly some things that gastroenterologists can recom­mend to try to facilitate changes in lifestyle or behavior,” Dr. Chey said. For example, yoga or a regular exercise plan can be very helpful in managing stressors that can lead to the symptoms of IBS, he noted.

But as in the case of diet, many gastroenterologists are not trained to provide more advanced behavioral counseling to patients with IBS. For example, cognitive-behavioral therapy, hypnosis and interper­sonal psychotherapy can be very beneficial for patients with IBS. But these therapies require specialized training—even more specialized than many clinical psychologists are equipped to offer.

PUZZLE PIECE C: MEDICATIONS AND RESEARCH

“Medications still play the really important role,” Dr. Chey noted.

Therapy for IBS is symptom-driven, depending on a patient’s needs. “For patients with mild or moderate IBS symptoms, sometimes all they need is a little bit of medication, such as an over-the-counter antidiarrheal or antispasmodic on an as-needed basis, and they’ll do just fine. Patients with more severe IBS symptoms will almost always need one or more medications,” Dr. Chey said.

Notably, Dr. Chey’s group has been involved in some capacity in the research that led to the FDA approval of all five prescription drugs indicated for the treatment of IBS in the United States.

Because of its dedication to research, patients at the University of Michigan have the opportunity to participate in ongoing IBS clin­ical trials, such as those involving the low-FODMAP diet and an upcoming trial of prebiotics in patients with IBS.

Building on this foundation in GI nutrition and behavioral therapy, a new effort—the Digestive Disorders Nutrition and Lifestyle Program—will bring together the diverse elements necessary to provide support in nutrition and behavior, as well as “vertically inte­grate research from the bench to the bedside,” Dr. Chey said. “So we’re not only providing excellent quality of care for patients, we’re also striving to make discoveries that will transform the role of diet and behavior and how they interact with medications to maximize benefit for patients with IBS and other functional disorders.”

BEHAVIORAL THERAPIES FOUND INSTRUMENTAL FOR IBS MANAGEMENT

The University of Michigan offers patients with GI disorders an opportunity to address symp­toms with a specially trained GI psychologist.

Megan Riehl, PsyD, is a clin­ical health psychologist at the University of Michigan, and the state’s only psychologist with a specific focus on GI disorders. IBS is the most common GI illness that brings patients to her clinic. “About 65 percent of patients present with IBS or a functional bowel disorder,” she said.

Megan Riehl, PsyD

Typically, patients are referred to Dr. Riehl by a gastro­enterologist who may have exhausted medical treatment options and/or believes a patient would benefit from stress and anxiety management techniques. Increasingly, behavioral therapy is becoming routine in the treatment of patients with IBS. “As more patients become aware of the GI behavioral health service, more of them are asking their gastroenterologists for a referral to the program,” Dr. Riehl said.

Behavioral therapy is personalized for each patient, but in general, therapy is designed to help patients deal with the “uncontrollable” and “unpredict­able” aspects of IBS. Patients learn relaxation and stress management techniques they can apply to everyday life stressors.

“My goal is to help patients learn to cope effec­tively and efficiently with worries that can interfere with social, occupational, and family life,” Dr. Riehl said.

GUT-DIRECTED THERAPIES

Most often, behavioral therapy for patients with IBS involves interventions based on cognitive-behavioral therapy (CBT), a short-term, collaborative treatment that is focused on a patient’s current problems.

“CBT involves helping patients find new ways of thinking and behaving to help in managing stressful situations,” Dr. Riehl explained. For example, patients with IBS may experience anxiety-provoking thoughts such as, “Where will a bathroom be if I need it?”, “What if I’m having symptoms before a big exam or presentation?”, or “How will I ever be intimate with a partner?” CBT teaches patients how to manage emotional responses to these potentially stress-inducing situations.

“My goal is to aid patients in self-management strategies that benefit GI health, emotional well-being, and overall quality of life,” Dr. Riehl said. “People learn tools to create long-term change, without remaining in treat­ment for long periods of time. It’s very rewarding.”

FOR COMMUNITY GASTROENTEROLOGISTS

The Division of Gastroenterology at the University of Michigan emphasizes a holistic approach to IBS treatment that incorporates modifications in diet, behavior, and lifestyle in the management of symptoms of IBS.

When a diagnosis of IBS has been confirmed, consider the following approaches to treatment:

  • Are symptoms triggered or exacerbated by diet? Consider a referral to a dietitian with specialized training in the treatment of GI disorders.
  • Are symptoms triggered or exacerbated by stress or a mood disorder? Consider a referral to a behavioral therapist with specialized training in the treatment of GI disorders.
  • How frequent and severe are symptoms? Are symptoms comprised mainly of diarrhea, constipation, or both? Consider using medi­cations that target the relevant symptoms in combination with strategies that address diet, lifestyle, and behavior.
  • Are symptoms severe and/or medically refrac­tory? Consider a referral to a tertiary referral center.

MORGAN’S STORY

Morgan Blenkhorn missed high school several times because of symptoms that doctors said were related to irritable bowel syndrome (IBS).

“Anything I would eat, I would get sick,” she said. “I was nauseous; I would have headaches, stomachaches; I had diarrhea and I was just ill all day, every day.”

Morgan’s symptoms started a few months after a severe food poisoning incident in 2010 during her junior year of high school. She endured pain, particularly while dancing and playing soccer. She eventually turned to apples and honey for relief, but they only made her symptoms worse.

“It was really hard having to come home from school being sick all the time, waking up sick, and trying to go to school and act like everything was fine,” she said.

A CHANCE MEETING BEARS FRUIT

Over the next three years, several doctors told her she was exhibiting IBS symptoms and gave her probiotics for treat­ment. But a chance meeting on an airplane between her father and gastroenterologist William Chey, MD, would lead to a series of interviews, tests, and a final diagnosis from the University of Michigan’s gastroenterology and dietitian team.

Her first visit to the University of Michigan was in 2013, during the fall of her sophomore year of college. She had several blood tests done before meeting with Dr. Chey. Upon her first appointment with him, she was promptly told what to expect: a fructose test, a lactose test, more blood tests, and an endoscopy.

According to Morgan, Dr. Chey went above and beyond preliminary tests to find the root of the problem. The test that changed it all, she said, was the fructose test, which consisted of a fructose mixture, water, and a breath test. A few weeks after her appointment, Dr. Chey spoke with Morgan and her family and told them the diagnosis: fructose intolerance.

“We all cried,” Morgan said.

FINALLY, CONTROL …

This experience was unlike any other for Morgan. The team’s gastroenterologists were briefed on her case and knew exactly how to address her issues. The dietitian they referred her to mapped out a zero-fructose eating plan that catered to her vegetarian diet and her love for veggies, pasta, and curry.

“They listened to my specific wants, not just me as a patient but me as Morgan,” she said.

After being diagnosed with fructose intolerance, Morgan now plans out her own meals and has full control of her symptoms. She continues to dance and play sports. Last summer, she was even able to study abroad in the Netherlands.

“It was beautiful, life-changing, something I didn’t think I’d ever be able to do before because I couldn’t sit in a car for two hours without having to pull over,” she said. “Biking 10 miles to work and backpacking alone through Germany was something I thought I’d never be able to do because I was so sick.”

Morgan is finishing up her fourth year at Grand Valley State University in Allendale, Mich., with another year left to complete her special education degree. She still checks in with Dr. Chey every once in a while. For now, she hopes to be accepted into Grand Valley’s Consortium for Overseas Student Teaching program in Ireland this summer.

MICHIGAN BOWEL CONTROL PROGRAM OFFERS A PIONEERING APPROACH

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Patients with severe defecation disorders or pelvic floor dysfunctions require care spanning multiple medical specialties, which is why the Michigan Bowel Control Program (MBCP) exists.

Dee Fenner, MD

“There are very few programs nationally that allow patients to get a comprehensive and integrated care plan from people who—we like to believe—are national experts in the care of patients with severe constipation and fecal incontinence,” said William D. Chey, MD, Director of Medical Services at MBCP and Timothy T. Nostrant professor of gastroenterology and the University of Michigan.

“In 2005, when we started this program, gastroenterologists, urogynecologists, and colorectal surgeons were all completely siloed,” Dr. Chey explained.

Over a decade ago, Dr. Chey, Dr. Fenner, and Emina Huang, MD, then a colorectal surgeon at the University of Michigan, established MBCP, with the vision of providing truly multidisciplinary patient care. “We thought we could do things a whole lot better if we saw patients together and developed integrated care plans.” Dr. Chey said.

Chronic Conditions Require Dedicated Follow-Up

If the success of their original idea can be measured by the growth of the program, then consider the team members visionaries.

Using a model of the pelvis, Dr. Fenner, with Anne Mcleod, helps a patient understand the relationship between constipation and pelvic organ prolapse.

“The first year we saw about 50 new patient referrals, and they were almost all from within the university,” Dr. Chey recalled. “Last year we saw over 500 new patient referrals, and we continue to grow on an annual basis.” The word is definitely out about the excellence of the program with some patients traveling thousands of miles to be treated at MBCP.

“A key message we stress to patients is that these are chronic conditions” Dr. Fenner noted. “Patients need to think about them as they would other chronic conditions, such as diabetes. The key is that we maintain contact; we don’t just send the patient out and then have them come back 3 months later,” Dr. Fenner said. Key to the program’s success is its careful attention to follow-up care. MBCP has a dedicated nurse concierge team that assists in the implementation of care plans, shepherds patients through their journey at MBCP, and provides follow-up care that is essential to positive patient outcomes.

Continuing Research

Dr. Chey cited innovative research as another feature that sets MBCP apart from other programs. For example, Dr. Fenner played an integral role in clinical trials of the novel TOPAS (Astora Women’s Health) minimally invasive surgical procedure that is under evaluation for fecal incon­tinence in women. Additionally, her team has just begun using an FDA-approved modification of the Eclipse System (Pelvalon).

Dr. Chey, along with University of Michigan gastroenterologist Stacy Menees, MD, is currently leading a randomized controlled trial comparing dietary fiber supplemen­tation with a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) for the treatment of fecal incontinence. He also has designed a glove-based manometry system, for which he holds a patent, that is being tested in clinical trials as a low-cost alternative to anorectal manometry for the evaluation of anal sphincter function. “At MBCP, we’re trying to grow beyond providing excellent care,” Dr. Chey said. “We’re trying to learn from the care we deliver, to create novel ways of understanding why patients suffer from the symptoms that they do, and to improve upon the excellent care we are currently able to deliver.