March is Colon Cancer Awareness Month and March 21 is Anal Cancer Awareness Day.
We thought it would be a good time to catch up with our favorite local bottom expert, Happy Hiney Health founder Dr. Elie Schochet, owner of the South Florida Colorectal Institute. Dr. Schochet, Fort Lauderdale’s only double board certified general and colorectal surgeon has been an advocate and ally in our community since 2009 when he started advocating screening and prevention programs for colon, rectum, and anal cancer.
Are colon cancer, rectal cancer, and anal cancer the same diseases?
No. Colon and rectal cancer or colorectal cancer is a cancer of the intestine, arising from early precancerous growths called adenomas or adenomatous polyps. Colorectal cancer is the second leading cause of cancer death and the third most common cancer in the United States. Anal cancer on the other hand is a squamous cancer like cervical cancer in women and throat cancer. It is usually caused by the Human Papilloma Virus (HPV). While anal cancer is considered a rare form of cancer in the general population, it can disproportionately affect several specific populations, including people with HIV (PWH), men who have sex with men (MSM), solid organ transplant recipients (SOTR), and women with a history of vulvar cancer or precancer with rates approaching 75 to 100 times the national average in some of these at-risk groups.
Are these diseases preventable?
While they are not entirely preventable, there exists scientifically proven prevention strategies in both cases which can help find them in easily treatable pre-cancerous states years before they turn into life-threatening cancers. In both cases, these screening methods are of utmost importance because with both anal cancer and colorectal cancer symptoms will often appear only after an advanced cancer has formed.
Let’s talk about anal cancer first. I didn’t know infections can cause cancer?
There are a number of different cancers that are related to initial infections and the link between HPV and cancer is one of the most studied. There are over 150 strains of HPV, which is typically considered the most common sexually transmitted disease. While a few strains are well-known to cause genital warts or condylomas, there are also a few strains (16 and 18 primarily) which can be shown to cause a precancerous condition called Anal Intraepithelial Neoplasia (AIN) which, if left untreated, can progress over time to anal cancer.
So how can we screen and prevent anal cancer?
The use of cervical pap smears and colposcopies in women has led to the near eradication of cervical cancer in the modern world since these techniques were introduced almost 70 years ago. These techniques were adapted to the anus 25 years ago in New York City and San Francisco, epicenters of the HIV epidemic, however we didn’t know until recently that they could effectively prevent anal cancer. Two major international trials, the ANCHOR and SPANC studies, were both completed and published which gave us the first scientific proof that the use of anal pap smears and High Resolution Anoscopy to aid in ablation of precancerous lesions does prevent anal cancers.
Wow, that’s great news. So should everybody be getting pap smears?
The recently published International Anal Neoplasia Society's Consensus Guidelines for Anal Cancer Screening. These guidelines delineate who and how often should be receiving anal cancer screening and prevention. To summarize, all MSM and Transgender women (TW) living with HIV/AIDS should start routine screening at 35. All other PLWH/AIDS and HIV negative MSM/TW should start at 45. Organ transplant recipients and women with a history of HPV associated precancerous conditions should refer to the guidelines for more specific recommendations.
Is screening painful or difficult?
Hardly, an anal pap smear is a soft-bristled brush placed in the rectum and can be performed by any health care provider. A positive pap smear and/or high-risk HPV type exam should be referred to a specialist for HRA which is a quick 15-minute office based biopsy procedure. If any precancerous lesions are found, they are easily treatable with short office based ablation procedures as well. Taken in context the treatment of anal cancer involves 3–4 months of chemotherapy and radiation treatments followed occasionally by major surgery and permanent colostomies.
So let’s switch gears and talk about colorectal cancer. Why is screening so important?
Screening for colorectal cancer is important because early colon cancers may be completely assymptomatic. Typical warning signs such as abdominal pain, rectal bleeding, anemia and fatigue often won’t present until the cancer is at least stage 3 or 4 when survival rates have plummeted from 90% to 40% or worse.
How old should I be when I start screening, and what is the best way to screen?
New guidelines recommend those at average risk to start screening at age 45. High risk groups include those with first degree relatives with either colon cancer or a history of colon polyps, patients with immune deficiencies, or inflammatory conditions such as ulcerative colitis or Crohn’s disease may start sooner and should ask their providers. While there are a few options for screening, two modalities have become the standard of care currently. All patients can undergo a screening colonoscopy every ten years beginning at age 45. This test involved flushing out the colon with an at home prep the evening before, and then minor sedation at an outpatient endoscopy or surgery center while the physician examines the colon directly with a long fiberoptic camera. For those patients with no personal or 1st degree family history of either colon polyps or colorectal cancer, at-home stool screening with the Cologuard test every three years is an option. This easy to use mail in kit is covered by most insurances, and avoids the prep, missed time at work and expense of a colonoscopy; however any positive test mandates a colonoscopy to ensure that no polyp or cancer exists.
Are all polyps going to turn into cancer?
No there are multiple types of polyps ranging over a spectrum from hyperplastic ones that are essentially small bumps like internal skin tags with an almost 0% chance of turning into cancer to varying types of adenomas which do have increased chances of turning into cancers based on their subtype, size and presence of abnormal cells within them. Even experienced physicians can’t always tell just by looking, so we remove any and all polyps we encounter and then wait for the final pathology report to give us an idea of what the overall risk is and then to decide if the next colonoscopy should be in 1,3,5,7,or 10 years.
Has anything been shown to decrease my chances of getting either anal or colorectal cancer?
Although HPV is a sexually transmitted disease, it is estimated that most people encounter their first strain of the virus as early as age 10. The Gardasil vaccine given at an early age has been shown to be nearly 100% effective in preventing the virus transmission and thereby preventing the development of genital warts and some cancers. The Vaccine is approved up to age 26 and should be considered in all patients. For those of us above age 26, practicing safe sex practices, utilizing good handwashing techniques before and after using the bathroom and sexual encounters may help decrease the spread of the virus and obtaining routine anal pap smears should allow pre-cancerous changes which are 100% curable to be found long before a cancer can develop.
Multiple factors have been suggested to prevent the development of colorectal cancer. Tobacco use in all its forms has been shown to increase cancer rates. It is suggested to have no more than two drinks a day for men and one drink a day for women. An active lifestyle with exercise more than a few times a week and avoiding obesity has been shown to decrease rates of colorectal cancer, and finally a diet high in fiber with whole grains, beans and legumes in addition to fruits and vegetables has been shown to maintain a healthy colon.
What is a colon and rectal surgeon?
Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery followed by an additional colon and rectal surgery residency and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.
Is South Florida Colorectal Institute currently open and seeing new patients? Do you take all insurances?
My practice was shut down temporarily in January as we had to train some new staff and change computer systems. We are currently open and taking all old and new patients. We take almost all major insurances, Medicare, Medicare advantage plans, Medicaid, and Ryan White. Check with your insurance and/or primaries to find out if you need any sort or referral or prior authorization prior to making an appointment. The office is located at 1960 NE 47th St., in Fort Lauderdale, just south of Holy Cross Hospital. I have inpatient hospital surgical privileges at both Holy Cross Hospital and Broward Health-Imperial Point Medical Center and outpatient surgical privileges at the Coral Ridge Outpatient Center, Broward Specialty Surgical center, and the Holy Cross Healthplex. You may call for an appointment at 954-573-1499, or email us at