May 1, 2010
By Jonathan Sackier
“I wish I had the voice of Homer, to sing of rectal carcinoma, which kills a lot more chaps, in fact, than were bumped off when Troy was sacked. Yet, thanks to modern surgeons’ skills, it can be killed before it kills.” So wrote J.B.S. Haldane in 1964 of his cancer, increasing awareness of this disease. The average AOPA member is a 50-year-old male who rarely seeks medical counsel other than to increase left seat time. This article might, so please read on!
The colon, or large bowel, dehydrates food, moving waste to the rectum for evacuation. Malignant change of the bowel lining, colorectal cancer, is the second leading cause of cancer death, most commonly in the fifth to seventh decades. In 2009, 146,970 people were diagnosed with this disease and 49,920 died (NCI data). These cancers usually develop in little cauliflower- or grape-shape outgrowths called polyps, which may be symptom-free and harmless for years. Other causes include ulcerative colitis; low-fiber, high-fat diets; smoking; and certain inherited conditions.
Colorectal cancer can be asymptomatic until changes in bowel habit, blood or mucus in the stool, abdominal pain, and bloating occur. This article is about attacking colorectal cancer before it is even there. That’s a challenge, to beat something that does not exist! How? Screening, or in flying-ese, “staying ahead of the airplane.” A regular medical is worthwhile, including the dreaded DRE (digital rectal examination), a test kit to look for blood in the stool works, but the best screening test is colonoscopy. There is plenty of room for humor here, so let’s, ahem, “dig in.”
A colonoscope is a long, steerable flexible telescopic camera about one-half inch in diameter, which is gradually inserted via the anus, allowing the physician to view the colon and last part of the small intestine. The device also allows introduction of air to separate the bowel walls, irrigation of debris and passage of biopsy and other instruments.
To ensure a clear image, pre-procedure bowel preparation is ordered, including a liquid diet and laxative medication such as Polyethylene Glycol, a chemical with many uses—from batteries to printers and for preserving wood. As a laxative it is marketed under several trade names including MoviPrep and GoLYTELY—I always thought it should be called “GoHeavilyandGoOften.” I recommend chilling it and drinking a cup quickly then use mouthwash followed by a glass of ice water. Close proximity to a toilet is obligatory and some good books such as The Origin of the Feces, Pride and Prunejuice, or The Incontinence of Being Earnest.
When sad, we say “the bottom is dropping out of my world.” During this bowel preparation you will feel the world drop out of your bottom! Continue drinking until passing clear fluid to ensure the doctor has a good view; six to eight pints are usually needed.
During the procedure intravenous fluids and sedation will be administered and the procedure is usually totally painless.
If no abnormality is found, celebrate and book a follow-up examination—with no family history and a clear test, every five years is a good guideline, but this is age-dependent. If a polyp or other abnormality is seen, biopsy or removal with a lasso-type device is usually feasible at the same time with no pain and little risk. If a cancer is seen, an operation and other therapy is guaranteed.
Virtual colonoscopy is another option; CT or MRI images are used to construct an internal colonic view, but small polyps can be missed, no therapeutic maneuvers completed and efficacy remains questionable.
I talked to Gary Crump, AOPA’s director of medical certification, about the implications of colonoscopy on pilots’ certificate privileges. He stated that after screening, pilots should report this to their aviation medical examiner (AME) providing the procedure report; no further FAA action is likely. If a polyp is removed, supply the pathology report, but again, other than a follow-up examination, further FAA scrutiny is unlikely.
Without screening colonoscopy, should colorectal cancer rear—forgive the pun—its ugly head, then surgery is in your immediate future. Apart from the pain, cost and inconvenience, your AME will lead you through an “AME Assisted Special Issuance” mandating at best an annual physical for a period of several years. With chemo or radiotherapy, clearance to fly will not even be considered for 30 to 60 days after the final treatment with special issuance to follow.
So a happy colon keeps you flying! Reduce dietary saturated fats, increase fiber, exercise regularly and stop smoking. OK, now that I am off my soapbox it is worth finishing with another snippet from Haldane’s ode to cancer. After some colorectal operations, surgeons are obliged to fashion a colostomy, literally a “colon mouth” to allow the feces to empty into a plastic bag on the abdominal wall. Haldane needed a colostomy and had this to say of his new orifice: “So now I am like two-faced Janus, The only god who sees his anus.” Don’t be like our muse speaking to us from the 1960s; get screened and have everyone you know and love screened. Get it before it gets you.
E-mail the author at firstname.lastname@example.org.
Jonathan M. Sackier has practiced medicine in the United States for more than 20 years.
Aviation Medical Examiner,
Pilot Health and Medical,
Special Issuance Medical,
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