November 8, 2003


The slide shows a picture of two men strolling through Vancouver's Granville Market in the evening. They're dressed to the nines in that post-Depression, prewar apparel commonly seen in old family photo albums. The men are lean -- their necks, like those of chickens, rise out of starched collars stiffened with ties; their coats flap in the breeze, fedoras firmly in place.


"More about them later," said Dr. Linda Rabeneck, the gastroenterologist, presenting her paper on colon-cancer screening at the Society of Obstetricians and Gynecologists of Canada in Charlottetown this summer.


I was there to present a paper on exercise and diet as part of a session on the comprehensive care of middle-aged women. But this column is about Dr. Rabeneck and her mission. She is a stately, suave and very cool woman. Her gestures are minimal but commanding, and she never raises her voice.


When she said she was passionate about the need to screen women for colon cancer, there was no passion in her voice. But it was clear she felt strongly that women should ask for and get the primary screening to detect polyps before they become cancerous. Finding cancer in a patient's colon usually indicates to her that the patient was never screened.


Her talk is peppered with examples of famous people who have been diagnosed with colon cancer. Most are in their 50s; some are still alive and have become "poster grownups" for colon cancer awareness and screening. She mentions Katie Couric, co-anchor of NBC's Today Show. In a bid to raise awareness of colonoscopic screening after her husband developed colon cancer, Ms. Couric underwent a colonoscopy live on camera before millions of viewers -- many of whom had tuned in over breakfast. There are many others, including Pamela Wallin, Canada's consul-general in New York, who speaks frankly and frequently about her illness and its cure. There's also the late Mariellen Black, who survived her cancer long enough to create the Colorectal Cancer Screening Initiative Foundation.


Their message is simple: Timely screening of women from 50 onward can prevent colon cancer. An annual fecal occult blood test is the simplest. It can detect hidden blood in the stools that may reveal 50 per cent of probable lesions.


Other screening methods vary in sophistication and accuracy, from barium enemas (done every five years) and sigmoidoscopy (done every five to 10 years), which capture about 75 per cent of lesions, to colonoscopic examination (Cscope), which raises the capture rate to as high as 92 per cent.


The good Dr. Rabeneck pointed out that we are still screening only about 25 per cent of the population. It's a figure that hasn't changed much despite numerous trials that have demonstrated the value of such screening and the fact that 75 per cent of colorectal cancers occur in people with no family history of the disease.


Because there's often a long lead time in the transition from polyps to cancer, screening can detect potential problems before they become serious.


Compare this to mammograms: By the time a mammogram picks up calcifications in the breast, there is already a serious problem, whereas finding and excising a polyp through colorectal screening is truly preventive.


Some people claim that the low use of colonoscopies to prevent colon cancer is a money issue or a human resources question -- colonoscopies require complex machinery and surgical skill.


But that's not the primary problem. The real problem has to do with our reluctance to talk about or get comfortable with our bottoms. Primary screening means a colonoscopy, which means sticking a long thin tube fitted with a tiny camera up your bum. It isn't the world's most comfortable procedure, nor the most dignified.


So if you think getting women off the couch and into some physical activity is tough, try getting them to talk about inspecting their bottoms. It is true that colon cancer is an equal-opportunity affair for men and women. True also that men, in my experience, find this even more of a hurdle to talk about than women do.


But messing around comes with the territory when you're scraping stool samples onto slides and clearing the bowel with foul drinks that have you sitting on the toilet "till it runs clear." And that's the night before you take the test.


But does it save lives? Absolutely, Dr. Rabeneck says. So how do we raise awareness and increase the numbers of people who ask for a screening? How do we keep from dying of embarrassment?


Two things have to change, according to the focus groups Mariellen Black engaged while she was setting up the Colorectal Cancer Screening Initiative Foundation: First, the very real sense of shame that surrounds any discussion of the bowel or its function must be dispelled. And second, you have to make it funny.


One of the results of input from the focus groups is a radio commercial called Euphemisms. It is a short list of all the ways we have of referring to "back there" -- derrière, tush, ass, rear end, etc. It isn't as elaborate as the 200 words some people believe the Inuit have for snow, but it makes its point about how to begin talking about the test.


My own mission is to help women rediscover themselves through fitness -- and grow strong and redefine themselves in the process.


Dr. Linda Rabeneck has a different mission -- to save women's lives by getting them to take a simple test. The symbol for this quest is the Pretty Bottom: a backside view of a woman's nice round ass, each cheek underscored with the words "pretty bottom."


As for the two men on a stroll in Vancouver so long ago, they were Dr. Rabeneck's father and uncle. During the 1980s, both of them were diagnosed with colorectal cancer within three years of one another. Dr. Rabeneck believes it didn't need to happen.

Dr. Jean



Doctor. Writer. Athlete.

Advocate. Adventurer.