ArcaMax

DEAR DR. ROACH: I am a 79-year-old female who is currently on biannual infusions for osteoporosis and high cholesterol. In 2018, I was diagnosed with Lynch syndrome with an MSH6 deviation. The genetic testing was done after I had breast cancer, endometrial cancer, and a colectomy for three years in a row. Yearly colonoscopies have been included in my preventive care.

In 2022, during my colonoscopy, I experienced excessive vagal tone and needed atropine to restore my heart beat. Since this time, I have been given Robinul prior to the procedure, which has prevented another incident of bradycardia. My gastroenterologist isn't recommending any more colonoscopies due to this cardiac issue and my age.

I have always been told that colonoscopies are necessary to prevent cancerous polyps from occurring. Is the risk of a colonoscopy under these circumstances greater than the risk of my getting colon cancer due to Lynch syndrome? -- F.M.

ANSWER: People with Lynch syndrome are at an increased risk for a variety of cancers, especially of the colon but also other parts of the gastrointestinal tract (stomach, small intestine, pancreas and bile duct). People with Lynch syndrome are also at an increased risk for endometrial and ovarian cancer (in women), prostate cancer (in men), and others including skin and brain cancer. Gastroenterologists know that cancer of the colon can arise without a polyp.

For people with Lynch syndrome, a genetic analysis is recommended. The exact gene may help determine the optimal beginning time and frequency of a colonoscopy. The decision of when to discontinue screening via a colonoscopy is not agreed upon by experts, but clearly when the risk of performing a colonoscopy is greater than the expected benefit, it's time to stop. This is less about reaching a certain age than it is about underlying medical conditions.

You have a slow heart rate during sedation for the colonoscopy, and it sounds as though your doctors have found a way to do the colonoscopy safely. Your lifetime risk of colon cancer, given your MSH carrier status, is estimated to be 20%, but at age 79, you have outlived much of your risk. Most cases of colon cancer in Lynch syndrome occur before age 80.

In my opinion, both the risks of a colonoscopy and the risk of developing colon cancer are low, which means that it is difficult to make a recommendation as to which way you should go. Stopping is reasonable, but if you feel strongly that you want to continue, this is also reasonable.

DEAR DR. ROACH: I am an 80-year-old female who had shingles 30 years ago for six weeks. It subsequently came back permanently (herpetic neuralgia). I take 2,500 mg of gabapentin daily, which mostly controls the pain but does not help the tingling and numbness in the soles of my feet. Do you have any suggestions? -- P.S.V.

ANSWER: I am sorry that you had this complication, which is one of the most known painful conditions. Gabapentin is an effective treatment for many people with painful neuropathies of any kind. A dose of 2,500 mg is very high but is often needed to get control of the pain; however, many people cannot tolerate this dose due to the fatigue and sleepiness that it often causes.

In my experience, some people can get pain relief from gabapentin without getting relief from the numbness and tingling. It is possible that even higher doses might help (the maximum dose is 3,600 mg), but before trying this, your doctor might consider a second type of treatment for neuropathy, such as a tricyclic agent or an SNRI.

These drugs were developed for depression but can be used for neuropathy symptoms. Sometimes, multiple medicines allow for better symptom relief with less side effects than very high doses of just one medicine.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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