Amanda Wilde (Host): This is BayCare HealthChat. I'm Amanda Wilde. Colorectal cancer is the second leading cause of cancer-related deaths, yet up to 90% of colorectal cancers are preventable. We're talking about risk factors, prevention strategies, and raising general awareness of colorectal cancer with gastroenterologists, Dr. Keshav Kukreja and Dr. Harsh Patel. Thank you both for being here and welcome. Dr. Kukreja, let's define colorectal cancer first of all, and what are the most common symptoms?

Dr. Keshav Kukreja: Kind of as the name implies, colorectal cancer is a malignancy that either starts in some part of the colon or in the rectum, which is the very tail end of the colon. Symptoms, as you mentioned, that's the interesting thing about colon cancer is that often there's no symptoms. So, sometimes someone comes in just for their first colonoscopy and you find cancer in there. But if it's advanced, some patients may report symptoms, such as a change in their bowel habits, like their stools are coming out thinner, pencil-shaped, or they have some blood in the stool, maybe some abdominal pain. All of a sudden their blood counts are low, they're anemic, or they're having a lot of unexplained weight loss.

Host: Well, Dr. Patel, why is there such a high incidence of fatality from this disease? Is it the fact that we don't spot those symptoms earlier on?

Dr. Harsh Patel: You know, I think that's one of the reasons why. As Dr. Kukreja alluded to, often colorectal cancer does not present with any symptoms. So by the time it's sometimes caught, it's too late at the advanced stage. And so, it's difficult to treat once it's at the advanced stage. And that kind of harks back to the point that colorectal cancer screening is very important, because 90% of colorectal cancer can be preventable if screening is done appropriately and early enough in patients.

So, I think it's the fact, a combination of, there's increased incidence of colon cancer over the last couple of decades, and also the fact that often colorectal cancer does not present with any symptoms. And when it is caught, what happens is it's too late, and that's why we have a higher mortality rate related to colorectal cancer.

Host: So, Dr. Patel, you're saying that screening is the key?

 Dr. Harsh Patel: Yes, I think so. All the gastroenterologists would agree that, you know, screening is key. Matter of fact, it's such an important factor that previously colorectal cancer screening started at the age of 50. But now over the last few years, guidelines have changed and now 45 is the new 50.

Host: Okay. So, Dr. Kukreja, could you elaborate on the screening recommendations?

Dr. Keshav Kukreja: In general, we always have a few options kind of with everything and we like to talk to our patients about all of the options that they have. There's pros and cons to everything we choose. But in general, for someone who's average risk, and I really highlight that average risk, 45 is the recommended age to start, like Dr. Patel was saying. And the options are really stool testing. And there's two different types of main stool tests that we use. Going forward with actual colonoscopy, which ends up being the best and most sensitive test. Or for some individuals, there's an imaging study that you can do. It's a special CT scan that kind of highlights things in the colon. But those are kind of the main types of screening tests we use.

Host: Of course, most of us just hear about the colonoscopy, which I hear the prep has improved over time. Dr. Patel, can you briefly describe what happens during a colonoscopy and these other screening procedures, like the preparation required and what we can expect?

Dr. Harsh Patel: I'll first start off with the stool-based testing. So as Dr. Kukreja pointed out, there's two main ones. Those are used currently on the market. One is called a FIT test and the other one's called a Cologuard test. Both of these are stool-based testing. The FIT test is basically you submit a sample of your stool. It's a kit that comes with a little toothpick almost, and you get some of the stool. And you submit it into a vial, and it's sent off to a lab. What the FIT test is looking for is, mostly specifically, blood product in the stool. Obviously, we know when there's high risk polyps or cancer, they tend to bleed. So, what the FIT test is looking for is blood in the stool. So for those stool-based testing, there's actually no preparation. You're just collecting stool sample and sending it off in the mail or to the lab.

The Cologuard test is also a stool-based testing as well, where you collect your stool sample and you mail it off.Now, what the Cologuard test is looking for is a couple things. First, human blood and also DNA particulate that is associated with colorectal cancer. So, it's a little bit more accurate in terms of picking up colorectal cancer, because it's looking at two components. So for the Cologuard test as well, there is no preparation required. That's why patients sometimes prefer them over colonoscopy, because there's no preparation required. You don't have to take a day off. You don't have to prep for these.

On the other hand, the colonoscopy, it is a little bit labor intensive in a sense where you have to do a bowel prep beforehand, so you have to clean out the colon. So, colonoscopy, as good as the bowel prep, the cleaner the colon, the better we can visualize the inside of the colon. Polyps come in different shapes, sizes. Some of them can be very small. If the colon is clean enough, we can pick it up and we can cut them out. So, preparation is key for colonoscopy.

The other factor for the colonoscopy is you have to take the day off for the procedure. So, once you do the prep the night before, which is probably the worst part about the colonoscopy. It's the night before where you have to drink bowel prep. Now, bowel preps have gotten better, like you mentioned. There used to be gallon bowel preps. But over time, we do have what we call small volume bowel preps, which is almost half or quarter of the volume what they used to be. And there are also pills, something called Sutab, which are also available in the market now. With that, you have to drink plenty of water, and you have to take about 24 pills over the course of the preparation. So, some people don't like taking pills, so the small volume bowel prep may work better for them.

The other caveat to that is the small volume bowel preps, they are not recommended for patients that have chronic kidney disease. So, you want to make sure you talk with your gastroenterologist if you do have chronic kidney disease, because, in those cases, you can't use the small volume prep.

So, as far as the colonoscopy, like I said, it's more labor intensive with the bowel prep. You have to take the day off, and you need someone to drive you to and from the procedure.

Host: Well, Dr. Patel, is the colonoscopy still the gold standard? Or do these other methods equal a colonoscopy?

Dr. Harsh Patel: No doubt, colonoscopy is the gold standard. And I'll let Dr. Kukreja talk about that.

Dr. Keshav Kukreja: Yeah. And one thing, Harsh, my friend over here, he's scaring people about how bad this prep is, but what I will say is a lot of is mind over matter. I always like to tell the patients it's one evening and one night in five to ten years depending on when you need your next one. And once you accept that, yes, it's going to suck, but you don't have to do it that often. And the outcome is you get such a good colonoscopy and a clean bill of health, at least from a colon standpoint, a cancer that is, like we've been talking about, so common. So, to me, the prep, yes, it's hard, it's bad, but totally worth it.

And the reason why colonoscopy is a gold standard, like we were talking about, is that, you know, some of these other tests, they miss advanced adenomas, or basically what we're calling dangerous polyps that have the potential to turn into colon cancer. I'll give you some numbers. For example, Cologuard is 93% accurate at detecting colon cancer, but a really big polyp, it's only 42% accurate.

The FIT test, the other stool test, it's only 39% accurate in detecting a big polyp, okay? And then, when you think about colonoscopy, it's upwards of 90-95% because we're in there, the polyp is big and we're staring right at it and everything is zoomed in on a big screen. So by missing these advanced adenomas or big polyps, patients are always kind of running the risk that, could this grow in a year? Could this grow by the time I get my next test? And then, there's always the concern that what if my test is a false positive, which happened in Cologuard almost 13, 14% of the time, which is kind of unacceptable to us as a false positive rate. You know, it's almost over one in 10 people are going to have a positive Cologuard. But nothing's going on in there, and it's kind of causing so much anxiety for no reason.

Host: And then, what happens if you do have a positive or a false positive? Is there follow up testing? What are the steps after that?

 Dr. Harsh Patel: Yes. So once a patient has had a stool-based test, either a FIT or a Cologuard test, their primary doctors will generally refer them to a gastroenterologist for a colonoscopy. And again, that harks back to the point that colonoscopy remains the gold standard for detection. So, you know, if it's negative, then you won't need a colonoscopy, but if it's positive, either the FIT test or the Cologuard, you will ultimately need a colonoscopy.

Host: Moving from the testing backward a little bit to prevention strategies and risk factors, Dr. Kukreja, are there risk factors for colorectal cancer? And if so, what are they?

Dr. Keshav Kukreja: Absolutely. So, risk, one, is it just increases with age, which, you know, I guess sounds a little obvious, but as you get older, your risk of colon cancer increases. Family history, like having a first-degree relative who was diagnosed younger in life, like below the age of 60, or multiple first and second-degree relatives, that can double or triple someone's risk for colon cancer. And those patients are really not eligible for any stool-based testing.

The other risk factors, there's often genetic syndromes. Those are more rare, like Lynch syndrome, as well as inflammatory bowel disease, like Crohn's or ulcerative colitis, that can increase the risk. And then, there is some data about diet high in red or processed meats, alcohol, smoking, and more of a sedentary lifestyle. All of these things can kind of increase your risk. And we're seeing colon cancer in younger and younger people. I mean, I'll say, you know, I've seen patients in their low 30s with colon cancer and we're all concerned why this is happening. And we're worried that a lot of it is these processed foods that we're eating, a lot of red meat and stuff like that. So, processed food is causing a lot of issues that we think data on that is I'm sure upcoming.

Host: Now, I'm thinking if you want to get routine testing or if you have issues, what's the role of primary care physicians in this? I would assume you would go to that person first before being referred to someone like you, a gastroenterologist. Is that correct?

Dr. Harsh Patel: Yes, I would say that is pretty spot on. Most of the patients that we are seeing for colonoscopies and colon cancer screening are first seen by the primary doctors, who will then refer them to us for colon cancer screening. Now, some of the primary doctors, if the patient is average risk, and the patient wants to do a stool-based testing, they'll have it done with their primary doctor.

But as far as colonoscopies, a lot of times the primary doctors will send those patients to us for consideration for screening or surveillance colonoscopy.

Dr. Keshav Kukreja: And in this day and age, you know, often the primary care is the hub and that's where everything starts. But some patients, depending on their insurance, they may be able to see a gastroenterologist directly, but more often than not, they come from their primary care doctor.

Host: Okay. Thank you, Dr. Kukreja. And Dr. Patel, are there resources you can recommend for further information? Are there websites or patient advocacy groups that you can share?

Dr. Harsh Patel: Yes, there's a few resources I would love to share. First of all, American Cancer Society has good patient information regarding colon cancer screening. The other one to consider is the uspreventativetaskforce.org. That's another one that not only discusses colon cancer screening, but other cancers as well. So, those are two resources I would recommend for patients, especially the American Cancer Society because I think it's very patient-centric and it could kind of present the information in layman's terms.

Dr. Keshav Kukreja: One thing I'll add is you can go straight to the American College of Gastroenterology's website and these articles on the updated guidelines for colon cancer screening are available for anyone to read.

Host: Well, thank you, Dr. Kukreja and Dr. Patel, for this important conversation so we know more about prevention and early detection and support regarding colon health. Thank you for your time.

Dr. Keshav Kukreja: Thank you so much, Amanda, for having us.

Dr. Harsh Patel: Thank you, Amanda, again.

Host: And that wraps up this episode of BayCare HealthChat. Head on over to our website at BayCare.org for more information and to get connected with one of our providers.

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