Melanie Cole (Host):  Colorectal cancer is the second leading cause of cancer-related deaths among men and women combined. However, there are tests that can actually prevent or detect colon cancer at its earliest stages. My guest today is Dr. David Newton. He’s a gastroenterologist with Gastroenterology Specialties. Dr. Newton, tell us about the current state of colon cancer today. what is the prevalence and are you seeing an increase or a decrease in occurrence?

David Newton, MD (Guest):  Well thank you so much for having me. Colon cancer awareness month is coming up in March, so this is a perfect time to talk about this important topic. In regards to your question, overall, we are seeing a decrease in the incidence of both colon cancer occurrence and then also deaths related to colon cancer. There is one demographic, one age group where we are seeing an increased rate of incidence in colon cancer-related deaths and that is individuals under the age of 50 and the thought behind that is that for the longest time, we have started our colon cancer screening at the age of 50 and not before then. So, we are seeing a small increase in the incidence of individuals with colon cancer under the age of 50.

Host:  What are the risk factors for colon cancer? Is there a genetic component? Is it hereditary? Is it diet related? Tell us about some of the factors that contribute to it.

Dr. Newton:  Absolutely. There’s a small proportion of colon cancers that are related to genetic syndromes such as Lynch syndrome or polyposis syndromes but that’s a minority of patients. There is definitely a genetic component to it, and we know that individuals with first degree relatives under the age of 60 who are impacted with colorectal cancer have a significantly increased risk of colorectal cancer themselves and therefore we recommend starting colon cancer screening at an earlier age. We do know that colon cancer incidence and death is increased in men more so than women, roughly one in twenty two men will be diagnosed with colon cancer during their lifetime compared to one in twenty four women during their lifetime.

As far as lifestyle choices, we know that tobacco smoking as well as alcohol use, obesity, the metabolic syndromes; so, things like diabetes, hypertension and cholesterol all increase the risk of colorectal cancer as well. We thing the western diet, so a low fiber diet, a high fat diet with red meat also increases the risk of colorectal cancer.

Host:  What signs and symptoms, because we are going to talk about colonoscopy and tests available, but what signs and symptoms might send somebody to a gastroenterologist in the first place? People see bleeding. Sometimes, Dr. Newton, they see blood in the toilet, but hemorrhoids do that too. So, when is it time to get into the gastroenterologist and then we’ll speak about colonoscopy.

Dr. Newton:  Absolutely, you know it’s important – a significant number of patients with colon cancer especially early on in their disease don’t specifically have symptoms and I know we will talk about the importance of screening, but that’s why that – getting screened for colorectal cancer is so important. In those individuals who haven’t been screened and do experience symptoms, the thing that we notice that are most concerning to us is rectal bleeding, while yes commonly seen with outlet disorders such as hemorrhoids; is commonly seen with colorectal cancer as well. Change in bowel habits, so somebody who is routinely having regular bowel movements and becomes constipated could be a red flag. Also, the change in caliber of the stool. Some individuals, if you start to lose weight unnecessarily, we are obviously concerned as well. So, we take kind of the overall presentation. But if an individual notices changes in their digestive health, it’s important to talk to your doctor to get tested, get the evaluation that is necessary. Because we do know that catching – similar to with other types of cancer, if we catch colon cancer early, the survival rates are much, much better.

Host:  Then lest talk about the tests that can be done to detect and diagnose colon cancer. Speak about colonoscopy and what are the current screening guidelines? When do you get your first one?

Dr. Newton:  Absolutely and this is an evolving topic this year. So, for the longest time, the last several years, the guidelines have stated that average risk individuals, so those are individuals without a family history of colon cancer, without other chronic digestive diseases such as inflammatory bowel disease: that they start average risk screening at the age of 50. African Americans who have the highest rate of mortality and lowest survival when compared to other racial groups; are recommended to start at the age of 45. So, up until the middle of the year 2018; those have been the guidelines from all of the different societies.

The American Cancer Society in the middle of 2018, made a qualified recommendation to start average risk screening in all individuals starting at the age of 45 and the reason for that is what we touched on earlier that the incidence of colon cancer occurrence as well as deaths is increasing in those under the age of 50. So, now we are starting to see a shift where we might see more organizations making that recommendation to start at the age of 45.

Host:  Where in Lincoln can you have your colonoscopy performed?

Dr. Newton:  There are several different places that we can have this performed. Gastroenterology Specialties, we have an ambulatory surgical center, or an endoscopy center called Lincoln Endoscopy Center here in Lincoln where these can be performed. They can also be performed at any of the three hospitals in town the two Bryan Hospitals as well as St. Elizabeth’s. We have an additional joint venture with Bryan Health called Lincoln Digestive Health Center which is on the fifth floor over at Bryan West Hospital which is another facility where we will perform endoscopic procedures including colonoscopy.

Host:  Dr. Newton, why is it important to go to your physician for a colonoscopy and not do one of the home kits that we have seen in the media and as far as insurance, now colonoscopy is part of a well preventive visit, right? I mean insurance covers it at 100%.

Dr. Newton:  So, there’s several different components to that. So, for – if we look at the multi-specialties, the task force in colorectal cancer, which is a group of professional organizations, gastroenterologists; they tier their recommendations on which specific test to do and the first tier includes a well-prepped colonoscopy should be offered first, if that is refused, then the patient should be offered FIT testing which is essentially a small test that evaluates for blood in the stool. In 2014, a product came on the market that looked at FIT testing in addition to DNA testing and since that time, they have aggressively marketed this to service not only an alternative to FIT testing but as an alternative to colonoscopy. From our – I think in general, if we are able to prevent a cancer, I think that’s better than detecting cancer. With colonoscopy, we are able to detect and prevent cancer, with prevention coming by the removal of these precancerous polyps. When we look specifically at the FIT DNA testing that’s now widely available; the sensitivity for that is 93% so they will catch 93% of cancers, which overall is a good number, but when we look at it closer and we are thinking about a diagnosis such as colon cancer; during the study that got this product approved, they missed one in 13 colon cancers. Additionally, they missed 40% of polyps that have high grade dysplasia which is a lesion that we think is the step immediately before this progresses into colon cancer and they missed roughly 60% of larger precancerous polyps in the right colon that we know through studies contributes to 20-30% of the overall numbers of cancers that are diagnosed in this country.

Now colonoscopy, while not perfect and some small lesions may be missed; is as technology continues to get better, is effective in identifying those and removing those specific polyps. We know just with a recent study that was released there are protective benefits of a colonoscopy that extend out through ten years if that initial study is negative. So, the decreased risk overall of cancer-related death carries out through that ten year interval.

Now, when it comes to insurance coverage; because I think that does play an important role; since I think roughly around the year 2000, Medicare beneficiaries were able to get preventative healthcare services covered at 100% that includes a colonoscopy. In 2010, with the Affordable Care Act; they extended those provisions to all Obamacare compliant health plans so that colon cancer screening was covered at 100% by the insurance carrier. Now if colonoscopy is the test that is chosen for colon cancer screening; that’s covered 100%. If we would pick either a FIT test or a FIT DNA test; that test will be covered under the screening benefit; but if those tests are positive; the next step is a colonoscopy; which would be recommended.

Host:  What a great explanation of the insurance situation and the difference between diagnostic and screening. I don’t know why anyone wouldn’t get their colonoscopy except for the fact, Dr. Newton, that people are afraid of the prep. The test is so quick, they wake up and say when are you starting, you say I’m done. But the prep is what seems to scare a lot of people off. Why is that? What’s going on with the preps these days and are some smaller amounts coming down the pipe do you think?

Dr. Newton:  Absolutely. I think this is – we hear this from patients all the time about the fear of the prep and going through this and everybody in the back of their mind they are thinking this gallon jug of salty water that they have to drink, and they will be on the toilet for the next 24 hours. Times have changed over the last several years. There are multiple small volume preps that are available on the market. The specific prep that we use in our center is roughly 25 ounces of actual laxative solution mixed with the clear liquid of choice by the patient. When we see individuals the next morning prior to their procedure and ask them how the prep went; most are in shock at how straightforward and easy it actually was. And it sounds like from people that have done the big four liter prep in the past and have now done this smaller volume prep that the difference is pretty significant so the prep is much easier, and I don’t think that alone should discourage somebody from getting a colonoscopy.

I think one important caveat with this too is that we have these noninvasive tests which I do think serve an important purpose. If somebody is hesitant to get a colonoscopy but would be willing to get that exam if they are nudged along by a positive noninvasive test; I think that’s the perfect situation. If we have an individual who is 100% against getting a colonoscopy and will not get a colonoscopy performed no matter what; there is no sense in doing any screening test in those individuals. Purely because all roads, all noninvasive tests, if they are positive; need to be followed up by a colonoscopy.

Host:  True, all roads lead to the colonoscopy eventually like you say if those tests are positive and one of the things about colonoscopy that makes it so amazing is that it’s being called a preventive tool because you see these polyps in there, you take them out while you are in there and then they go to pathology. Tell us a little bit about polyps. What is it that you are looking for, if there is a good prep involved and what do polyps typically mean?

Dr. Newton:  So, polyps are common and we’ll – probably over 50% of the time, we’ll identify at least some abnormality with polypoid growth in the colon. A polyp is – there are several different types of polyps. There are benign polyps which have no clinical consequence and then there are the polyps that we want to identify and remove. Those are precancerous polyps. The most common of those are tubular adenomas. They can range in size from a couple of millimeters to several centimeters. They can be incredibly flat sometimes even depressed and difficult to identify to a pedunculated polyp which has a long stock and kind of a ball like appearance on the end.

All of those different attributes make identification of polyps and removal of polyps difficult in some cases and we know that as we discussed, the right side colon polyps contribute to 30% of the colon cancers. Those are the ones that are difficult to identify, difficult to remove. Those specific ones, the flat ones are why it is so important to have a good adequate colonoscopy prep going into this. if there is some adherent stool in that side of the colon, we may miss those small polyps. The majority of time, if the prep is adequate, we can identify and remove those polyps, especially as the polyps get bigger and higher risk.

Once they are removed, we send those to the pathologist. They will look under the microscope and tell us the specific features and give us the diagnosed. The tubular adenoma like I talked about is the most common precancerous polyp. We are looking for other changes, more advanced features such as villus features or dysplasia which we know are higher risk polyps. Based on that information, and then the size of the polyp; that will determine the recommended surveillance interval for the next colonoscopy exam. It’s important to know that if precancerous polyps are removed at any point in a person’s life they really do not qualify for the noninvasive tests and should undergo colonoscopy for surveillance purposes indefinitely.

Host:  As we wrap up, can diet help to prevent? You mentioned it a little bit before and the Western diet. So, just kind of reiterate for us what we can do. Lifestyle modifications, things that we can do to hopefully prevent colon cancer and the importance of getting our colonoscopy at the recommended times.

Dr. Newton:  So, one of the big risks and what we are trying to figure out why those rates of colon cancer is increasing in those younger individuals less than the age of 50 is what we are finding is obesity is playing a major role in this. so, maintaining a healthy weight. As we see with all other cancers; tobacco use, and cessation of all tobacco use is important. Use of alcohol in moderation as we know excess can increase you risk for colon cancer as well. A high fiber diet is I think beneficial in most aspects of digestive health. There are some suggestions that a high fiber diet can help to lower that risk of colon cancer. All those things being said, there is no magic diet. There is no magic pill that can prevent colon cancer 100%. Getting the screening performed in a safe, effective manner with colonoscopy is the best way to prevent being diagnosed with colon cancer in the future.

Host:  Thank you so much Dr. Newton, for coming on, sharing your incredible expertise about colon cancer, colonoscopy and the important screening tool that can help to prevent colon cancer in the first place. If you are still nervous about your colonoscopy; watch a patient as they prepare for and go through the actual colonoscopy procedure at www.bryanhealth.org/colonoscopy, that’s www.bryanhealth.org/colonoscopy. It’s a lot easier than you think and could save your life. This is Bryan Health podcast. I’m Melanie Cole. Thanks so much for listening.