Melanie Cole, MS (Host): Colorectal cancer is now the leading cause of cancer-related deaths for men under the age of 50 and the second leading cause for women under 50 as well. However, with regular screening, it can be caught early and even prevented.

Welcome to Bryan Health Podcast. I'm Melanie Cole. And joining me today to talk about colorectal cancer screening and prevention is Dr. David Newton. He's a gastroenterologist Gastroenterology Specialties in Lincoln, Nebraska. Dr. Newton, thank you so much for joining us today. I know the trends have been changing a little bit recently. Can you speak a little bit about the trends that you're seeing with general colorectal cancer rates, but also specifically in the younger population that we've been seeing that a little bit more too?

Dr David Newton: Of course. And thank you so much, Melanie, for taking the chance to talk with me today. You know, when we talk about colorectal cancer rates and trends, there's some good news and there's some bad news. The good news is that overall incidence of colon cancer in the United States is decreasing, and the overall rates of death related to colon cancer is decreasing as well. Much of this improvement is noted in our older population, and we'll talk briefly about the younger population as well. And much of this has been attributed to the effects of colonoscopy with polypectomy, which not only detects colon cancer, but can also prevent colon cancer from forming by removing precancerous polyps. Now, that's the good news.

The bad news is that there's increased rates of colon cancer diagnoses, so incidence as well as colon cancer-related deaths in individuals under the age of 50. Twenty percent or 1 in 5 new colorectal cancer cases are diagnosed in individuals under the age of 55. When we compare this back to 1995, that rate has doubled. And as you mentioned, colorectal cancer death is now the leading cause of cancer-related deaths in men under the age of 50, and it ranks number two just behind breast cancer in women of that same age under the age of 50. If we go back just 20 years ago, colorectal cancer was number four for both men and women in cancer-related deaths, so those rates are increasing.

Not only are we seeing the rates increasing in younger adults, but we're also seeing the rates of more advanced cancer at the time of diagnosis is increasing. We know that finding cancer earlier leads to better outcomes. If you catch a cancer early, the five-year survival rate is 92% versus 14% if you diagnose the cancer at an advanced stage. This stresses the importance of getting colon cancer screening completed at the age at which it's recommended. But then also, in younger individuals who may not qualify for colorectal cancer screening, to pay attention to their bodies and talk to their doctors of any changes in symptoms, such as blood in the stool, change in bowel habits, frequency, caliber, consistency, those types of things. Advocate for yourself, talk to your doctor. And if you're not getting the answers you want to, where you feel like they're not taking those concerns seriously, get another and get those symptoms investigated.

Melanie Cole, MS: So while we're talking about symptoms and I'd like you to talk about when we start our screening and if it's based on risk factors, family history, genetics, that sort of thing. But when we think of the symptoms that might warrant us to even visit a gastroenterologist, things like you mentioned, blood in the stool, but hemorrhoids cause the same thing, when do those sorts of symptoms warrant that visit? And then, following up from our doctor, would it then warrant a colonoscopy?

Dr David Newton: I think in general, gastroenterologists have a very low threshold to complete a colonoscopy. If an individual comes to see me with blood in the stool and the history sounds consistent with hemorrhoidal bleeding, examination is consistent with hemorrhoids, I still talk to that individual that, "Okay, we see hemorrhoids on exam, and that's likely the cause of your bleeding. My exam today does not exclude lesions or polyps or cancers that are up above this area that we can see, and colonoscopy still may be beneficial." If those individuals are apprehensive, then we would be aggressive and treat hemorrhoids or treat the other symptoms that they're having. And if the symptoms persist, then proceed with colonoscopy at that time.

Other symptoms in addition to bleeding, so you can have bright red blood, that's pretty obvious. Sometimes you can have darker stool that may also be indicative of bleeding that may be a little bit higher up in the gastrointestinal tract or in the more proximal colon, that may be of concern. Changing caliber of stool, people will describe ribbon or pencil-thin stools that may indicate a more obstructing lesion that needs to be closer evaluated. And then new constipation, new diarrhea. So if somebody has a bowel movement regularly once a day, and then all of a sudden they go three, four, five, six days between bowel movements, those are things that they should talk to their doctor about. Those are symptoms.

When we talk about screening, you asked a great question of when we should start screening. People don't realize when they should start screening. We look specifically at our state of Nebraska. We ranked 41st for screening rates, so in the bottom 20% nationwide, as far as our population getting screened. If we break down the demographics even a little bit further, we have an exceptionally low screening rate among Hispanic individuals, less than 50%.

Current screening guidelines, and these were updated a couple of years ago, recommend that most individuals undergo first screening at the age of 45. Surveillance intervals or screening intervals are then dependent on the specific test that is completed. If you have a colonoscopy completed, and no precancerous lesions are identified, your next examination would be completed in 10 years. If you use one of the stool-based or non-invasive tests, next exam is anywhere from one to three years, depending on which test specifically we choose. Up to a third of people diagnosed before the age of 50 have a family history or a genetic predisposition and should begin screening prior to the age of 45. In general, if there's a family history of colon cancer, the latest we recommend starting screening is the age of 40. And we, in current guidelines, recommend starting 10 years prior to the age at which that family member was diagnosed. So if, Melanie, per se, you had a brother that was diagnosed with colon cancer at the age of 45, You should start your screening at the age of 35, so 10 years before that. Important to note, too, in individuals that are higher risk with genetic predisposition or with a family history, the only screening test that is recommended is a colonoscopy. The non-invasive options are not recommended by our current guidelines.

Melanie Cole, MS: Wow. What a great educator you are. Dr. Newton, you just cleared that up so succinctly for people that really have some confusion about when they're supposed to start screening. So, that was excellent. Thank you. We've talked before about colonoscopies and that they are the gold standard, and we're still going to talk a little bit more about them, but can you touch on some of the other non-invasive options that have come out lately. You mentioned a stool-based. Tell us a little bit about some of those other options.

Dr David Newton: So, we can talk about the benefits of colonoscopy until we're blue in the face, but there's some individuals who are more apprehensive about getting this procedure completed for various reasons. Fortunately, over the last 10, 15, 20 years, there's been some non-invasive options. The quality of those non-invasive options is improving. They are easier to complete than a colonoscopy, as simple as either providing a specimen at your doctor's office or submitting a specimen through the mail to a third party company.

There's no free lunch. So when something does come easy, there are some trade-offs for that convenience. The two trade-offs when we look at non-invasive screening options are the lower sensitivity. And what that means is that they do not detect the cancer or advanced lesions that they are aiming to detect. When we look at the best or most sensitive non-invasive screening test, which combines checking for microscopic amounts of blood as well as DNA markers that are found in colon cancer, that sensitivity is 91%. What that means, if there are 100 individuals with colorectal cancer who all undergo that non-invasive screening option, that test will reliably diagnose 91 of those 100 individuals with colon cancer and turn back nine of those saying they have a negative test when there is in fact a colon cancer.

Also, as we try to get better, more sensitive tests from a non-invasive standpoint, we increase the false positive rate. What that means is you do a stool-based test that comes back positive, but there's no cancer present within the colon, that would be termed a false positive. With the best non-invasive test, that false positive rate has been linked up to 13%. While we like that trade-off, we want to increase our sensitivity. Having increased false positive rates can lead to unnecessary worry with patients. We'll often see patients who come in with a positive non-invasive test convinced that they've got colorectal cancer, when in fact, the majority of those positive tests are false positive results. But the important part is that they do get their followup colonoscopy completed to complete that screening process.

Additionally, there's going to be some more options coming in the coming years. There's going to be a couple more stool-based tests FDA-approved within the next 12 to 18 months, showing maybe slightly better sensitivity, but not yet to the level of colonoscopy. Also with that, obviously, trade-offs with increased false positivities. And then, there's going to possibly be a blood-based test that gets FDA approved that can also help to screen for colon cancer.

Melanie Cole, MS: Well, that's exciting to look forward to some more of these other ways. But as we've said, and we've said it many times, gold standard is the colonoscopy. And if people do some of those other options and then it's a little suspicious, they got to have their colonoscopy anyway, like you said. So, let's talk about colonoscopy.

The reason in my mind, Dr. Newton, that people don't do it is because they're scared of the prep. I mean, the colonoscopy itself, you say, "When are you starting?" And the doctor says, "I'm done" because it's a little nap. It's a nice little nap, you lose a pound, but it's the prep. Tell us a little bit about that and what's changed. Are we still doing the big gallon of TriLyte or are there some new options out there?

Dr David Newton: You know, there's some new options, and this is a very timely interview. I, myself, just underwent a colonoscopy in December. And so, we'll talk about some improvements in the prep and changes in sedation. And then also, I'll talk a little bit about my experience now that I've got some first-hand knowledge. It's a lot easier to talk to patients now that I've been through it as well. We're not drinking gallons of salty solution to get the bowel prep complete. There are still some instances where patients request that type of prep because it's easier to tolerate. There is a lot of volume, but the taste is maybe a little less potent, a little more palatable. Some folks have less nausea. And then, sometimes there's some insurance coverage issues with a smaller volume prep. So, some individuals will still use the larger volume prep. But in general, most people have transitioned and are using smaller volume preps that range anywhere from 8 to 16 ounces on a split prep with two different dosages.

So, the tolerability is better. If you talk to somebody that had a colonoscopy 10 years ago and they did the four-liter prep and compare it to a small volume prep now, in general, you know, 95% of those people say, "Yeah, the prep was significantly better now than what it was before."

Melanie Cole, MS: I can attest to that. I've done both of them. I've had so many of them. And I've done both, that huge gallon and the dual dose of the smaller prep. And for a little while, Dr. Newton, there was like a packet of some powder you poured in, but that was too explosive and they took that one off the market. But that was my favorite one. But yes, I can attest to exactly what you're just saying.

Dr David Newton: And then, also another addition to our regimen of prep options or pill-based preps. And so, there's a new prep on the market. It's pills, it's 24 total pills. So, you take 12 the night before and then you take 12 the morning of. And that's been very well-tolerated, very well-received by our patients. And so if that's something that's interesting for our listeners, ask your provider if this is an option for your colonoscopy prep.

Locally, we've made some changes as far as sedation goes as well. We'd historically used conscious sedation, which is a mix of some light sedative medications. People were groggy throughout the day. And post procedurally, nausea and vomiting was a problem. Nationwide standard of care has really switched to something called monitored anesthesia care, where an anesthesia provider provides, in general, propofol for sedation. It's a much quicker onset, a much quicker offset, so individuals will wake up very quickly once the procedure is over. They'll generally remember talking to me after the procedure. Nausea and vomiting is almost non-existent post-procedure now. Just the overall experience for our patients has been very well received. And so, we're doing that now with 90, 95 plus percent of our cases here locally.

In regards to my experience, really straightforward, I'm only 41 years old, so I do not meet criteria for screening. I'd had some change in symptoms that I wanted to investigate. And so, I talked to one of my partners and had the procedure scheduled. I did do the pills. Really, really straightforward, 12 pills, and I'm not a good pill taker, but 12 pills and a lot of fluid the night before. I still got a good couple hours of sleep before waking up the next morning and finishing the prep out.

Some individuals elect to not use any sedation for their procedure, whether it's because they have things to do, they want to drive, they need to go back to work. I made the decision that I wasn't going to use sedation. And so, I went through the procedure without sedation. With the exception of just some mild abdominal cramping, it was really, really well-tolerated. And then, I had my day run errands and this was right before Christmas, so I had some Christmas shopping to get done. And I was able to do all those things that I wanted to do to get that done. So all in all, pretty well about what I tell my patients and, you know, the prep is the worst part and even that has gotten better as you so eloquently described.

Melanie Cole, MS: Wow. Well, I mean, that's really impressive, Dr. Newton, that you did it without the sedation. I personally like it. I get that really deep nap, wake up, and then I get to go home and nobody gets to bother me. I don't have to get up and mess around. I don't have to clean the house. And I kind of love that day off. But agreed that it is such an important test. Now, one of the things you're looking for when you do that besides colon cancer are polyps, which can or cannot be cancerous. As someone who has polyps, usually every time I get a colonoscopy, tell the listeners what those are. You remove them. And one of the things in my mind that makes colonoscopy just the gold standard and so amazing is that you are literally preventing cancer by removing those things. And it's one of the only procedures we have that does that kind of thing. So, tell us about those polyps and what you're doing when you're removing them.

Dr David Newton: Correct. And I think this has been a messaging issue. You know, gastroenterologists and people that complete colonoscopies have known this for forever, that it's not just a screening test. It's not just a detection test, but it's a prevention test as well. The majority of colon cancers start as a small abnormal collection of cells that look like a little bump in the colon, and those are polyps. And over years, those cells can change and turn into a cancer. By removing those polyps at the time of colonoscopy, we can prevent that polyp from ever turning into a cancer. There are some studies that show that upwards of 90% of all colon cancers could be prevented through routine use of colonoscopy. There are those colon cancers that grow much quicker or can't be detected at colonoscopy, that can't be prevented that way, but preventing, you know, 90% of cancers with a straightforward test is pretty impressive.

We talked about sensitivity a little bit with the non-invasive tests, 91% for the best non-invasive test. Sensitivity for colorectal cancer detection with colonoscopy is greater than 95%. And I would argue that that sensitivity gets even better when it's performed by a high-performing endoscopist who's tracking quality metrics. We've got these specific quality metrics that we track quarterly, and this is prep quality. So if prep isn't good, the colonoscopy is not going to be as worthwhile. And then, the quality of the endoscopist themselves, we track a number called the adenoma detection rate, and we've got benchmarks that we need to meet. Fourteen physicians in our practice, we all well exceed that number. I think it's important for listeners to ask their endoscopist, ask their physicians, you know, if they're tracking these numbers, and make sure that they're getting a high quality examination at the time of their colonoscopy so that they can really get the most bang for their buck when it comes to completing the procedure.

Melanie Cole, MS: And we get those lovely pictures afterwards, which, I mean, I save those and I love getting that because it shows you the inside of your body. I think it's so cool. And as we wrap up, Dr. Newton, what can people do to help reduce their risk for colon cancer other than getting their colonoscopy, which we've made very clear here today. And it's such a great preventive tool in the toolbox of you brilliant gastroenterologists. But what else? Tell us a little bit about your best advice for diet, exercise, hydration, whatever you'd like to say.

Dr David Newton: The same recommendations that people get for cardiovascular health and reducing the rates of other cancers really stand true for colorectal cancer prevention as well. We need to have a healthy diet that's low in processed foods, moderate amounts of red meat, moderate alcohol use, no tobacco use. I think importantly and unique to colorectal cancer prevention is diets that are higher in fiber intake. And we know that increased fiber intake has been associated with a decreased rate of colon cancer formation as well.

And I think, most importantly, listen to your body, especially young individuals or young listeners. If you've got symptoms that develop that are concerning to you, talk to your doctor. Sometimes those symptoms can be signs of precancerous lesions that can be taken care of before this causes the problem. Those are kind of the main takeaways.

Melanie Cole, MS: Thank you so much, Dr. Newton. What a great episode this was. You've got really given us a lot to think about and it was so informative. Thank you again. And to learn more about colon cancer screening and see a video of a colonoscopy, you can visit bryanhealth.org/coloncancer. And to listen to more podcasts from our experts, you can visit bryanhealth.org/podcasts. That concludes this episode of Bryan Health I'm Melanie Cole. Thanks so much for joining us today.