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Melanie Cole (Host): Recent advances in medical technology and advanced screening tools have made it so that more patients are really able to receive optimal and tailored treatment if they are diagnosed with colon cancer. Here to tell us about screening tools and treatment options is Dr. Michelle Olson. She’s a colorectal surgeon with The Carle Foundation Hospital. Dr. Olson, tell us about the current state of colon cancer today. What’s the prevalence and do you feel as a colorectal surgeon, that there’s an increased awareness that providers are able to tell their clients and their patients about colorectal awareness.

Michelle Olson, MD (Guest): So, I think there is more awareness of colorectal cancer in general but clearly, we’re still not reaching our target population for screening. So, patients with average risk over the age of 50 need to be screened for colorectal cancer and our current state is that about 2/3 of eligible patients are actually being screened at the moment. So, nationally, we’re actually pushing for an 80% of eligible people to be screened by the time we reach 2020. That’s really the goal is for us to get more of these patients actually in for screening, some type of screening for colorectal cancer.

Host: I’m glad you said some type of screening because there are a few different options and some people are afraid of colonoscopy which we will discuss, but tell us about some of the other types of screening that are available and who and when should they consider having one?

Dr. Olson: Okay so, as I mentioned, when we’re talking about screening, we are generally talking about patients who are at average risk. That means they have no current symptoms and they have no family members who have either had advanced polyps or cancers themselves. So, patients who are at average risk should start screening for colon cancer at age 50. Colonoscopy is certainly an option and if that option is chosen, we recommend that colonoscopy be done at least every 10 years.

But again, as you mentioned, some people are concerned about getting colonoscopies and so for those folks and another viable option certainly is to do stool testing and that can either be fecal occult blood testing or what’s more common certainly is fecal immunochemistry testing or even FIT DNA testing also known by the trademark Cologuard. And those tests either need to be done annually or every three years. The every-three-year recommendation is specifically for the FIT DNA or Cologuard test.

Aside from that, the only other option would be to do an imaging study and the most common imaging study recommended today would be a CT colonography which is also commonly known as a virtual colonoscopy. The thing is is for that imaging study, patients still have to undergo the same bowel preparation that they do for a colonoscopy. So, it doesn’t really make it any easier on the patient to do necessarily and that test if it is chosen as a screening test is not covered by all insurances but when it is covered, it’s covered to be done about every five years.

Host: And therein lies one of the biggest things that I think people wonder about is that prep and as someone who has had colonoscopies, many of them in my lifetime, it’s the biggest pain, but it’s also, it’s a nothing and the test itself is so easy. So, speak to other providers Dr. Olson, about how they can counsel their patients about the ease of colonoscopy since it is the gold standard and it’s also a prevention tool as well.

Dr. Olson: Right, yeah, that’s the most important thing I think that providers can explain to patients is that if you elect to choose one of these other screening methods; the test that gets ordered, if one of those screening tests comes back positive is going to be a colonoscopy. So, if you decide to do stool studies or an imaging study for your patients; then if you have a positive result, colonoscopy is the next step.

The preparation for colonoscopy has improved significantly over the last ten years. Lots of patients will remember having to drink a gallon of relatively salty concoction to try to help make that work and the preps have decreased in their volume. There really is no way around having to do it though. And the most important thing is to counsel patients to really try to stay hydrated during that process. The more clear liquids that patients drink during the process of doing the prep; actually the cleaner the prep will be and the more successful the colonoscopy will be.

The procedure itself is an invasive procedure so, that is something that does worry patients, but they are sedated for the procedure and the major complication risks are actually quite low. I mean the risk of a perforation is less than half a percent. The risk of bleeding if you have a biopsy is also less than half a percent. I mean they are really low complications in terms of doing the procedure itself and the sedative that’s given allows most patients not to remember the procedure at all.

Host: Well I can certainly attest to that, but I appreciate that you said to remain hydrated. I don’t think enough providers stress that point because you are drinking that gallon of liquid which is what I had to do, and they don’t tell you to be drinking clear liquids along with it. Maybe the day before or day of. But not along with it. So, that’s a really great kind of tip for a cleaner prep. Tell us about what you find in there. What are polyps? Why do they matter?

Dr. Olson: So, what we know is that most colon cancers actually arise initially from polyps. So, polyps are abnormal growths that occur on the lining of the colon. Given enough time, these polyps can undergo mutation into an invasive cancer. So, the whole idea of a colonoscopy is identify the polyp and remove the polyp at the same time before it ever has a chance to turn into a cancer.

Host: And do you always biopsy the polyps?

Dr. Olson: If we see polyps, we will routinely remove them whenever possible. If they are too large to remove, then definitely biopsy. I think the only time that a biopsy wouldn’t be done is if for some reason a patient was fully anticoagulated where the bleeding risk was going to be too high. But the whole purpose of – the whole benefit actually of a colonoscopy is that ability to diagnose and then also treat at the same time in one test.

Host: If somebody is diagnosed with colon cancer Dr. Olson, what does prognosis look like these days? What are some new and exciting treatments that you see or that are on the horizon for colon cancer?

Dr. Olson: Yeah, so first of all, what patients and providers should know is that localized cancers, so your early stage cancers have a 90% five year survival rate. And so the most common treatment for a colon cancer is certainly going to be surgery. Now your higher stage tumors, your tumors that have had a chance to metastasize to lymph nodes or to other organs are obviously going to need a combination of treatment with chemotherapy and depending on the location of the tumor, possibly radiation treatment.

One of the great things about the surgical treatment for colon cancer is that we are doing more and more minimally invasive operations for colon cancer and patients have excellent outcomes from that both oncologically but then also medically, so they are in the hospital for a shorter time, they get back to work faster because their recovery is faster from having a less invasive surgery.

Host: Do you feel that the world of colon cancer is headed towards newer treatments, updated treatments, or more awareness? Colonoscopies, getting people in for them, getting them to be aware. Where do you think it’s going more directly?

Dr. Olson: Well so, one of the things that we can track over time is that doing colon cancer screening has saved lives. So, if you look back from the early 90s to 2018, you can actually see a decrease in the number of people who die from colon cancer and also the number of folks that are actually diagnosed at a later stage. So, we are saving lives by doing screening. So, that is really important and that’s why this push to make sure that at least 80% of our eligible population is being screened.

But there is also new treatments that are being developed all the time and just new approaches even to things like the chemotherapy. So, it’s common for us – or it’s becoming more common for us in the treatment of rectal cancer specifically, to give the chemotherapy that usually would be given after the surgical treatment to maybe give that upfront so that there are fewer interruptions in the patient’s therapy and that’s actually shown that the survival is just as good if not better in being able to do that.

We’re working on ways that we can be even less invasive in treating specific tumors like in the rectum where previously, 20 years ago, it would require patients to have a permanent colostomy. We’re able to take out tumors lower and lower in the rectum and not have people require a permanent colostomy. And we are even wondering well, with the advent of this total adjuvant chemotherapy with radiation; and basically melting the tumors away ahead of time; does the radical surgery even need to be done. So, can we actually treat people without surgery at all for very specific cancers?

And so some of those studies are ongoing. So, I think we’ll see a lot more coming up around that in the next few years.

Host: That’s cool. What a fascinating time to be in this field, as you’re saying really, it’s decreasing, and awareness is increasing. Where does diet fit in, as we wrap up Dr. Olson, how would you like providers to counsel their patients on not only awareness of colon cancer screening and the ease of these tests that are available, but of things that they can do that can possibly prevent polyps or colon cancer and what you would like them to know about that?

Dr. Olson: So, I mean just like with most medical conditions, the healthiest lifestyle the patients can live is obviously going to be the best for them. So, a diet that is healthy, that has good leafy greens and is avoiding a lot of – an overabundance of fats and processed foods are always good.

But the one things that patients can stop doing that will really help decrease the prevalence of colon cancer is smoking. So, smoking cessation has actually been shown to also – it decreases a number of cancers and the risk for getting cancers, but again continuing to counsel patients not to smoke is important. And then just healthy diet and exercise, those things all help but there’s not a specific anti-colon cancer diet that patients can follow or anything like that. The most important thing is really paying attention to your overall health and making sure that your screenings are getting done.

What we find is that women tend to be the healthcare seekers of the family, making sure that their parents, their husband, their children are all taken care of, but sometimes they neglect their own screenings. Just making sure that people are aware of it is important. I mean colon cancer still is the fourth most common cancer that’s diagnosed in our country and it represents about eight percent of new cancers that are diagnosed in any given year. So, it is still important. People do still – 140,000 people will be diagnosed with colon cancer this year. And about 50,000 people will likely die from a colorectal cancer, but they are completely preventable if you follow screening.

Host: Wow, it’s great information and that’s why we’re doing this segment Dr. Olson, and making that awareness more on the frontlines both for patients but also for other providers so that even primary care providers can encourage their patients and say now it’s time for you to get your colonoscopy. And that we can all be aware together. Thank you so much for sharing your expertise with us today. You’re listening to Expert Insights with The Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities please visit www.carleconnect.com, that’s www.carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole.