Intro: Duly Noted, a health and care podcast, is the
official podcast series of Duly Health and Care. Each podcast features
physicians or team members discussing groundbreaking topics and innovations
that help listeners reimagine and better understand an extraordinary health and
care experience.  

Jennie Ng, MD: Good morning. Thank you for having me.

Cheryl Martin (Host): First of all, please share any
insights on the shift we are seeing. For example, here in the US overall cases
of colon and rectal cancer are down, but they're on the rise for younger
adults, and they're also being diagnosed more frequently at an advanced stage
of the disease. Your thoughts on that.

Jennie Ng, MD: Well, for sure. We know colon cancer
is the third most commonly diagnosed cancer in males, second in females, and we
have seen that rise. Between 1995 to 2019, the American Cancer Society reported
an 11 to 20% increase in the diagnosis of colon cancer in patients under the
age of 55. So that was unprecedented. Over 86% of them are symptomatic. And so
we know that this is not a result of us doing screening earlier, this is actual
real pathology. In terms of why, the reasons are likely multifactorial. We know
that there are genetic influences. Definitely some contribution from changes in
environment and lifestyle measures, and a lot of that is being studied right
now.

Host: So is there a way to determine if you're at a
higher risk for colorectal cancer?

Jennie Ng, MD: For sure. Known risk factors that we
always address, will be a known family history of colon cancer or adenomatous
polyps in a first degree relative, a history of smoking, somebody with
inflammatory bowel disease, such as Crohn's disease and ulcerative colitis,
even history of, you know, abdominal radiation therapy as a young child.

Those are all known risk factors for colon cancer. But then
in the United States, up to 35% of these young adult cancers are also
associated with some sort of genetic syndrome, like hereditary colorectal
cancer syndrome, Lynch syndrome, familial adenomatous polyposis. Those are all
different ones that are caused by genetic mutations in certain genes or
mismatch repair genes and lead to an increased risk of cancer, not only in
colon, but also endometrial, ovarian, stomach, and whole other plethora of
cancers. So when we have a patient who comes in and is diagnosed at a young
age, we also recommend genetic testing.

Host: I know you mentioned genetics is a key factor,
so what steps can a person take to lower the risk for colorectal cancer?

Jennie Ng, MD: Well, the first thing that comes to
mind is live as healthy a lifestyle as you can. And second is to really tell
your doctor when you develop symptoms such as blood in your stool, changes in
your bowel habits, unexplained weight loss, new onset of abdominal pain, or
even new diagnosis of anemia. I think those are all what I call red flags that
prompt your doctor to then look into things a little bit more quickly and a
little more, a little sooner to make sure that nothing is going on. And the
best thing you can do is to get screened. Just find a way to be able to be
evaluated because early detection is key.

Host: What about this younger population, when I
still believe that doctors are saying, get your first colonoscopy at age 50.
Should they go in and get one younger than that?

Jennie Ng, MD: Well, starting in 2018, the American
Cancer Society and in 2021, the US Preventive Service Task Force, including the
American College of Gastroenterology, have all lowered the initial screening
recommendation down to the age of 45 for all adults of average risk.

Host: And talk again about why this is so critical.

Jennie Ng, MD: Again, early detection is key. Colon
cancer, the way that I explain it to my patients is good and bad. It's great
because it is a cancer that can be beat when we catch it in an early stage. It
is so easy to get rid of, to treat. But if you wait until you develop some of
those symptoms that I mentioned before, sometimes by that time it's too late
and then you're looking at having to undergo chemotherapy, going through
surgery. It becomes just so much harder to tackle.

Host: So in essence, getting a colonoscopy can
actually prevent cancer as well as determine if you have cancer.

Jennie Ng, MD: Yes. A lot of people wonder about
that. How can it prevent and determine if you have cancer? And that's the
beauty about a colonoscopy is compared to other screening modalities, it can
actually do both. Because the goal of a colonoscopy is to find a cancer in the
beginning stages. And colon cancer starts in a form of a little polyp, a small
little bump in the colon that grows over time, and during that time it changes
the, there's these epithelial changes that change from normal cells to cancer
cells. So during that timeframe, if we are able to get rid of the polyp and
we're able to get, go in there and completely remove it, you've basically
gotten rid of the cancer and prevented any chance of any cancer developing from
that polyp.

Host: That is great. Now, would you walk us through
the prep and procedure process to help put a potential patient's mind at ease?

Jennie Ng, MD: Sure, I'll go through what I usually
go through with my patients then. So,

Host: Okay.

Jennie Ng, MD: The colonoscopy, first and foremost
for all intended purposes for you to know is a procedure done under sedation.
So most patients are relieved once they hear that, but it is a procedure in
which I use a small rubber scope.

It's about the size of my index finger, and it's got a light
and a lens at the very end of it. With that scope, I evaluate the colon, which
is just the path that food comes out. That's all that we're looking at. We're
not doing surgery. I'm not looking at other organs or anything. The colon is
shaped like a question mark.

It starts in your right side of your belly and it moves
across your belly and down into the rectum. That's the area that we're looking
at. So what we use is, we give you some medicine, help you go to sleep, use the
scope to go in through the rectum and get up to the top of the colon. And on
our way back, we take a look to see how healthy that colon lumen is.

If we see any polyps, we'll get rid of them at the same
time. If we see anything suspicious, we can do biopsies, we can evaluate a
whole plethora of things. The whole process takes probably 15 to 20 minutes.
Afterwards, you wake up, you get to go home. It's not an overnight procedure.
And then depending on the pathology results, then we can determine when you
need to have your next colonoscopy.

Host: Now, what is the difference between a
preventive and a diagnostic colonoscopy?

Jennie Ng, MD: For the patient, it's the same thing,
it's the same test, it's the same prep, it's the same sedation. But as a
physician, it really is defined by the reason that we're doing the test. So a
screening or preventive colonoscopy is one that is done solely because the
patient has reached the age required for screening.

So it's equivalent to needing a mammogram when you hit a
certain age, when you prostate evaluation you know, things like that. Just
because you've hit a certain age and you know that your risk has gone up, we do
that test. A diagnostic colonoscopy is a colonoscopy that we do for a patient
who has come in for certain symptoms.

So if the patient comes in for some rectal bleeding or
changes in bowel habits, weight loss, abdominal pain, something that's, that we
don't know why. Then we're doing a colonoscopy to try to find the reason or to
try to find an answer to their symptoms.

Host: When you mentioned changes in bowel habits,
give me an example of a change that one should be aware of.

Jennie Ng, MD: So I always think of it this way, when
you think of your colon, it's almost like your plumbing system, right? Things
are kind of going through and passing through. So think of it like your sink.
As things kind of get blocked up, things slow down, you can't get everything
through. Sometimes things move slowed down to a trickle.

So symptoms that are typical of colon cancer can be a change
in bowel habits such as somebody all of a sudden not being able to go as often
or as frequently, or having difficulty going. We think about the stool having
difficulty passing, so it could be constipation. And even at higher levels of
colon cancer, it changes to diarrhea because it's no longer able to pass the
solid stool, now you're passing just the liquid. So something that's a dramatic
change in your bowel habits from your usual norm. Other symptoms could be
change in bowel habits, but all of a sudden now you're passing blood or you're
seeing more mucus in your stools, or you're having more cramping every time you
go. Those are all things that would concern me.

Host: Great. Now, if a patient is hesitant or unsure
about getting a colonoscopy, what do you recommend?

Jennie Ng, MD: Well, first and foremost, I would
recommend talking to your primary care physician or to your gastroenterologist
to make sure that your specific concerns are addressed, and that way you're
making a good informed decision. And even though you know the colonoscopy is
the gold standard, the best screening option recommended by most expert groups,
there are other screening tests available.

There are stool tests. Some people may have heard of the FIT
test or the Cologuard test, and those are looking at maybe stool DNA or
evidence of blood in the stool that might indicate that there's a polyp or
colon cancer. They, they're not as sensitive and specific as a colonoscopy, but
they do check for those things.

Some of my patients ask for a CT scan, a CT colonoscopy and
it is better than a stool test, but it still requires you to do a bowel prep,
which is something that people really don't like doing. And, it can be
dependent on the machine itself and the technique and the radiologist reading
it. And ultimately, if any of these alternative tests are positive, you're
gonna need a colonoscopy.

But basically, in my mind, the best screening test is one
that the patient is willing to follow through with. So if they absolutely are
hesitant with doing colonoscopy, I would still recommend that they get checked
in another way just to make sure that they are looked at.

Host: Now have you experienced other barriers that patients
share that prevent them from getting a colonoscopy?

Jennie Ng, MD: Yes. I think the main barriers that
come to mind when I think about my patients would be not really fully
understanding the purpose of the test or how it's done. Being fearful of the
prep, being scared of stories that they hear of risks or things that gone wrong
or went poorly for other people. And then there's also barriers including
availability to a colonoscopy and unfortunately cost. Those are all things that
come into mind.

Host: And what answers do you provide?

Jennie Ng, MD: In terms of the purpose of the test, I
think we talked about why it's important to be evaluated and I want patients to
know that I don't want them to wait until they have symptoms because sometimes
by that time it's a lot, it's a lot harder to treat.

I try to go through with them like we discussed, the process
of the test, so they know what to expect when they come in. So that way it's
not so scary. Risks, alternatives, and benefits. Benefits. We talked about
alternative testing. We talked about the benefits and risks. The main ones that
I really do try to have my patients understanding are three things, the risk of
bleeding, perforation and sedation. The risk of bleeding is actually pretty
low. I think it's one to 2%, can sometimes be higher if somebody's on certain
medications that increase their risk of bleeding. But I try to have patients
understand that the bleeding is almost like when we take a little polyp out,
it's almost like a paper cut, you know, small little drop of blood.

If there's anything more, we have different modalities
through the scope that we can use to stop the bleeding. Risk of a perforation
is one people always ask me about. They're scared about a tear that can happen
in the side of the colon. And I try to remind them though, the colon wall, even
though it's thin, it's really strong and the risk of perforation usually goes
up when there's something there that's inherently compromising the integrity of
the colon wall.

So, regular colonoscopy, for the most part, the risk of
perforation is pretty low. It's one in 1000. And for a therapeutic, meaning
we're doing something for a reason. And then for routine screening, it's one in
1400. So pretty low and then the risk of sedation, like we discussed. The
sedation itself is light conscious, moderate sedation.

We're not putting anybody on a ventilator to support their
life or anything. It's some people even do this procedure without sedation, so
it's very light, it's just in twilight. So that way it makes people comfortable
and we always have them on monitors to make sure they're bleeding and oxygen
levels are fine during the test.

So I try to address those things so then that way they have
a clearer picture of what to expect. And it's not such a scary, unknown
procedure that they're heading into.

Host: This has been very, very comprehensive. Thank
you so much, Dr. Jennie Ng for sharing not only your time, but your expertise
on this vital topic, colorectal cancer.

Jennie Ng, MD: Well, thank you for having me. It's a
pleasure to be here.

Host: If you'd like to learn more, visit
duly.com/colonoscopy. That's duly.com/colonoscopy. If you found this podcast
helpful, please share it on your social channels and check out the full podcast
library for other topics of interest to you.

This is Duly Noted, a podcast from Duly Health and Care.
Thanks for listening.