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Bill Klaproth (Host): Of all cancers effecting both men and women, colorectal cancer is the second leading cause of death from cancer in the United States. Here to talk with us about the importance of screening for colorectal cancer is Dr. Scott Gering, vice president of surgical services and a board-certified colorectal surgeon, and Dr. James Conti, a board-certified gastroenterologist. Both with Eisenhower Health. Dr. Gering and Dr. Conti, thanks for your time.

Dr. Conti, let’s start with you. Guidelines for colon cancer screening say we should start having colonoscopies when we’re 50 unless we’re at high risk for colon cancer. How does someone know if they're at high risk?

James Conti, MD (Guest): Typically, high risk is based on two things. One, we look at individual’s family members who have already undergone colon cancer screening by colonoscopy. So, if you have a sibling who has undergone a colonoscopy and they’ve been diagnosed with a colon cancer, or if you have another first degree relative such as a parent that also has colon cancer diagnosis. Typically, if they were diagnosed with colon cancer, that puts you in the high-risk category. Based on the age of their diagnosis is when we determine when the person’s screening examinations should start. Typically, we’re going 10 years earlier than the age of diagnosis. So, if someone was actually diagnosed under the age of 60, we would be starting earlier than the age 50 for their initial first screening examination.

Other things that could potentially put you in the high-risk category is having certain gastrointestinal diseases. These are typically patients who have chronic Inflammatory Bowel Disease. They are considered in the higher risk category. Once they’ve had that disease established, such as Crohn’s disease or ulcerative colitis for a period of eight years or more, we are starting to do screening examinations on them in the high-risk category. Those are typically set at three-year intervals. But that is reserved only if you have that disease process.

Host: Gotcha. Good information. Dr. Gering, when people have colonoscopies, they're told if polyps are found. Can you explain what a polyp is and why it’s important that they're found and removed.?

Scott Gering, MD (Guest): Yeah. A polyp is simply an abnormal growth or normal lining tissue of the color. These polyps, as they're called, are typically adenomatous polyps. Those are the ones we worry about. These are precancerous polyps. They are benign, but they also a propensity to turn into cancers over a period of time. We typically think of five to ten years from a polyp to a cancer. Removing those polyps prevents you from developing colon cancer. So, the fact that people have polyps, if we can remove them, we can actually impact the incidence of colon cancer. We can, theoretically, prevent most colon cancers from developing if we’re screening and removing appropriately.

Host: Dr. Conti, so if they are found, they are removed immediately. Is that correct?

Dr. Conti: Typically, that is the case. Obviously, it’s a judgement call at the time. When we’re seeing the colon polyp during the colonoscopy procedure. If we think it’s safe to remove it at that time, they are removed at the time of the actual colonoscopy. Occasionally we do come in contact with larger polyps that may require a more set time for the actual polyps to be removed or even a surgical removal of the polyps. Then sometimes just a biopsy is performed. But the majority of the time, the polyp was able to be resected or removed. That’s really the whole purpose is to identify those precancers, as Dr. Gering was mentioning. And by removing them hopefully not only identifying the patient as a higher risk patient, but also preventing cancer from forming in that patient.

So typically following that, they don’t necessarily have screening exams anymore. Those patients, I tell them you're not in this general screening pool anymore. You're now a surveillance patient, which is important to convey that to the patient. That they understand that it’s important now that we've identified them as a high-risk patient that makes colon polyps, that we want to do our surveillance intervals. Typically, it’s done at five years depending on the type and size and pathology that the pathologist gives us will determine the actual specific surveillance interval.

Host: So those patients then require more follow up or additional frequent screenings. Dr. Gering, we’re usually told then if you have a good outcome on your colonoscopy, you won't have the next one for 10 years. Is there a point when people can stop having colonoscopies? Do we effectively age out of colonoscopies at any point?

Dr. Gering: Sure. Again, this is the distinction Dr. Conti was trying to make is that there’s really two groups of people. There’s people that make polyps and people that don’t. Those people that don’t are in the screening group typically, and that’s the point of doing a colonoscopy at age 50 and then every 10 years thereafter. If, in fact, you have a colonoscopy at age 50 and 60 and 70 and all of those are negative and you’ve never had a polyp and you have no family history, you have essentially sort of aged out of needing to do further screening. You just don’t have the genetics or the exposures in your lifetime that turn you into a polyp maker, if you will.

The other group, however, is quite different. It’s as Dr. Conti mentioned, it is a surveillance group. This is the whole point of doing the screening program in the first place. We have found somebody that makes polyps. In that case, we need to do more frequent colonoscopies. That frequency of colonoscopy, as Dr. Conti was mentioning, is really focused on how many polyps did we find? How big are they? How good of look did the colonoscopist get? How good was the prep? How confident is he that he’s cleared the colon? So, all of those things factor into the interval in which you do the next colonoscopy. It’s anywhere from a year to five years.

I would say that most people that make polyps, my typical routine is to tell them, “You're a polyp maker. You're in the surveillance group, and you should never go more than five years as long as your healthy enough to do the bowel prep.” Now when does that stop? Well at some point, your other comorbidities add up to the point where you can't tolerate the bowel prep and your life expectancy at that point is fairly short and you should probably stop colonoscopies. I have plenty of 90-year old’s getting colonoscopies before they have a history of polyps and we’re still preventing colon cancer and they proceed on.

Host: That’s really good. Very easy to understand. The screening group and the surveillance group. So, when you explain it like that, I totally get it. Being a polyp maker and not being a polyp maker. Dr. Conti, everyone gets anxious about the pre-colonoscopy prep. That’s what I hear all the time. Oh the prep. I don’t want to go through the prep. I believe it’s changed though over the last few years where people drink less of the prep and it’s completed in a shorter amount of time. Is that accurate? Has it gotten easier for patients over the years? Why is the prep so important? Do people have to do it correctly? Does it affect the screening?

Dr. Conti: Sure. I don’t want to set the expectation bar too high. The prep, it still requires, obviously, a lot of going to the bathroom to clean the intestines out effectively. But the style and how we do the bowel proved has improved somewhat over the years. Typically, a lot of gastroenterologists are using lower volume preps. The older prep was a gallon of solution that had to be drank the night before. It was quite unpalatable from what patient’s experiences have been. Newer preps are much smaller volume. They attempted to make them taste better. The actual prep solutions are much less. They're sometimes drinking as little as two glasses of prep solution.

And we do split dose prepping. It’s also helping improve the quality of the prep. Meaning the patient won't administer all the prep at one time, which is a little more gentler on the GI tract. So, the complications of nausea or bloating or sometimes feeling sick to the stomach don’t happen as often when we do prepping in that regard.

Ideally the end result is the most important thing. It’s just making sure that the patient has a very clean intestine at the time of the colonoscopy, so we can assure that we’ve seen all the areas that need to be seen and rule out polyps.

Host: So, you get a better result.

Dr. Conti: Exactly. It’s a case by case basis. Obviously, there’s a lot that factors into picking bowel preps when we do these smaller preps. It depends on patient’s medication, other medical conditions they have, issues related to chronic constipation. So, we have to kind of pick and chose our patients carefully and who can receive some of these other options for bowel prepping as it wasn’t the case in the past.

Host: Gotcha. I'm raising my hand. I have had a colonoscopy and I can tell you the prep wasn’t that bad. It’s better than getting cancer. So, get the colonoscopy. The prep is not that bad. Dr. Gering, younger people aren’t being screened for colon cancer since guidelines advise waiting until the age of 50. Aside from significant family history, are there signs and symptoms that young patients should look out for or bring to the attention of their primary care doctor? In fact, I've read recently that younger people are getting colon cancer earlier.

Dr. Gering: That’s correct. The typical screening age is 50. The American Cancer Society just came out with a recommendation recently that they would like to drop that number to 45. That hasn’t been adopted universally yet, but I think we’re heading there. The other aspect is you're right. We don’t screen for people under 50 typically. So, you’ve got to be attentive to the symptoms that sort of potentially precede a colon cancer.

Obviously, the biggest one is rectal bleeding. Bleeding with bowel movements and blood in the stool. Those are concerning findings, and anytime you have that, you should let your doctor know. That’s not normal. So, we need to get to the bottom of that and what the cause is and make sure it’s not a colon cancer. That may warrant and earlier colonoscopy. Change in bowel habits is a frequent symptom that I see of people that develop colon cancers at younger ages. The frequency or the character of the bowl movements changed from what it normally was. Unexpected weight loss is occasionally there. Then potentially pain with bowel movements. All of those should raise a flag that maybe there’s something else going on and you should bring that to the attention of your primary care doctor and decide whether a colonoscopy is warranted.

Host: Good to know. Dr. Conti, continuing on talking about younger people. Do you have any thoughts about why we might be seeing this increase in younger people? Could it be dietary? Could it be obesity related?

Dr. Conti: The jury really is still out as to the exact cause of colon cancer increase in that population. Approximately 40% of the colon cancers diagnosed in patients under the age of 50 are related to hereditary cancer syndrome. It’s really trying to figure out what is the other 60% related to. It does seem to be more predominant in western countries—United States, northern Europe, and certain other countries—where they are seeing higher rates of obesity. So, some of the theories are that it is possibly related to obesity, dietary changes, or different types of foods that people are eating now. But we really don’t have an exact cause as to why this younger population has been increasingly getting colon cancer.

They have, through population studies, seen that this has been about a 2% increase per year over the last 10 years. But it’s still the smallest demographic of all cancers. Certainly, the American Cancer Society is finally paying attention in that regard. We are probably, like Dr. Gering was saying, heading in the direction of pushing the screening guideline down to being 45 for all patients at some point.

Host: Well something to watch certainly and to keep monitoring. Dr. Gering you get the final word if you could wrap it up for us. Tell us why is it so important to be screened?

Dr. Gering: It’s really simple. You can prevent colon cancers. It’s one of the few cancers we can actually prevent through the screening program. So, if you're identified early as a polyp maker and you're attentive to getting regular colonoscopies as we talked about earlier, you can prevent it. Staying on top of that is important. That’s the whole point of developing a screening program is finding the high-risk people and then treating them a little bit differently so we can avoid the colon cancers. The vast majority of these colon cancers are completely preventable.

Host: Absolutely Dr. Gering. As I say to my friends who don’t want to get a colonoscopy, I say you're not allowed to get colon cancer because the screening is good, and this type of cancer is so preventable. Dr. Gering and Dr. Conti, thank you for your time. To find a primary care physician or a gastroenterologist, call Eisenhower Health’s physician referral line at 760-568-1234. That’s 760-568-1234. This is Living Well with Eisenhower Health. I’m Bill Klaproth. Thanks for listening.