Scott Webb (Host): Colonoscopies are the gold standard for detecting and preventing colon cancer, and my guest today is here to explain and encourage us all to be screened if we meet the criteria. I'm joined today by Dr. Kevin Bree. He's a general surgeon who practices at Franciscan Health.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, it's great to have you here today. We're going to talk colonoscopy and there's never a bad time to do that, but we want to remind people that it's simple, easy, effective to get those colonoscopies. And we want to kind of remove any stigmas or fears or anything that may be going on in their heads. So, let's start there. Let's just start with the basics. What is a colonoscopy, and why is it so important?

Dr. Kevin Bree: Colonoscopies are probably the best way to identify colon cancer in patients. I like the analogy of if you've seen those cameras that people stick up, maybe a fireplace, to kind of look or through plumbing, to kind of look around those tubes that they have that go down and have a camera on the end. That's the exact same thing we're doing except to your colon. So going in the bottom and going through, looking for polyps or abnormalities, taking pictures, taking biopsies as needed, and using that to help identify cancer before you typically get the symptoms of cancer, because then it's very treatable if that's the case.

Host: Yeah, early diagnosis. I've learned from the experts that Franciscan Health is so key. And let's talk age, I know that maybe some of the guidelines have changed over the years and maybe affected by family history or whatever it might be. So, like, what age should we start getting colonoscopies and how often then after that do we need one?

Dr. Kevin Bree: So, this is actually something that's changed during my training. When I started training and I'm, you know, kind of a young guy. It was originally age 50. You started your colonoscopy. Now, they've got it down to 45 for the general population is when you should start getting your colonoscopy. Now, if you have a family history, that changes things a little bit, let's say your father or your brother or someone, first-degree relative, had colon cancer, then the recommendation is to start at 40 or 10 years prior to that age they were diagnosed, whatever comes first. So, that would be when you should start.

In terms of how often, it really depends on what's found. So for a general screening, let's say we do your colonoscopy and we don't find anything, everything looks good, everything's excellent, then your next one should be in 10 years. If we find some polyps or other abnormalities, then it could be shorter than 10 years. It just all depends on what's found. And that could range anywhere from the very shortest, maybe a few months later or seven, 10 years later, just depending on what's found.

Host: Sure. Yeah. So, some variables there of course. And family history plays a factor as it does with so many things in medicine.

Dr. Kevin Bree: Right.

Host: All right. So, take us through this, Doctor. I know that a lot of the reasons why folks drag their feet while they don't get their colonoscopies is because of the horror stories that they've heard about prep. And I know that it's changed, it's easier. There might even be some pill forms. Let's put everybody's fears aside and have that not be the reason that they don't get the colonoscopy.

Dr. Kevin Bree: Yeah. So, part of the prep would be the day before, you're going to be on a liquid diet instead of taking solid. That just helps so that you don't form any stool in the coming hours before your procedure. If there's stool during the procedure, it makes it very hard to see and it's not really a good test. So, a lot of times if a patient has stool present or, you know, wasn't able to prep, then it's something we have to repeat maybe in a few weeks once they can reprep. There's various ways to prep, kind of like you talked about. There's liquids, there's pills. And that, again, all depends on several factors on which one is used.

So, one major factor is insurance. A lot of times insurance will pay for what's cheaper, and the liquids are much cheaper in terms of cost. And so, getting those to patients is easier to do. There are pills, like I said, but those are much more expensive. And a lot of times, insurance won't pay for it. That's less liquid and less bad tasting liquid that you have to drink. But the liquid that, you know, most people are probably used to is, I think, probably, you know, a gallon or four quartz. And that was back in the day that people had to drink that and drink the whole thing.

The other one we use now is a little bit less than that, and it doesn't taste quite as bad. It's less liquid, it's less powder that's mixed in the liquid. But there are various options and ways to do it and ways to prep. It's not that terrible and it's important to do it. Because like I said, if it's not done, then, you know, myself or whoever's doing the colonoscopy can't see what they want to see.

Host: Yeah, I hear you. And as someone who's had a couple of these over the years, the volume has gone down, the taste has improved slightly. And it's definitely not a reason, shouldn't be the reason you don't get your colonoscopy. As best you can doctor on audio form here, just sort of take us through the procedure, if you will, maybe not the nitty gritty. You know, just in general, what's involved in a colonoscopy and when, you know, we talk polyps, what does that mean and what do they look like to you and so forth.

Dr. Kevin Bree: Yeah. And then, I was also going to add, you know, I hope that one day we can have some flavored, you know, prep. Like maybe you want the grape or the orange or the apple flavored. So hopefully, that's coming, because—

Host: I mean, that's how we got our kids to take their medicine when they were sick, when they had strep throat or whatever is, you know, the flavored meds. So, it works for adults too. Yeah.

Dr. Kevin Bree: Yeah. So colonoscopy, basically, you'll come in the day of the procedure, myself or whoever's going to do the procedure will meet you, talk with you, you know, get a little bit of your history if they haven't met you yet. And then, the anesthesia doctor will come in, they'll speak to you, they'll talk to you as well. Then, we'll take you back to a room, which is our room where we do the colonoscopies. We put you to sleep for this.

Now, it's not the typical completely asleep and paralyzed like you would have if you were getting a big surgery, like your gallbladder removed or your appendix removed. There's no breathing tube inserted. This is more in terms of like a twilight, where, you know you're just taking a little nap, you're breathing on your own. You just kind of forget anything that you're not going to remember the procedure that we do.

So once you're asleep, we do what we call a rectal exam just to look at the outside area. And the first inside area of your colon, where your rectum is. And then, the device or the colonoscope—like I talked about that long tube with a camera and has a light on the end as well—that goes into your bottom. And the main thing we're trying to do in the beginning is just get all the way to the cecum. And the cecum is the first part of your colon where your small intestine connects. So, we're only looking at your colon in this procedure, not your small intestine. Once we get all the way to the end, then we start pulling out the scope. And as we're pulling out, that's when we're looking for any of these abnormalities.

So, polyps is one of those that we talked about. So, a polyp is essentially a small growth of tissue. And there can be several kinds of polyps. They can be benign or they can be malignant, or they can have cancerous potential. There's no way to really tell just by looking at them most of the time, but that's why we biopsy them. And then, we send them to a pathologist. The pathologist looks at our microscope, and then can tell us what they are in terms of benign, precancerous or malignant. Sometimes though, you can tell, if something looks malignant, and I'll often tell my patients if I see something that, "Hey, I think there's a good chance that this might be cancer" or moving in that direction.

The other things we can see, diverticula. Those are little pouches in your colon from not getting enough fiber in our diets, which is very common. I recommend everyone make sure they're taking a fiber supplement or getting enough in their diet. We can see hemorrhoids either on the inside or the outside, and anything else that might be abnormal that we see in the colon.

Host: Yeah. And I know that, generally speaking, I don't want to put words in an expert's mouth. But generally speaking, it feels, anyway, Doctor, that colonoscopy is still the gold standard, but I know there are some other ways to screen for colon cancer that aren't the gold standard. Maybe you can go through that for us and then remind us, or tell us all why you still recommend colonoscopy as the thing as the gold standard.

Dr. Kevin Bree: Yeah. So, there's several tests you can do. One is a test that will detect for blood in your stool. And the reason that blood is important is because usually polyps or large cancerous polyps will bleed. And so, they'll have a little bit of blood. And so, that's a reason that those tests are done is to look for that.

There's also ones that can look for sort of tumor DNA. There's also blood tests that can be done. Those are a little bit newer and, again, probably more expensive to my knowledge in terms of insurance getting to pay for it. If you take those tests, you have to understand there's such a thing as a false positive or a false negative as well.

So, what I mean by false positive is you take the test, it comes back positive, that doesn't a hundred percent mean you have cancer. So then, you have to get a colonoscopy anyway to take a look and see, you know, what the reason for it to be positive was. And sometimes about 10-20% of the time. And sometimes some literature says 40% of the time, it can be a false positive. It can also be a false negative, meaning it can miss some things. So if you take the test, it comes back negative, there's a chance that, You know, albeit low, but you could have still have a cancer growing and not know it, especially if it's a very small polyp.

Colonoscopy is the gold standard because, like I said, if you have a test that comes back positive on one of those, you still have to get the colonoscopy anyway. And then, I like to tell my patients seeing is believing, right? So if I can go through your entire colon and look and not see anything, then we know you don't have anything bad in there. So, that's probably the best way to explain why it's the gold standard.

Host: For sure. Yeah. And so, you know, it's not our primary focus today. Let's talk just a little bit about colon cancer in general and know that cancer screening isn't the easiest, and we're talking about colonoscopies and polyps and all of that. Just tell us, you know, briefly, if you can, a little bit about colon cancer and why it's important to diagnose early.

Dr. Kevin Bree: Yeah. Well, colon cancer, as probably a lot of people know is the second most common cause of cancer deaths for men and women combined. And I'm seeing it a lot more in younger patients too. I know we talked about the screening age a little bit earlier, being 45, but I actually foresee that in the next several years being even lower, being maybe 40 or even 35. Because like I said, we're seeing it in such younger patients.

In terms of colon cancer, you know, with the colonoscopy, it's really the only tool we have for any cancer that can be used to prevent that cancer by removing these precancerous polyps. So, removing them before they turn into cancer, you know, you have pancreatic cancer, there's nothing you can really do to prevent that before it happens. Same with, you know, other cancers, like skin cancer, things like that, other than avoiding sun exposure. But in terms of really removing those polyps and seeing it early, colonoscopy is the best test for that.

If the cancer is found early, which is the whole goal here, because you may not have symptoms, but we may find a cancer, it's very treatable. And the survival rate is very high. And the prognosis and outlook's very good. So, that's why we try to find it early.

Host: Yeah. So, let's say that, Doctor, we don't want to scare anybody of course, but because we want them to get their colonoscopies because you've outlined all the benefits today, obviously, in survival, if there is cancer. So, let's focus on that then. Like if a polyp is cancerous, what would the next steps be for a patient?

Dr. Kevin Bree: Yeah. So if the polyps cancerous, then the next step is ultimately going to be a surgery to remove that part of the colon. And that surgery serves two purposes. One, it removes the cancer and it's potentially curable, depending on if the cancer hasn't spread to any other parts of the body. And two, it helps us stage the cancer. So in order to stage any cancer or most cancers, you have to have the tumor itself. You have to have lymph nodes in the vicinity to tell you if it's spread to the lymph nodes. And you also have to determine if it's spread to other organs. So, the way we determine if it's spread to other organs is you'll get a CT scan, which will kind of scan your body and say, "Is it in the liver? Is it in the lungs?" No. Great.

And then, the way we get to lymph nodes is actually through surgery. So when we remove part of the colon, we also take several lymph nodes with us. Then, when the pathologist looks at that specimen under the microscope, he tells us what the tumor itself looks like, the characteristics of the tumor. And then, he'll also tell us how many of those lymph nodes that we took out were positive. And depending on that criteria, how aggressive the tumor itself is, how many lymph nodes are positive, then you may require chemotherapy or other treatments. But if all those are negative and look good, then potentially the cancer is curable.

Host: Right. Yeah. Yeah, it's pretty amazing. And I know we could stay on longer. But for today, I just want to give you an opportunity here at the end. Final thoughts, takeaways, whether it's nudging people to get that colonoscopy or whatever it might be.

Dr. Kevin Bree: Yeah. No, I think it's very important. Like I said, we're seeing it in a lot younger patients. So if you have any question, and if you have family histories especially, it should be something you do. It's a very benign procedure. Everything comes with complications. But in terms of risks for a colonoscopy, they are relatively low and not as high as many of the other things we do.

The other thing I want to add too is a lot of people, I think, assume that gastroenterologists are the only ones that do colonoscopies. But if you go to a smaller hospital system where maybe they don't have a lot of different specialties and physicians, the general surgeons will actually do the colonoscopies. That's part of our training as well. So like in my hospital, myself and my partner are the ones that do all the colonoscopies and we're both general surgeons.

Host: Okay. Yeah. Well, I certainly appreciate your time and your expertise today. My words of advice to listeners would be it's the best nap I've ever had. And I'm not saying that I look forward to that nap, that I look forward to the colonoscopy, but it's really no big deal. The prep is no big deal. So many benefits in catching cancer early and treatment and all of that. So, thank you so much.

Dr. Kevin Bree: Yeah. Yeah. Thanks for having me. I appreciate it.

Host: And to learn more about colonoscopy or to make an appointment, visit franciscanhealth.org/coloncare. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.