Scott Webb (Host): There's never a bad time to encourage folks to get screened for colon cancer, and my guest today is here to explain why colonoscopy is the gold standard for detecting and preventing colon cancer and more. I'm joined today by Dr. Dipen Maun. He's a board-certified colorectal surgeon with Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, nice to have you here today. We're going to talk colorectal cancer, colonoscopy, colorectal treatment options, all of that. So, let's start with the basics. What is colorectal cancer? And for listeners to better understand, can you explain a little bit about the anatomy of the colon and the rectum?

Dr. Dipen Maun: So, the colon and rectum are the last parts of your digestive system. It is also known as the large intestine. Its main job is to turn the leftover food your body can't use into a stool or otherwise known as poop and move it out of the body. It's shaped like a long tube- like organ, and it's about five-feet long. It sits in really all parts of your abdomen and it's shaped like an upside down U. And it's divided into multiple sections.

The first section of the colon is the ascending colon, also known as the right colon. This is the area that you might know because the appendix hangs off of this part of the colon. And this section of the colon is actually most responsible for absorbing water out of the leftover waste that you have in your body.

And as we move down towards the end, we pass through that transverse colon, the descending colon, the sigmoid colon, and finally enter into the rectum. The rectum is the last six inches before waste exits to anus, And the main function of this entire organ is absorbing water in the first half and then shaping and storing stool in the second half. The rectum is the main organ involved in defecation. It is the organ that ultimately sends a signal to your brain you have to use the toilet. And ultimately, the muscles of the rectum and anus are what's responsible for getting the waist out of your body.

Host: That's perfect. No diagrams needed in audio form here. That's perfect. You know, Doctor, most people know that colonoscopy is a colon cancer screening, right? And we start that at 45 now or younger if you have close family history of colon cancer. And I've discussed it with some other Franciscan Health providers on some of the podcasts we've done. And we just didn't really go into depth though about what happens during the actual procedure, like while you're sedated. So as a colorectal surgeon who's performing the colonoscopies, maybe you can walk us through, like, what are you looking for And what happens during a colonoscopy?

Dr. Dipen Maun: Yeah, I'm more than happy to. One of the most important parts of the colonoscopy, if not the most important part, is the actual colon preparation, which occurs the night and morning before. Typically, the day before there's a special diet, that diet really focuses on just very, very clear liquids so that we're not adding additional roughage into the body.

Your physician will then prescribe to you a preparation protocol, and usually involves a laxative solution. The volumes of this prep are usually 64 ounces, which is almost a half a gallon. And mostly, this is at least drunk half the night before and partly the morning of the procedure.

I do want to stress that this is extremely important, because if the prep is poor, there'll be residual stool coating large intestine, and the doctor won't be able to see or examine the lining nearly as well as they'd like to. And this will lead to potentially missed things. That night and that morning, the prep will unfortunately lead to a very large volume of diarrhea as the entire larger intestine is expelled of all the waste. This doesn't hurt at all, but it can be very frustrating as you're running into the bathroom over and over again. Sleep is unfortunately pretty limited that night. And this is without a doubt the most uncomfortable part for many people. But once you get through it, it's really kind of smooth sailing.

The next morning, you'll probably arrive to your facility. Typically 60 to 90 minutes before, the operating room or the procedure room staff will kind of do a bunch of basic checklists, take your medical history, sign some consent forms. An IV is placed in your arm. You'll be changing to a hospital gown, and then you'll be wheeled back into the procedure room. It is very common to receive some sort of sedation for the procedure. It could be a moderate or it could be a deep sedation. Both ways are completely safe and designed to maximize the comfort of the procedure so that you'll have very little or zero recollection of the entire experience. If it's a deep sedation, you may receive a medicine called propofol. And if it's a moderate sedation, you may receive medicines called Fentanyl or Versed.

Once you're in the procedure, you'll lie on your left side with your knees bent, your body's really completely covered except for the backside. The doctor will then insert a colonoscope, which is a very long, flexible tube. It's fairly narrow. And on the end of it, it has a tiny camera and a light, and also has a bunch of small channels so that the doctor can do some procedures if necessary. The doctor will then insert the colonoscope through the rectum, through the entire large intestine that we just described. And then, while withdrawing the scope, very thoroughly examine the colon, to look for things that don't belong.

If something is found, such as a polyp, the doctor can remove it, and that's called a polypectomy. Or if there's a growth that's found that can't be removed, the doctor can take a biopsy. And even if there's some bleeding from something, the doctor can actually control that during a colonoscope. It's a very functional test, and the whole procedure typically last 20 to 40 minutes.

And the whole idea of this is to examine the lining and look for polyps. Imagine that a polyp is like a little growth and it's a seed for a future cancer that can grow, and this can happen anywhere throughout the entire large intestine. Finding these polyps and removing them, we can reset that potential cancerous process and prevent a colon cancer from developing.

At the very end, you'll be brought into a recovery area. Probably spend 30 to 60 minutes recovering. You may have a little bit of bloating or some mild cramping. But most times, patients have no symptoms at all. You'll need someone to drive you there and drive you home because of the sedation and can resume all your normal activities the next day.

Host: So then, Doctor, what happens if you find cancer during the colonoscopy process?

Dr. Dipen Maun: If a doctor suspects a cancer during the colonoscopy, several things usually happen during and after the procedure. First of all, it's important to know that the colonoscopy doesn't actually confirm the cancer. It just identifies a suspicious area, and that area must be tested. Usually, the doctor is able to take a biopsy during the colonoscopy and then send that specimen off to the lab.

The pathologist will then take anywhere between three and seven days to analyze the tissue under the microscope and then confirm whether cancer is found. The most common type of colon cancer is adenocarcinoma. There are other types that can be found, but this is by far the most common variety.

At this point, the patient will get a phone call from the doctor explaining what was found. And then, we will likely recommend some additional testing, and typically a referral to a surgeon and/or a medical-oncologist who can then outline the next steps in the treatment. While this is very anxiety-provoking for patients, I do want to stress that polyps and tumors are generally slow-growing. So, waiting a few days or a week to get the test done, to get the right appointment set, and imaging done is completely safe.

The most likely imaging or radiology test that is ordered, it is called a CAT scan or a CT scan. And that's a scan that really looks at the entire body from neck down to your pelvic area. And the goal is to see if any cancer cells have spread outside of the colon with the most common locations of spread being the liver and the lung. And in cases of rectal cancer, an MRI is typically added to the imaging regimen, and sometimes even a PET, P-E-T, scan can be used to get additional inflammation to see if the cancer has spread anywhere else.

Host: Yeah. And, Doctor, if a patient is found to have colorectal cancer, how do you determine staging?

Dr. Dipen Maun: That's a great question. Every tumor has its own staging protocol and colon and rectal cancer has its own as well. And there are typically four stages of colon or rectal cancer, and they're numbered between stages I to stage IV. Stage I is the earliest stage. It's the most curable, and it kind of goes up down to stage IV, which is unfortunately the hardest stage to get cures.

A very short answer for staging has to do with the extent of the spread. Stage I usually means the cancer is confined to the inner layers of the wall of the large intestine, and it hadn't spread through the wall. Stage II means it did erode through all the layers of the wall, but the tumor is still confined to the colon wall only. Stage III means that the tumor cells unfortunately have figured out how to get into the lymphatic system and have spread to the lymph nodes. And stage IV, the tumors now learned how to spread far away, usually through the blood or the lymphatics, and has attached to another organ like the liver or the lung.

The imaging tests that I mentioned, such as the CT scan and the PET scan are very good at determining whether or not a cancer is stage IV or not. But oftentimes, to figure out stages I through three, this comes after surgery when the tumor is removed and the pathologist can look at the entire specimen in the lab.

Host: Okay. So then, for colorectal cancer patients, what are the treatment options? Maybe you could share a little bit about the surgical treatment, medical oncology, radiation-oncology, and when patients, you know, might need each of those.

Dr. Dipen Maun: The treatment for colon anorectal cancer does take a village, and it's important to assemble the best possible team. This is called a multidisciplinary approach, and it'll involve a handful of doctors. It might include a surgeon, a medical-oncologist, a radiation-oncologist, a radiologist, a pathologist amongst others. So, pretty important to have a very good team that's on your side.

Every case will be different, and every case will need a customized treatment plan. To help simplify things starting with colon cancer, most colon cancer treatment plans that are not stage IV typically start with surgery. Surgery will entail removing the segment of large intestine that has the tumor in it and all of the surrounding lymph nodes that the tumor could possibly drain into. It's very commonly done in a minimally invasive fashion. That means making small incisions and using technology like laparoscopy or robotics.

The surgeries typically take two to four hours, and most patients stay in the hospital between one and four days if the recovery is uneventful. If the final pathology, however, is stage III, many patients will then be recommended to see a medical-oncologist, be offered to do some chemotherapy for a few months after surgical recovery is complete. Most chemotherapy regimens involve having a port access device placed in the chest so that the medicine can be diffused directly into large veins into the body. And what chemotherapy does is it circulates throughout the body. And it's able to kill cancer cells that are floating around or in another organ.

When it comes to rectal cancer, even though it's the same tube, treatment is a little different. Most patients still need that CAT scan like we mentioned, but they also need an MRI upfront, and it's very common for the regimen to treat rectal cancer to start with either or both chemotherapy and radiation therapy. As I mentioned, the chemo is infused into the bloodstream to help kill cancer cells. And the radiation machine actually sends really high focused energy to a part of the body, such as the rectum to kill cancer cells. And the chemo and the radiation work together to actually kill the cancer cells and make the tumor smaller.

Once all of that's complete, then your surgeon may consider removing the segment of the rectum that has the tumor in it. Rectal cancer surgeries are typically more challenging. They take longer, and they can sometimes require an ostomy or a stool bag to divert the stool away from the surgical site. Most of the time, that bag is temporary. But sometimes that bag is permanent if the tumor is very close to the anus. Unfortunately, it's just necessary to ensure that all the cancer is removed and sometimes the entire organ does need to be taken out.

Host: Right.

Dr. Dipen Maun: And the last thing I want to mention, if the colon or rectal cancer is stage IV, that means it spread to another organ, most commonly the liver or the lung. And unless the tumor is posing an imminent risk like a blockage or it's actively bleeding, these patients will start treatment with the medical oncologist, usually with chemotherapy only.

Host: Yeah. It's a lot to take in. And I appreciate your time and your expertise today, Doctor. And I know that colonoscopy really is the best way to screen for colorectal cancer, and hopefully diagnose it in its earliest stages—the gold standard, if you will. But for people who are maybe hesitant to get a colonoscopy, maybe nervous about the prep, maybe they just don't want to prioritize the time, you know, away from work or family, what would you say to encourage them to get this important screening?

Dr. Dipen Maun: Yeah. This is such an important task. So for people who are hesitant, I think the first thing to help them acknowledge that you're not alone. These concerns are, unfortunately, very common. And many people worry about the preparation, the procedure, or maybe taking time off away from work or family or having something inserted into your anus, into the large intestine.

But screening for colon cancer is one of the most powerful things you can do to protect your long-term health. Colon cancer is unfortunately the number two killer in the United States for cancer-related deaths, yet it's also very preventable. What is really unique about a colonoscopy is that it doesn't just only detect polyps and cancer, it's actually used to prevent it. Many screen tests can detect cancers such as a mammogram or a Pap smear, but those tests can actually prevent it. A colonoscopy can do better. It can actually find polyps, which are the pre-cancerous lesions that can lead to developing cancer, and then they can be physically removed right during that procedure. So, it's one of the most impactful tests that you can receive that both detects and prevents colon cancer.

Another thing is that the procedure is actually a lot easier than people typically expect. And I can speak firsthand. I've actually done two of them myself. I went at age 45. I had no symptoms and had a large polyp removed, and I had to go back three years later. So, I'm not even 50 yet, and I've had two colonoscopies. And I do agree the prep is the hardest part, but it doesn't hurt. You can do it in the privacy of your own home. The prep regimens are getting better. They used to be one gallon in size, and we've now streamlined that to now that half a gallon. After the procedure, I felt fantastic. That was about five pounds lighter, which was great. I had no pain before, during, or after. And I had that polyp removed and now I have the peace of mind that colon cancer was prevented.

As I said earlier, the stage is very important. So, finding polyps when they can be removed or finding cancers when they're small is much better than finding when they're later. And lastly, as a colorectal surgeon, I've unfortunately seen many patients undergo cancer treatment, and that is a lot harder than undergoing a colonoscopy. If the colonoscopy's normal, you have a 10-year warranty, which is amazing. And so, that's not like it's something that has to be repeated year after year after year.

Host: Well, that's perfect. Like I said, I appreciate your time and your expertise today. And, you know, difficult for some maybe without diagrams and video form, but you did great in audio form today. So, thank you so much.

Dr. Dipen Maun: I appreciate it. Thank you very much.

Host: And to learn more about colonoscopy and to make an appointment at Franciscan Health, 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.