Melanie Cole, MS (Host): Welcome to GW Hospital HealthCast, an informative health podcast from the George Washington University Hospital. Joining me today to talk about colon cancer screening and treatment is Dr. Marian Khalili. She's a fellowship-trained colorectal surgeon specializing in the minimally invasive and robotic treatment of colon and rectal diseases at the George Washington University School of Medicine and Health Sciences. And she's affiliated with the George Washington University Hospital.

Dr. Khalili, thank you so much for being with us today. I'd like to start with prevalence of colon cancer and awareness, what you've been seeing in the trends, and we've even now noticed a trend toward younger diagnoses of colorectal cancer. So, can you speak about colon cancer and what you've been seeing?

Dr Marian Khalili: Yes. So, thank you so much for having me discuss this very important topic. Colon cancer is the second most common cancer that we see. It's after breast and prostate cancer. The prevalence of it is the second most common. And yes, there has definitely been a trend towards younger patients presenting with colon cancer. By younger, we mean less than the age of 50. Over the years, colonoscopy has actually reduced the overall incidence of colon cancer, colon and rectal cancer. However, we are unfortunately have seen an uptick in the number of patients less than the age of 50 with colon cancer. So, the recent recommendation is to start colonoscopies at the age of 45 as opposed to 50. And also importantly, those red flag symptoms that make us concerned about younger patients having colon cancer need to be taken more seriously. So when we have patients who have bleeding or changes in their bowel habits and unexplained weight loss, those are all really important things that need to be investigated.

Melanie Cole, MS: Then, let's talk about screening. So, you mentioned the guidelines. And based on what you've been seeing as far as younger patients, when do people have their first one? And then based on what they find out, now you mentioned 45, but is that now across the board? And we're starting at 45. And then based on whether or not you have polyps, every 5 or 10 years, every 3 years based on that? Because there's been some confusion about these new guidelines.

Dr Marian Khalili: An average risk patient. So, what's an average risk patient? Somebody who doesn't have a family history of colon or rectal cancer or advanced polyps. That is an average risk patient. Those patients start colonoscopies at the age of 45. And if you do the colonoscopy and you don't find any polyps, then they repeat the colonoscopy in 10 years. If you are a high-risk patient, so that is patients who have family members who have colon or rectal cancer, especially first degree family members, so the guidelines for those patients is to start colonoscopies at the age of 40 or 10 years before the age of the youngest family member who got cancer. So, for example, if your Aunt Rita got cancer at the age of 50, you can start colonoscopies at 40. If it was 49, then you would start at 39. And also when they do the colonoscopy, if they're a high-risk patient, you just repeat it no matter what every five years.

Now for those, average risk patients, you would consider doing more frequent colonoscopies if on the colonoscopy you found multiple polyps, more than three that are adenomatous polyps. Adenomatous polyps are those precancerous polyps. Or if you find one polyp that's quite large, so greater than a centimeter in size, you would do more frequent colonoscopies, so every three years, as opposed to every five years or ten years.

Melanie Cole, MS: Well, thank you for telling us about that. Let's speak about the procedure itself. Many people are scared to get a colonoscopy. As someone who's had a lot of them, the prep is not fun. It's just not, but it's not that big a deal. And now, there's been so many advances in prep that it's not quite always the big gallon of TriLyte that we're seeing. There's new products on the market. Tell us a little bit about the procedure, how easy it is. You're speaking to consumers here. Let them know why this is so important.

Dr Marian Khalili: So by far, the number one complaint is about the prep. And you know, it's not the most pleasant. There are newer, it's not just the four gallons of Golytely anymore. There are other options. There is Nulytely, there is Miralax. For patients who have a history of constipation and often have a poor prep or they're at risk of having a poor prep, we might do two-day preps, where we split the prep into two days. But yes, unfortunately, the prep is the worst part, but I will say that even if you try the other modalities to screen for colon and rectal cancer, so you can check your stool for fecal occult blood tests or there's FIT tests that is more specific to human blood. It looks for blood in the stool. If they're positive, you need a colonoscopy. If you do Cologuard, you still have to take the prep. And if it's positive, you need a colonoscopy. If you do a CT colonography, you still need a prep. And if it's positive, you need a colonoscopy. And it's so important to do this procedure because we have seen a reduction in the incidence of colon and rectal cancers, and that is because we do colonoscopies. You can actually prevent cancer by finding polyps sooner rather than later, and that's really unique to colon cancer. The other modalities that we have for screening for other kinds of cancers, like breast cancer or lung cancer, don't have that advantage.

Melanie Cole, MS: No, it really is amazing. It's one of the better preventive tools, literally a cancer preventive tool. And it's not that big a deal. So listeners, it's really-- and I don't mind the way it feels because you feel like you're really cleaned out and you get the nice little pictures afterwards.

Now, I'd like you to speak about the polyps for a minute. So, you take those out. Now, they are no longer a risk for cancer. But then, it changes when we get our colonoscopies. And what if, God forbid, they are cancerous?

Dr Marian Khalili: Let's start with we find the polyps and we remove them. Sometimes polyps are quite advanced and quite large and they just cannot be safely removed via endoscopy. Those patients need surgery. And then, sometimes we remove polyps, we look at them under a microscope and they have cancer in them. Those patients also need surgery. So, that's when you get sent to your colorectal surgeon to have a discussion about the surgery that you need. Depending on where the polyp is, if it's in the colon, so if you think of the colon as a big tube, the beginning part is your colon and as you go closer to your anus, you get to the rectum, there is a difference on how we treat patients who need surgery from having either cancer or polyps that can't be excised via endoscopy if it's in the rectum versus if it's in the colon.

For the colon, typically you need just surgery first. Those patients need to be first stage. So, you need to get a CT scan of your chest, abdomen, and pelvis. And that's to make sure that you don't have cancer anywhere else in your body. If you have cancer anywhere else, that's considered metastatic disease and those patients need chemotherapy first. Now, this is true for both colon and rectal cancer. If it's colon cancer and you do the CT scan, there's no metastatic disease, then we just resect that part of the colon. And we ideally put everything back together. We also remove all of the lymph nodes that are associated with that part of the colon. And we look at them under the microscope. And when we look at the specimen under the microscope, we have an idea of whether or not this is a more advanced cancer that needs chemotherapy or not.

With rectal cancer, part of the staging workup, in addition to CT scan of the chest, abdomen, and pelvis, is an MRI of the pelvis. Because if you have a more advanced rectal cancer, we often treat these with chemotherapy and radiation first before we do any kind of surgery.

Melanie Cole, MS: That is so interesting, and the advancements in your field are really happening quickly. It's really an exciting time. Now, I'd like you to speak to consumers now, Dr. Khalili, about the importance of watching their own stools, you know, knowing what's going on down there, keeping up with their fiber, their diet, their exercise, and their hydration and the importance of a colonoscopy. Give us a great summary of your very best advice.

Dr Marian Khalili: Yes. So, first off, get the colonoscopies when you're supposed to. So if you're supposed to start getting at the age of 45, do that. And sometimes you have to be your biggest advocate. So, that's number one. And no one knows your body better than you do. If you think that something's off, then go see your primary care provider, tell them what the problem is. And they'll send you over to the correct person, get a colonoscopy, get things checked out. If you're having bleeding, if you're having a change in your bowel habits, if all of a sudden you're poops are really thin or you're having a hard time using the bathroom, if you're having anorectal pain, all of these things are things that need to be discussed with your doctor. So, take care of yourself and be your biggest advocate.

You know, there are things that are known to be risk factors for getting colon cancer. So that includes smoking cigarettes or your diet. So, having a diet that's really high in nitrates. So, those are the barbecued foods and high-fat diet, obesity, and having a low-fiber diet. So, having those fresh fruits and vegetables goes really, really a long way in making sure that you have a healthy colon.

Melanie Cole, MS: Thank you so much, Dr. Khalili, for joining us today and sharing your incredible expertise on this topic. And for more information, you can call 1-888-4GW-DOCS, or you can visit gwhospital.com. Thank you so much for joining us on GW Hospital HealthCast, an informative health podcast from the George Washington University Hospital.

Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary and there are risks associated with any procedure. Please speak with your physician about these risks to find out if this procedure is right for you. I'm Melanie Cole. Thanks so much for joining us today.