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Prakash Chandran: According to the CDC, colorectal cancer, better known as colon cancer, is a disease where cells in the colon or rectum grow uncontrollably. A way to detect abnormalities in this part of the body is by undergoing a colonoscopy. But what exactly is this? And what are the benefits of getting one done? We're going to talk about it today with Dr. Carline Quander. She's a gastroenterologist at Health First.

This is Putting Your Health First, the podcast from Health First. I'm your host, Prakash Chandran. So Dr. Quander, thank you so much for joining us today. Truly appreciate your time. I'd love to get started with the basics. What exactly is colorectal cancer and how common is it?

Carline Quander, MD: Colorectal cancer is cancer that arises from the colonic mucosa. And it is the third most common cancer among men and women in the United States. So it's a pretty important cancer.

Prakash Chandran: Okay, understood. And is there actually a way to prevent this cancer from forming?

Carline Quander, MD: Well, we're lucky with colon cancer, because colon cancer has a precancerous lesion called a polyp, which can be removed, which can decrease your risk of colon cancer in the future. So we believe that by doing colonoscopies, we can decrease by 90% your risk of colon cancer in the future. There's not that many cancers that have a precancerous lesion. For instance, breast cancer or prostate cancer, you can have a normal mammogram one year and then the next year, you can have a cancer. But because colon cancer grows at a much slower rate, we think that it takes five to seven years to go from a polyp to a cancer. And we have an opportunity to prevent colon cancer in the future by removing polyps before they turn into a cancer.

Prakash Chandran: Now, I definitely want to talk about prevention and colonoscopies. But before I do that, I kind of wanted to understand the demographic of people that this affects. Is there certain age or part of the population that this affects more than others?

Carline Quander, MD: We know that there's a rising rate of colon cancer as we get older. So we used to use the landmark of 50 years of age when we felt that the risk was high enough to warrant a screening exam. But actually, if you look between the ages of 50, 60, 70, 80, the risk goes up as time goes on. So our risk goes up as we get older. The other thing that we're dealing with is right now, we're seeing a lot of younger people with colon cancer. And we can talk about why that's happening and there's a lot of reasons if you want to talk about risk factors later. But you may be aware that there is recent guidelines that have stated that, that we should start screening at 45 years of age, as opposed to 50, because we know there's a rising rate of people getting colon cancer based on trends in the cancer rates.

Prakash Chandran: Yeah. I would maybe like to talk a little bit about that right now. You know, I, myself, for example, just turned 40 and what was in the news most recently was that Black Panther actor, Chadwick Boseman, I think he died at 43. So it is something that is on my mind. Talk to me a little bit about the reason why you think there might be this rising rate and what we can do about it.

Carline Quander, MD: Well, we believe that the reason for the rising rate in people, and they actually specifically looked at people born after 1990 versus people born between 1950s, that the trends are showing that we're having more cancers related to colon cancer. And we think it has to do with the change in our diet, we're more sedentary than we used to be back in the '50s and more obesity. But when you think about Chadwick Boseman, he's an African-American, and we also have known for a long time that African-Americans are more likely to present with more advanced disease and they actually don't do as well. Because of the advanced disease, they don't do as well with colon cancer. So African-Americans, we have been recommending early screening for African-Americans for at least five to ten years. But the recent guidelines are saying, even for all Americans, that we should be screening at 45 years of age and higher.

Prakash Chandran: Yeah, that's really interesting to hear about. And, you know, you mentioned the African-Americans being more susceptible. Why exactly is that?

Carline Quander, MD: Well, it's very complicated. It may have something to do with socioeconomics. Everyone tries to say that there might be a biological difference. We know that African-Americans are less likely to seek care. They may not have as much resources to get care when they have problems. They may be less likely to do the screening, and they may be more troubled with some of the risk factors that we talked about, which is obesity, diet, exercise, all of those things that actually play an important part in terms of your risk of colon cancer, so putting that all together. And the same is seen with breast cancer. African-American women are more likely to have more advanced disease when they present. So that highly impacts their survival, because everything we know about colon cancer is about what stage of disease that you're diagnosed with. So if you're a diagnosed with a higher stage of disease, your survival is much less. So I think it's a combination of lifestyle habits, but also there is some element of socioeconomic access to medical care, the supports that are necessary, because with a colonoscopy, you need someone to drive you there, you need to have some support with that. And if you don't have that, then you're less likely to do screening.

Prakash Chandran: Yeah, that's fascinating. So I want to move on to the screening itself. Talk to us a little bit about, what that screening is, the colonoscopy itself, and what does the procedure look like.

Carline Quander, MD: Well, the colonoscopy, for most people, the hardest part is to make the decision to have the test. And we're lucky that most of the impetus to have the test is usually provided by your primary care physician who will recommend it. I would say probably 70%, 80% of the time when I get someone to come into my office, it's because their doctor told them to do it. It's important to have a primary care physician so that they can recommend it. I think maybe 20%, 30% of the time people will come because they heard about the need for screening. So the hardest part for most people is just coming in to get screened, to get appointment to have the exams. And once the appointments made, the next step is to set the date and then prepare for the test.

So, after you've made the decision and made the appointment for the exam, the next big step is to drink the prep. And we could talk about that, but there's different ways now to prepare for a colon exam. There's the tried and true method that we used to use almost a hundred percent of the time was the gallon prep. Most people know a little bit about this prep and it tastes kind of bad and it's hard to finish. Now, we have other preps that have been studied and validated based on pretty clear studies looking at ease of the prep, completion of the prep and how good it gives a result with the colon exam. So, you know, drinking the prep is never a walk in the park. And I can tell you, I had my colonoscopy three weeks ago, and I know exactly what patients go through. The prep is terrible. But I chose a prep that was just two small bottles, as opposed to the gallon. There also are pills that you can take, but there's 24 of them. You would take four pills every 15 minutes. And some people who don't want to take that nasty tasting stuff, you know, I have no trouble taking the prep because I just chug it, I just drink it really fast, and so I had no trouble drinking it. But there are preps that are pill-based, which makes it a little bit easier.

So the most important thing we want is the patients do the best prep they can so that we can see every little piece, every bit of the colonic mucosa so that, you know, it helps us to improve what we call polyp detection rate, because there are national databases that compare different doctors and how many polyps they can detect. So we like to detect as many polyps as we can because it tells us that we're looking as good as we can.

So once you get your prep, the hard part is pretty much over. All you'd have to do for the procedure itself as you come into the endoscopy suite, you will see an anesthesiologist that will give you medication to make you sleepy. You have an IV placed, you go into the room. And I can tell you from my exam, which was three weeks ago, you fall asleep and you wake up and you really have no remembering of anything that's going on. The test itself takes about 15 to 20 minutes and the medicines that they use to put you to sleep, you don't need to be on a breathing machine. It's called deep sedation. So you're put to sleep, but you're breathing on your own. And basically, you wake up. The nice thing about this medicine that they use is that you wake up very fast. So frequently, after we finish our procedure, I do my report. By the time I do my report, which is like five or ten minutes, by the time I walk outside, the patient is usually a little awake, it's pretty much awake. And then, usually a hundred percent of the time, the patient has to have a ride to get home.

Ninety percent of the information you want from a colonoscopy you can get from when we finish the exam. The biopsies take another week to come back. Most of the time, most GI doctors know if it's a polyp or if it's a tumor or if it's a cancer. Usually, I'm going to know if it's a cancer and I can usually give that information to the patient, even though the biopsies are not back. And then, we could prepare for what needs to happen next. If it's a polyp, 95% of the time, I'm going to know that at the end of the procedure. So you're going to get most of the information you need to know when you leave.

And then, within the next 24 hours, you can eat whatever you want to. I didn't mention on the day before the procedure, you take this prep, but you're also on a clear liquid diet for that day. So I would tell people to plan ahead, something that will be liquid that will make them feel halfway happy. When I did my exam, I actually went to a restaurant that had some flavorful broth that gave me a sense that I was eating something because I did miss my food at the end of the day. And I was very happy to eat, right? And you can eat, do whatever you want to after the procedure, but you can't drive a car because of the sedation that you had with the procedure.

So the hard part for most people is just making the decision. And the second hardest part is probably the prep.

Prakash Chandran: Yeah, I definitely want to get to making the decision itself, but I think that you gave a really nice and comprehensive overview of the entirety of the procedure, you know, starting with the prep and that's really just meant to flush your system or your colon out to really give the best chance possible during the colonoscopy to see everything that you can possibly see. And that requires kind of the clear liquid fast, as well as those bottles that you need to take to help facilitate with that flushing. Is that more or less correct?

Carline Quander, MD: Yes, that's very correct. That's very correct.

Prakash Chandran: Okay. You then talked about after the procedure, which is like 15 to 20 minutes, you'll most likely be able to tell like 90% of what the patient needs to know, whether you found something that was of concern or it was a polyp that needs to be analyzed. And I also heard that with this specific procedure, you're actually able to treat some of the polyps while you're in there, like during the colonoscopy. Is that true?

Carline Quander, MD: Well, basically anything that we see that we can remove, we remove. And there are some polyps that are non-precancerous and then there's some polyps, we call them hyperplastic polyps. And then there's some polyps, the polyps that we want to remove and we love to remove are the tubular adenomas. And those are the ones that could turn into cancer. No one's ever really done a study to see how many of these tubular adenomas would turn into cancer because that would just not be an ethical study. But we presume that it takes five to ten years to go from a polyp to a cancer, which is why our screening intervals are every five years. So if you have a normal colon exam, and you have no family history, you probably could get screened every 10 years. However, if you have tubular adenomas, which are those precancerous lesions, we would recommend a colonoscopy every five years. And if you have three polyps or more or polyps that are greater than a centimeter, those are high risk lesions that we would recommend followup in three years. Sometimes there's some variation in the followup because if the prep isn't good, then we might recommend an exam sooner or if there's unusual polyps, there are some other types of polyps that are more unusual, and sometimes we'll follow those up in two years. So it all depends on the prep, how good the prep is and what type of lesions that are found on the exam and also your family history.

Now, I didn't mention other risk factors. We know about age being an important risk factor. And we also talked about race, you know, that African-Americans are more likely. But there are other risk factors that are associated with colon cancer besides lifestyle and diet, is that people with a family history are obviously at higher risk. People with a family history of colon cancer or people with a family history of polyps, they are recommended to have screening at a younger age. And for people with a family history of colon cancer, we usually say 10 years before the index case or the family member with the cancer. So if your mom had colon cancer at the age of 50, we would recommend you start screening at 40. If your mom had colon cancer at 35, we start screening at 25. So that's another factor to take into place in terms of the screening issue.

Another risk factor is inflammatory bowel disease. If there's like Crohn's or ulcerative colitis, we screen for colon cancer much more frequently in those populations.

Prakash Chandran: Yeah. That makes a lot of sense. And thank you for that clarity there. You know, one of the things that I wanted to make sure to ask was you mentioned that the hardest decision was actually getting the test itself, like someone has to say yes to that test. Can you talk to us about some of the reasons people decide against actually going through with the colonoscopy?

Carline Quander, MD: There's actually been a lot of studies looking at compliance rate with colorectal cancer screening. There's some people who have barriers and we're trying to break down those barriers. Some people feel uncomfortable with something. I mean, I know there's some men that feel a little strange about something going in their backside. But, you know, I kind of lighten it up a bit. Sometimes with my patients. I say, "Well, your colon's getting a spa treatment today" or "Your colon is going to get the light of day. It's an exciting day for you. Your colon gets to have the light of day because you know, it is getting the light of day, so that we can look and see. And I can't stress how important it is to know that colon cancer, the pathogenesis of this disease is from a polyp that we can actually get to. And we can actually see before it turns into a cancer. So it's a very unique cancer and that we can predict the presence of it five years from now. And we do know that the cancer rate overall in the United States for all age groups have gone down since we initiated screening for colonoscopy. When I finished my fellowship in GI, colon cancer was not paid for for screening. And it was some of the advocacy from Katie Couric and her husband having colon cancer, that somewhere in the '90s is when we started getting insurance coverage for colon screenings for everybody, because we used to do colonoscopies just for people with symptoms. And we were looking for cancer at the time. So, we're lucky that we're able to do these tests for people in order to prevent colon cancer in the future.

Prakash Chandran: Absolutely. Before we close, is there anything else that you would like to share with our audience here today?

Carline Quander, MD: Well, I think if you look at the numbers in terms of people who adhere to the recommendations for screening, depending on what state you're in, somewhere around 70% of people will proceed with screening. So we still are missing about 20% to 30% of the population that won't get screened. We should be aware that there's other ways to screen, but are not as and good in terms of prevention of colon cancer. And I think a lot of people hear about the stool DNA test. It's a great test to do. It has to be done every three years. But the problems that we have with the stool DNA is it doesn't prevent colon cancer. It's made to look for cancer. It's not made to look for polyps. And I think this is kind of a lesser known thing is that if you have a positive stool DNA test that you do for screening, and then you go to have a colonoscopy, you may get charged higher for the colonoscopy because it becomes a diagnostic test as opposed to a screening test. So some people are a little upset because if they had just done the colonoscopy, they might not have as much to pay for the test if they had just done the colonoscopy. So, you know, it's something to be aware of.

Prakash Chandran: Yeah. And the colonoscopy is the gold standard test anyways, right?

Carline Quander, MD: Exactly. But we still have to get to that 20% that won't do the test. Maybe the stool DNA testing positive will push them to go for screening.

Prakash Chandran: Yeah, there you go. Well, Dr. Quander, thank you so much for your time today. I really appreciate it.

Carline Quander, MD: Thank you. I had a wonderful time.

Prakash Chandran: As did I. That was Dr. Carline Quander, a gastroenterologist at Health First. Thanks for listening to this episode of Putting Your Health First. For more information, you can visit hf.org/digestivecare. My name is Prakash Chandran, and we look forward to you joining us again.