Maggie McKay (Host): Welcome to Thrive With Holy Cross Health, presented by Holy Cross Health in Fort Lauderdale, Florida. I'm your host, Maggie McKay. We hear a lot about gut health, colon cancer prevention, diagnosis, and treatment, but how much do we really know? It's important? So today we're going to learn a lot more with Gastroenterologist, Dr. Patrick Amar, thank you so much for joining us.

Patrick Amar, MD: Thank you, Maggie. It's a pleasure to speak with you today.

Host: You too. I am very interested in this because in my family there's a long line of people who have had colon cancer, so you know, you have to get colonoscopies all the time, like every three to five years. So I feel like people can never learn enough about it. So what is the importance of high quality colonoscopy in the early detection and prevention of colon cancer, and how does it contribute to reducing cancer risk?

Patrick Amar, MD: Great question. First of all, kudos on being up to date on your own colon cancer prevention with that family history. High quality colonoscopy is really critical and I would argue probably one of the most powerful cancer prevention tools that we have in reducing your cancer risk in the future. In terms of when we talk about quality colonoscopy, we're talking about different ways that a colonoscopy differentiates itself to really improve and maximize your cancer reduction risk over time. Done properly, a high quality colonoscopy can really reduce your colon cancer risk in excess of 90 plus percent, and that protection can last you 10 to 12 years based on the available data that we have. So the maximum interval that we typically set between colonoscopies is no greater than 10 years for patients who have no family history.

But we do see patients at shorter intervals depending on their family history, their personal history, and otherwise in order to match and tailor their needs to their screening protocols. At this point really, colon cancer prevention has started, is now starting, I should say at age 45. We previously started at age 50. And part of the reason is that we're seeing earlier onset of colon cancer, in general. And part of the effort is really to reduce the likelihood of ever diagnosing a patient with cancer altogether. We do have to remember that the goal of colonoscopy is actually not cancer detection as much as it is cancer prevention.

So a colonoscopy, done carefully and properly will really impact your health in a major way for a solid 10 years. What we're looking for are precancerous growths that produce no symptoms. You have no particular idea that anything might be going on inside and left alone over time, those growths or polyps can develop potentially into cancers.

To give you an idea, we see pre-cancerous polyps in roughly a half of the colonoscopies that we do. The standard sort of from our professional societies is that we should be detecting these in about a quarter or so, and we're going to be talking about this a little later, I think. But it's really critical that we improve as much as possible, the ways in which we look for these polyps. Another aspect of high quality colonoscopy is really making sure that you're using the newest technologies, the newest equipment available. So think of your phone or your TV at home.

The imaging has improved. In the same way it's definitely affected medical technologies and our own tools that we use on a daily basis. So if we're using tools that are out of date, then we're correspondingly going to get poorer quality images and not be finding as many things. Really more than anything is the emphasis of prevention that is over detection by looking for things very carefully.

That means that what should you expect when you're signing up for a colonoscopy? So, you're expecting an exam that's roughly 15 to 30 minutes long, you're sound asleep, you're perfectly comfortable and basically unaware of what's going on during the procedure, which is exactly the way we like it because we need the endoscopist, the clinician to be focused entirely on your exam, on the quality of your exam, on taking their time and not being otherwise distracted so that they can really do a good job in terms of the cancer prevention aspect of the exam. The other positive thing that comes out of this is that you get results immediately. So there's no wondering, there's no mystery to what's going on.

When you wake up, typically, your gastroenterologist will let you know right away what they found. Perhaps even show you pictures if you're interested of the findings. And it's really important that the team that's involved in taking care of you for your colonoscopy is a cohesive and well-trained team.

And so, I, I have to say that really at Holy Cross, we're blessed with an amazing team of nurses, of technicians, of nursing leaders that really are dedicated to what it is that they do in gastroenterology for many years already. And it shows in their work and every patient interaction. So that's something that's really also really important to us.

Host: And how does withdrawal time during a colonoscopy impact the overall effectiveness of the procedure in detecting adenomas and malignant polyps?

Patrick Amar, MD: So I see you've done your homework. Withdrawal time is really important. It's one of these little spoken aspects of the colonoscopy that probably are one of the most critical. When we do a colonoscopy, there's sort of vaguely two parts. We're putting the camera in to get to the very beginning of the colon, and then we're pulling the camera out slowly to look at as many surfaces as we can of the entirety of the colon.

Now the colon is not flat, it's not linear, it's sort of got folds and twists and so on. So it's really important to look over, behind, under and really explore every angle, so that we can really improve the likelihood of finding those precancerous growths or polyps. If you rush that portion of the exam, then you're really sacrificing the quality of cancer prevention that you're getting. Many studies have essentially shown us that if we are taking a minimum of six plus minutes, we're doing, that's sort of the threshold for doing an adequate job for cancer prevention, in terms of polyp detection.

And some of the newer studies are actually even suggesting eight minutes plus for average withdrawal time. So as clinicians, as we're doing the procedure, we sort of have an awareness of what that time might be as it's moving along during the exam. If we're not sure, we can turn to our technician and ask them, what's the withdrawal time currently? 

Did we go a little too quickly? And if we're getting a sense that the exam was very easy and so on, we might take another quick look at everything just to make sure that we satisfy the withdrawal time and also that more than anything, that we have a good sense that we're at peace with the quality exam.

Host: Dr. Amar, why is adenoma detection rate or ADR considered a critical quality indicator in colon cancer screening and how can it influence the patient's outcome?

Patrick Amar, MD: Sure. So if the main portion of the colonoscopy, the main intent is to look for these colon polyps or adenomas, you have to imagine that the more adenomas that you're finding in more patients, the higher likelihood that you're doing an effective job in terms of cancer prevention. So, to give you an idea, adenoma detection rate really varies very widely.

Unfortunately at the low end you might find some reports of ADRs in the range of eight to 10%. On the high end, ADRs of 50 plus percent may be up to two thirds of colonoscopies. So that means that if you take a hundred patients, you really want to be detecting polyps on as many of those patients as you reasonably can.

And the science seems to back up that probably a third to two thirds of patients who come for colonoscopy without any risk factors, without any symptoms, have precancerous polyps of some sort. And it's our job as gastroenterologists to be looking carefully for those polyps and remove them appropriately to then lower their cancer risk.

So, the higher the adenoma detection rate, the lower the rate of interval cancers as we call them, meaning a cancer that occurs between the time of the colonoscopy that we're doing now, and the time of the next colonoscopy that's recommended. We want to see as few if zero interval cancers. That's really the goal.

And from the patient standpoint, you want to know that if your doctor gave you a five year interval, a 10 year interval, that you can sleep at night and that the doctor can sleep at night knowing that they've done a careful job. The adenoma detection rate really speaks to the quality of the exam and the higher that rate is, the lower the likelihood of having an issue down the road.

Host: What are sessile and flat polyps and why is it so challenging to detect them during a colonoscopy? What advancements, if any, are being made to improve their detection? 

Patrick Amar, MD: Great question. Polyps can be either sort of what we call the pedunculated or sort of mushroom like, so they stick up. They're a little more obvious. I say a little more because they're still challenging to detect, in the first place. But they're typically larger and have a sort of rounded appearance that sticks up from the surface.

A sessile polyp is completely different. It's very flat to the surface, so, what you're looking for are changes in the texture or in the coloration of the lining of the colon. If you have any level of any stool residue, any secretions that reacccumulated, even mucus, you can have a very hard time in evaluating that flatter lining of the colon, and making sure that there's no flat lesions.

In terms of finding those sessile versus pedunculated polyps, we're back first of all at the withdrawal rate that we talked about before, the withdrawal time, which is taking your time and looking carefully is really important. Number two, it's really important that the physician doing the exam is deliberately looking for those types of polyps. Because it's not enough to glance over an area and look for anything that's more obvious, you're looking for subtle textural changes. You're looking for things that are not as plain to the eye. And some of the tools that we have, I use for instance, a technology that's been on the scopes for about 10 years or so called Narrow Band Imaging, which allows us to switch the light filter a little bit on the scope, and these flatter lesions show up a little better on NBI or narrow band imaging than they do with regular white light colonoscopy. So frequently on the withdrawal, we'll be looking with special attention, especially if there's an area that's a little suspect, a little questionable, in terms of whether it's normal or not, we might switch over to that light filter and take another second, or careful look at that area with NBI.

And depending on the characteristics, we can either be reassured and leave something alone or decide that it's something that needs to be looked at more carefully and take out a polyp or a sessile lesion in question. The other thing with sessile polyps, they're actually a little trickier to remove, so.

Because they don't project from the surface, you can't just grab them as easily. You have to sometimes raise them from the surrounding flat surface to sort of create a bubble and to raise them up from the colonic wall. And what that does is it protects the layers of the colon underneath in order to avoid complications from the polyp removal, and also in, in order to fully remove the polyp with some margin of normal tissue around it, to reduce the likelihood of any polyp recurrence.

So those are some of the challenges with sessile polyps. The other thing is that, there's some suggestion that sessile polyps may go through a slightly different pathway in terms of possibly developing into colon cancer as compared to the larger or pedunculated polyps.

Those sessile polyps might have almost a bypass pathway towards a more rapid development of colon cancer, where the pedunculated polyps have a more well described and well understood pathway, that requires sort of multiple genetic alteration that happen over time that then culminate in a possible cancer. Whereas sessile polyps possibly have a little bit of a, of a different pathway for cancer development.

Host: Well, when it comes to colonoscopies, we already know a lot of people avoid them or put them off because of the bowel preparation. It is unpleasant, to say the least, but it is crucial, right? The quality of bowel preparation and the results of the colonoscopy you get. What are the best practices for optimal prep before the procedure?

Patrick Amar, MD: So this is really something that I think patients sometimes don't fully understand, at least coming into a visit for a colonoscopy. And it's really important that the care team in the office really explain this well, because if the colon is not optimally cleaned, you're not finding some of these polyps. They're going to be missed pretty much guaranteed. If there's any stool residue, if there are any areas that are not as clean as they possibly could be.

What happens is that you can actually hide some of these polyps, especially these flatter or sessile polyps. It doesn't take much in terms of any sort of residue to get them to hide or to disappear really. Some of it, some of the best practices, certainly at this point, what's called a split dose bowel preparation.

Meaning you take part of the preparation the evening or the afternoon before the procedure, and you take the second portion or the remaining portion of the prep, usually a few hours before your scheduled arrival time for the colonoscopy. And that essentially gives you two bowel cleansings. It gives you, sort of a major flush the day before. You rid of all the solid stool, et cetera. And then the following day, when you're doing that second portion of the prep, what you're really doing is you're maximizing the likelihood that any polyps might be found. So that second flush is critically important in terms of making sure that every surface is as clean as possible.

Once you've done your job as a patient, what we try to do as clinicians is if there's any areas that need any, we'll say touch-ups or anything like that, we can irrigate, we can clean up at the time of the colonoscopy, but to a limited extent. Because we can only clean up anything that is not too troublesome. And as long as we work in tandem with that, the patients maximize their prep and then the clinician completes any gaps, then we can do a great job in terms of cancer prevention for patients.

Host: What if you have a weak stomach and you can't keep that stuff you have to drink down?

Patrick Amar, MD: Some of the preps, I should say, have improved a great deal. So it used to be that patients would drink a gallon of preparation that was just horrible the whole way through. And that was really standard of practice, probably 15 years or so ago plus. We're actually in a, in a situation where there's actually a great deal of different preparations that are currently available that are lower volume preps. At this point, most preps are 10 to 16 ounces of actual medication with perhaps a few cup fulls of water afterwards. So you do that the evening before you do that, the morning of. You're really talking about drinking

one to two cups of medication and you can sip that. It doesn't need to be rushed. As I tell patients, it's really not a race to the finish line. You want to just get the medication down slowly and at your own pace. And as long as you do that, and if you need a little more time to let your stomach settle, then that's perfectly fine.

Take an extra hour, take an extra two hours. It really doesn't matter. It's more important to get it down and keep it down obviously. So we see a lot less in the way of any GI upset, than we used to with the larger volume preparations.

Host: What do you recommend to patients like MiraLax or, or can you say?

Patrick Amar, MD: Yeah, I'll be honest, the preparations are mostly equivalent at this point. There's a number of low volume preps. There's CLENPIQ and SUPREP and Plenvu among others, and that are all very well tolerated and that are lower volume. And really what we're comparing to is to GoLYTELY, the gallon that patients used to drink, which was a lot more difficult.

There's a pill option which is available. Sometimes, we select patients a little bit for that because it can cause a little bit of gi upset or irritation for some patients. But the overall theme is that really the lower volume prep and the divided preparation schedule is really key in terms of maximizing the effectiveness and the quality of the preparation.

Host: So what are the latest advancements in non-invasive colon cancer screening methods? How do they compare to traditional colonoscopy?

Patrick Amar, MD: Sure. So you've probably seen advertised on TV or otherwise, stool-based options like Cologuard, where you can sort of mail in a test and then get a response, through the mail or otherwise. That's one option. Other options, which actually are even newer, are blood tests that look for alterations in DNA of either what's called circulating tumor DNA, or, methylated DNA, that are looking for possible colon cancer.

But it's important to point out that these tests are, they're good at finding colon cancer that's already existing. They're not nearly as good in finding or predicting the likelihood of colon polyps that are currently there that have not turned into something more serious. When we talk about colonoscopy, we're talking about

the detection of precancerous polyps and nobody wants to have any diagnosis of cancer, obviously. The other tests that are currently available are excellent at finding existing cancer, but come up much shorter in terms of identifying existing pre-cancerous polyps.

That gap is really important in terms of patient care. Because we want to be more in prevention mode than we want to be in detection mode. The other aspect that's important for patients to note, and for ordering physicians if they're ordering some of these tests, sometimes when an abnormality is detected on one of these alternative noninvasive tests, for instance Cologuard, if that then triggers a colonoscopy appropriately afterwards, that can sometimes fall under what's called a diagnostic colonoscopy as opposed to a screening or preventive colonoscopy. The financial impact for the patient can sometimes be important because that can be covered differently by insurance carriers versus a screening or preventative test, which should be fully covered by their insurance.

I think these are all really exciting and upcoming technologies that still have a lot of room for continued improvement and development. And I think it'll be a great option, hopefully, as they continue to improve some of these DNA based tests, to give patients a non-invasive option instead of colonoscopy.

But I think the science still needs to improve and further progress before we can rely on them properly for cancer prevention rather than detection.

Host: I'm still waiting for that day when we don't have to drink anything.

Patrick Amar, MD: Yeah.

Host: Thank you so much for sharing your expertise on this very important topic that affects everybody.

Patrick Amar, MD: Maggie, thank you so much for taking the interest and taking the time to speak with me today. I hope that today's podcast encourages people to have the courage to speak with a gastroenterologist and to talk about the benefits of possible colonoscopy for them, in order to reduce their cancer risk in the future.

Host: Absolutely. Isn't it one of the most preventable cancers if you stay on top of it?

Patrick Amar, MD: It it is one of the most preventable cancers. It's, and it's number three, in terms of cancer death for both men and women. And when you're talking about a 90, you know, a 70 to 90% risk reduction in colon cancer, that can last you a decade, that's a very big impact. So it's worth the trouble, the inconvenience of the preparation, of taking the day off of work, in order to have the exam, to then have that peace of mind for five to 10 years.

Host: So true. Thank you again. Again, that's Dr. Patrick Amar. And if you'd like to find out more, please visit holycross.com/drAmar A-M-A-R. If you found this podcast helpful, please share it on your social channels. And check out our entire podcast library for topics of interest to you, Thanks for listening to Thrive With Holy Cross Health, presented by Holy Cross Health in Fort Lauderdale, Florida.