Bill Klaproth (Host): Colon cancer is a rising threat, but with proper screening, colon cancer is one of the most preventable cancers. So let's learn more about colon cancer, diagnosis, treatment, and prevention with Dr. Sean Maroney, a colon and rectal surgeon at MarinHealth General and Colorectal Surgery, a UCSF Health Clinic. This is the Healing Podcast brought to you by MarinHealth. I'm Bill Klaproth. Dr. Maroney, welcome!

Sean Maroney, MD: Bill. Great to be here.

Host: Thank you, Dr. Maroney. Before we get started, could you give us a bit of brief background on yourself?

Sean Maroney, MD: Okay. Sounds good. So, I did my undergraduate degree at the University of Albany in New York, and then I obtained my medical degree in Syracuse, New York. Then I was in the military for five years as a flight surgeon prior to finishing my general surgery training in Loma Linda, California.

And then I went on to complete a fellowship in colon and rectal surgery at the Ohio State [00:01:00] University in Columbus, Ohio. I practiced in Boston for a few years, with my wife, who's also a trauma surgeon. And then we moved our family out here, in January of this year. And she's currently a trauma surgeon at Marin General as well.

Host: Wow, you are very well traveled, Dr. Maroney. That's quite a journey.

Sean Maroney, MD: Yeah, it's kind of been all over the place, but we are happy to be back home. She was born and raised at MarinHealth at Marin General, so we're happy to be back.

Host: Oh, how about that? I love that. Oh, what a great story. Well, we are happy to have you here for sure. So we're talking about colon cancer on this podcast. So Dr. Maroney, can you explain to us just to start off what colon cancer is and how it develops?

Sean Maroney, MD: Yes, of course. So, colon cancer is simply when cells in the superficial layer of the colon undergo a genetic mutation that causes them to multiply. And this is uncontrolled cell growth, and then when those tumors invade healthy tissue, that is when it begins to spread to other [00:02:00] parts of the body, and that's where it can cause problems. So that's what colon cancer is.

Host: And I know colon cancer is sometimes called one of the silent killers because most people don't really know they have it, but can you talk about the common signs and symptoms of colon cancer that people should look out for?

Sean Maroney, MD: Right, you are exactly correct. So, the most common presentation is no symptoms at all, or what we call asymptomatic. So, we catch a majority of colon cancers through screening colonoscopies which by definition, a screening test is done when the patient is having no symptoms. However, if the cancer grows very large, the symptoms that we typically see are blockage or obstruction, difficulty eating, weight loss, blood in the stool, and then also a change in the caliper in the stool.

If there's a partial blockage, then the stool can be thinner. We call it pencil, pencil stools, and this can indicate a partial blockage, and that's a sign that there can be problems and you need to get a colonoscopy.

Host: So, that's really important what you said there. There are [00:03:00] some signs and symptoms, and if you are experiencing any of those symptoms, it's good to get that checked out right away. Isn't that right, Dr. Maroney?

Sean Maroney, MD: Absolutely, yes.

Host: Colon cancer is, if caught early, one of the most preventable cancers, too. Is that right?

Sean Maroney, MD: Yes, absolutely. Well, preventable, meaning you have a cancer diagnosis, but it's very treatable. If it's caught early, we typically can do a segmental resection of the colon, which means you take a piece out, sew everything back together, and you can move on with your life relatively quickly.

Host: Which is really important. So who is most at risk then? Are there specific risk factors such as age or family history that can increase the likelihood of developing colon cancer?

Sean Maroney, MD: Yes, you've kind of hit on those top two are the most important. So as you get older, the chance of colon cancer diagnosis increases and also if you have a strong family history. So if anybody in your family has had a colon cancer diagnosis, then you need to be, our current guidelines are that the screening colonoscopies need to begin 10 years [00:04:00] before that age.

So if you had a family member that was diagnosed at 55, then you would, our recommendation is that you would get a colonoscopy at 45.

Host: Got it. So age and family history are things we need to watch out for. Then how is colon cancer diagnosed?

Sean Maroney, MD: So the most common diagnosis is during a colonoscopy, but I also see patients probably once a week or so that present to the emergency room with bleeding or obstruction. And then I occasionally see patients in clinic that are referred for hemorrhoids or rectal bleeding. And most of the time they're blaming their hemorrhoids, but when I do an exam, I can actually see or feel a cancer on the anoscopy exam. So if you're having any of those symptoms, it's definitely important to not ignore them and to either see your primary care doctor or see a subspecialist.

Host: And Dr. Maroney, colorectal cancer is on the rise among young adults, I'm reading. Can you discuss this trend and what might be causing it? What is the age now we should think about starting to get our first [00:05:00] colonoscopy? I had always been told when you hit 50, it's time to get that first colonoscopy. Has that changed?

Sean Maroney, MD: Oh yes, that's a relatively recent change. So there was a study done by the American Cancer Society in January of this year that shows us that colorectal cancer is now the primary cause of cancer related death among males under 50 years old and the second leading cause of cancer related death in females in the same age group.

Our guess as to why this is happening is that there's an astronomic increase in obesity rates over the last 20 or 30 years in combination with a low fiber diet. Those two things together have made the incidence of colorectal cancer increase over time. They've changed the guidelines. So the U. S. Preventative Services Task Force and the current recommendations are to start screening colonoscopies at age 45 in all Americans, both females and males, and that's a relatively new guideline.

Host: Right. So, when we talk about the screening process, can you walk us through that [00:06:00] and what that entails?

Sean Maroney, MD: The screening process is typically what we recommend in the national guidelines is the colonoscopy exam. So, you have to call your primary care doctor or a GI doctor or colorectal surgeon. And then they will set you up with an appointment and then we'll go over the details of how the test actually works.

And we're, again, we're starting that at age 45, which is new. The other question I get a lot is if you're over age 75 or 80 do we ever stop doing colonoscopies as you get older? It's a little bit of a case by case basis, but in general, the life expectancy in the United States is now 75 for males and 80 for females.

So once you get over that 80 year old mark, we typically don't recommend screening colonoscopies and you only get a colonoscopy if you're having symptoms.

Host: So, Dr. Maroney, can you talk about the new SHIELD blood test and can you speak to its efficacy and whether you see this becoming a standard part of the screening process?

Sean Maroney, MD: That's a great question. [00:07:00] Unfortunately, despite our best efforts and outstanding primary care physicians, about 30 percent of Americans will never undergo a colonoscopy. So there are multiple tests available that aren't quite as good as the colonoscopy, but it's a good alternative in this patient population and somebody who's never going to get a colonoscopy.

The FDA approved a blood test in July of this year, which is kind of the holy grail for screening tests, is if you can find a good test that is only a blood test and you don't have to undergo a big procedure, then that would be ideal. However, the specificity for this test and sensitivity is around 83%.

That means if you have cancer today, and I test your blood with this test, it's going to miss around 17 percent of cancer, which gives you a false sense of security if you do receive a negative test result. The other downside is that the test is not good for polyps or advanced adenomas, which are considered pre cancer.

So another great reason to undergo a colonoscopy is not necessarily to detect or diagnose cancer, but to [00:08:00] find these pre cancerous polyps and then we can remove them during the colonoscopy and that prevents these polyps from turning into cancer down the road.

Host: So the new SHIELD blood test really is aimed at the 30 percent of people that just will not get a colonoscopy. Is that right?

Sean Maroney, MD: That's true, yeah, so there's, we're still working on education as this is, it's tempting to just give everybody this test and stop doing colonoscopies but, the test is not quite good enough for us to do that yet.

Host: Right. And the colonoscopy, seriously, is the gold standard of screening. Is it not?

Sean Maroney, MD: Yeah, correct, so the colonoscopy misses less than one percent of cancers as opposed to this this blood test which misses about 17 percent of cancers.

Host: All right. So I've had a colonoscopy. I'm of the age. Okay.

Sean Maroney, MD: Great.

Host: Like many people.

Sean Maroney, MD: Good. Yeah. Tell your friends.

Host: It's not that bad. Right. Yeah, right. Listen, for anybody listening to this podcast, like, I don't know. I've heard the prep is really bad. Just get it done. It's not bad at all. It's really easy. And it is the gold standard, like Dr. Maroney said. Just get the colonoscopy, but I [00:09:00] guess the new SHIELD blood test is better than nothing, in this instance, I guess you could say that about it.

Sean Maroney, MD: Correct. Yes.

Host: Yeah. Let's talk about the different stages of colon cancer. So, can you explain those different stages and how they affect the progression and treatment of the disease?

Sean Maroney, MD: Colon cancer is divided into four stages. The first two are stage one and stage two, where the cancer is invading into the wall of the colon. And that's typically treated by only surgery. So no other treatment. The surgery alone is considered curative. If the cancer has spread to the lymph nodes, that upstages it to stage three, and then the patient would typically undergo chemotherapy after the tumor is removed in the operating room.

The final stage is stage four disease, which by definition, it means that the cancer has spread to other organs, which is typically the liver or the lungs, or the bone, or the brain. Some of these cancers still can potentially be curable if it's only one spot and we [00:10:00] can take that spot out during the surgery to remove the colon cancer.

But typically in stage four disease, we typically focus on quality of life and regression rather than cure.

Host: Right. So, then, what are the standard treatment options for colon cancer and how might treatment differ based on the different stages that you just described.

Sean Maroney, MD: So the standard treatment for colon cancer most of the time is still surgery. So regarding the surgery for colon cancer, I do all of these surgeries robotically, which means that it's laparoscopic with a robot assistant, meaning there's very small incisions, less pain, less time off of work. Most patients are out of the hospital in one to two days and back to work within one to two weeks.

If the cancer is caught very early, most likely surgery is the only recommended treatment and the cure rates are very high. There is some controversy regarding stage 4 disease, if surgery is beneficial in this group. So we take that on a case by case basis and [00:11:00] individualize the treatment and have a multidisciplinary discussion with the chemotherapy doctors and the radiation doctors and the pathologists.

Host: Now, I know this depends on the stages, but I'm just curious how successful are the current treatments in curing or managing colon cancer, and what are the survival rates?

Sean Maroney, MD: Great question. So we break the data down into something called a five year survival rate. This means that for each patient, what is the chance they will be alive at the five year mark after the diagnosis of cancer? So for stage one disease, survival rates are very high, around 90 percent at five years.

For stage two, it's similar, around 80%. That's why it's so important to catch these cancers early, is because stage three cancers, meaning once it spreads to the lymph nodes, the survival rate drops to 60%, and then stage four, survival rates are typically 15 to 20 percent in five years.

Host: Wow. Yeah, you're absolutely right. If you can catch these early or catch 'em with that colonoscopy, that [00:12:00] is the best. So in terms of prevention, are there any specific lifestyle changes that can help reduce the risk of colon cancer?

Sean Maroney, MD: Yes, definitely. So, obesity is a big risk factor, sedentary lifestyle, cigarettes, alcohol. Eating a healthy diet, high fiber diet, fresh fruits, fresh vegetables, whole grains. Avoiding processed red meat and avoiding high nitrate meats also can decrease the risk of cancer. So maintaining a healthy weight and avoiding cigarettes and then lastly, there is some literature on a baby aspirin or is a anti inflammatory which will decrease your lifetime risk of developing colon cancer, but there are risks with taking a baby aspirin. So the current guidelines don't recommend that in everybody. So we can't add that specific recommendation to our national guidelines.

Host: Yeah, so it sounds like the things we've heard pretty much our whole life about eating healthy, right? Just to what you eat, eat healthy, exercise, don't smoke, those [00:13:00] types of things will cut your risk of colon cancer. Is that right?

Sean Maroney, MD: That's correct. Yep. And then also constipation. So Americans in general don't poop as often as other countries. So it has to do with a low fiber diet. So if you're pooping once a week, if you can increase your fiber intake, or if you can potentially even taking a minor laxative and getting you a poop in once a day or once every two days, that's going to decrease your risk of colon cancer as well.

Host: Yeah, that's a great tip. There's one simple thing you can do is increase your fiber intake. Besides trying to eat healthy and not smoking and, reduce alcohol, those types of things, that's, that's a great tip is to increase your fiber intake. So thank you for that, Dr. Maroney. Before we wrap up, is there anything else you'd like to share or wish more people knew about colon cancer that we don't or what people should ask you and they don't?

Sean Maroney, MD: Yes. So this has been a very good in depth discussion. Thank you for having me on the podcast today. Colon cancer is still the second leading cause of cancer death in the United States. So anything that we can do [00:14:00] as physicians and get the information out there to raise awareness about the diagnosis is greatly appreciated and super important. So call your primary care physician, discuss getting a referral for a colonoscopy. My office and most GI physician offices will take self referrals for colonoscopies as well. And thanks to the Affordable Care Act passed a few years ago, all colonoscopy screening is required to be 100 percent covered by insurance. So there's no co pay, no deductible. So you don't really have any excuse to avoid a screening exam.

Host: Yeah, and as I said before, just do it. It's easy. It's not that bad. People freak out about the prep. Oh, I gotta do this. It's not that bad. It's really

Sean Maroney, MD: Yeah. And it's, and it's got a very high cure rate. So it's one of the cancers that we can cure surgically, but only if it's caught early.

Host: Yes, and the good thing is if there's nothing in there, the best is when you wake up, you feel great, and the doctor goes, hey, you look great. See you in ten.

Sean Maroney, MD: 10 years. Yeah.

Host: That's a great feeling. Hey, see you in 10. Thank you. I mean, that is a [00:15:00] great feeling.

Sean Maroney, MD: It's still 10 years. Yeah. Everything, the cancer grows so slow and it just takes a long time spread. So we still are recommending a 10 year colonoscopy. So if you, if it's totally normal and there's no polyps, then you only have to do it once every 10 years.

Host: Yeah. And if there is a polyp, you will diagnose it and find out what it is. Most are benign. Okay. See you in a, I don't know what it is, Doctor 5 or 3, we're going to do it every three years, but at least then, you know, hey, I got to get checked more often, right?

Sean Maroney, MD: Yeah, exactly. Yeah. It depends on the type of polyp. It depends on the pathology and the number of polyps. And that determines our recommendations for the repeat colonoscopy. So anywhere between three years or five years or seven years.

Host: Yeah, so hey, I'm glad you caught it. You snipped them out great. Okay, now I know. I got to come back in three years. That's better than saying, sir, you have cancer or ma'am, you have cancer. I'll see you in three is a lot better than you have cancer.

Sean Maroney, MD: Yeah, absolutely.

Bill Klaproth (Host): You want to hear see you in three or see you in five or see you in 10 other than, come back to my office. You have cancer. [00:16:00] That you don't want to hear.

Dr. Maroney, thank you. This is really an important discussion, and, again, we urge everybody, go get the colonoscopy. Just go get it, really. So, it's not that bad. Dr.

Maroney, thank you for your time. We appreciate it.

Sean Maroney, MD: Appreciate it. Thank you so much, Bill.

Host: And once again, that is Dr. Sean Maroney. And to schedule an appointment with Dr. Maroney, and again, please do, all you have to do is call MarinHealth General and Colorectal Surgery, a UCSF Health Clinic at 415-924-2515, that's 415-924-2515, and to learn more about MarinHealth, visit MyMarinHealth.org. And if you found this podcast helpful, and I hope that you did, please share it on your social channels and spread the word, and check out the full podcast library for topics of interest to you.

This is The Healing Podcast, brought to you by MarinHealth. Thanks for listening.