Michael Smith, MD (Host): Meaningful Medicine is a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today I'm sitting down with Dr. Whiyie Sang, and we're going to be talking about colon cancer.

You know, before we get started, why did you choose to become a colorectal cancer surgeon? Like, what, motivated you to go down that path?

Dr. Whiyie Sang: You know, it's interesting. First, once you get to medical school, you got to figure out, first you have to go through everything, see what you want to do. I knew from the beginning I wanted to do something procedure based, so that led me to general surgery. But everything pretty much goes down to your initial interest is on your mentor.

So I had a lot of mentors that were colorectal surgeons, and they kind of showed me the way. And then once I started looking, you know, behind the scenes, it seemed like a very rewarding subspecialty. So you get to deal with things like benign disease, like hemorrhoids and cancer, like colon cancer, rectal cancer, anal cancer.

And then you could do things like screenings, which is the whole point of what we're going to talk about today, colonoscopies.

Host: That's really cool. You know, I've been seeing, and everybody has been seeing in the headlines recently, that colon cancer rates seem to be increasing in younger people. What's going on there? What's your take on that?

Dr. Whiyie Sang: The answer will surprise a lot of people and the answer is, we don't know. It's scary how much younger the patients that we're seeing that we need to do cancer operations to remove their cancers. I've done operations on people's in their 20s and 30s and 40s to remove colon cancer. And we just don't know. The research is still out.

We're still looking into it. There's things that we can theorize. Potentially diet has to be a big thing about it, genetic predisposition, the environment. We're doing a lot of research now into something called the microbiome and that's just a fancy way of saying the type of bacteria that lives inside your gut and so that can potentially predispose you to cancer. So we're waiting and finding out.

Host: Something's going on, right? Lifestyle, diet, microbiome. I remember being in medical school years and years ago, probably way before you, Dr. Sang, and I mean, colon cancer wasn't heard of until you were in your sixties, mainly, and it was like, things have changed so much. So I'm glad that we're looking into that.

With those kinds of trends in mind, obviously prevention we have to talk about that, right? Let's start with diet. The standard American diet is not great, as you know. What do we feel about that and how important is that for people to really get serious about changing in their lives?

Dr. Whiyie Sang: Diet's very important. It's one of those things that has really changed, going from baby boomers to Gen X and millennials and, we're consuming more red meat, we're consuming more processed foods. So these are things that we think that might be leading to this higher incidence of colorectal cancer.

 So trying to control for that, eating more fruits and vegetables, eating more fiber. These are things that we kind of try to preach in the office of things that we can try to do to just overall have a healthy lifestyle.

Host: Yeah. I mean, we've been saying that for so long. Does the message have to change a little bit Dr. Sang, cause you know, as physicians, we've been telling people exercise more, eat better, get your vegetables, get your fruit. A lot of that doesn't seem to be impacting the average American too much, or the average person so much.

Do you have any ideas of how to better message that? Like eating more of the leafy greens. Like, do we need to be more specific and offer recipes or what do you think?

Dr. Whiyie Sang: That could be a good approach. A lot of it has to do with a lot of public health initiatives. So they do a good job of this in Europe that, you know, a lot of people, you know, eat more fiber and the Mediterranean diet is very common. And, those kinds of public health interventions are very important. Potentially teaching it at an early age in school. So that's, possibly something that can help with the behavioral change.

Host: Yeah, I think you're on to something there. Speaking to people younger, getting people better eating habits, right at a younger age. What are the risk factors should we be talking about though with colon cancer?

Dr. Whiyie Sang: So we talked about diet. Another big one is sedentary lifestyle. So in general making sure the general recommendations that every primary physician talks to patients be at moderate exercise most days of the week that's also very important. The other thing obviously we talked about is early screening and just watching out for the warning signs.

Cause there's some factors that you just can't control for. So genetics, things you're inherited with, you're born with, you can't really control for those things. You just have to be able to know what the signs are. And, when you do, then you seek medical attention or you ask your primary doctor, Hey, this is happening. Is this normal? No. Then maybe I should get checked out.

Host: Yeah. We're going to get into some of the signs and symptoms and stuff of early colon cancer. Before we do that, though, if somebody is at, you know, based on the risk factors, we know genetic, et cetera, if somebody is kind of at higher risk, though, aren't some of these lifestyle changes, some of the dietary changes, getting more, those can still help everyone, right?

Dr. Whiyie Sang: Absolutely. I agree with that.

Host: So regardless of where you fall into that risk category, eat well and exercise, right? I mean, that's, that's kind of a key thing in life in general, I think, right? Doesn't really matter if we're talking about colon cancer, heart disease, what have you. So colon cancer may not present with symptoms, correct? And if that's the case, screening, right? How important is that?

Dr. Whiyie Sang: Screening is absolutely very important, and it's an initiative that we've been trying to push for for a very long time. Our colorectal society, the ASCRS, in conjunction with all these other preventative task forces, we've been trying to push for screening and expanding what is considered an acceptable screening methodology, not just colonoscopies, we can talk about the different methods, but none of them, are better than colonoscopies.

Host: That's still the gold standard without a doubt. I've spoken to a lot of other colorectal surgeons in the past and stuff. And do you agree that one of the best things about colonoscopy is that you can also treat right there. Like, you can see a polyp and you can get rid of it right there and send it to pathology. Doesn't that make that a better preventative screening tool than pretty much anything else?

Dr. Whiyie Sang: And that's why it's still the gold standard. So the beauty about colonoscopy is that you can catch a polyp when it's small, tiny, years away from it ever becoming a cancer, and then just throw it in the garbage. So you grab it, you remove it, and you, toss it away. So that's the whole point of colon cancer screening. You get these things before they become a cancer. And then you have to go down the road of surgery and potentially having to do chemotherapy and stuff. So prevention's always the key.

Host: So much easier, right? On everybody, across the board. What age should we start screening?

Dr. Whiyie Sang: So recently we changed screening recommendations to 45 for average risk individuals. Average risk meaning no family history of colon cancer, no genetic predisposition, anything like that. So 45 is when you should have it done.

Host: So that's no matter what, doesn't matter risk, doesn't matter family, whatever, doesn't matter lifestyle. So, 45 is now that new age. I think that's an important message, because for a long time, we were saying, what was it, in your, 50, right, or, yeah. So that's an important change, and do you believe that's going to help to maybe catch some of these younger people, maybe, with colon cancer as well?

Dr. Whiyie Sang: It will, but I have a feeling that they might be changing the age recommendations to much younger, so we'll just have to wait and see.

Host: Yeah, well, I think that's a good point, right, if younger people are getting it, as you mentioned, you've seen 20s, 30s. So maybe it is earlier, right? We, I guess we have to see how that all plays out. A lot of people, Dr. Sang, I gotta say it; a lot of people are opting out for colonoscopies and they want these in home tests. There's a lot of different ones out there. You've got your stool analysis ones. You, we don't need to go into the details. Where does all this fit? Is it okay to get a baseline colonoscopy and then maybe do some of these in home things? What do you feel about that?

Dr. Whiyie Sang: It all falls under the category of acceptable methods of screening. So, we can't ignore the fact that colonoscopy is the number one, the gold standard for screening, right? But, we're really only catching 50, 60, if you're optimistic, maybe 70 percent of people are getting colonoscopies. So what happens to the other 30? The other 40 percent that they're too afraid or they don't want to. So that's where these other alternative screening methods come into play. There's a famous brand name one that basically it's you take a stool sample at home, you send it in the mail and they check for DNA of potentially cancer in your stool.

Whenever you have it done or what your primary doctor will tell you is that if it's positive, you still have to go back and do a colonoscopy because you have to see why is it positive in the first place? The problem with some of these stool studies is that there can be as high as a 30 percent false positive rate.

There can even be, I forget the exact number, but it's around the twenties of a false negative rate. So you might not be capturing all the cancers that are potentially that you have with the stool based study.

Also these stool based studies, they don't catch polyps when they form.

So you might still have a big old polyp and which you would have caught in a colonoscopy, but

Host: Yeah. I was just going to bring that up. We just mentioned, colonoscopy is great because you, you can see the polyp right there in real time and remove it. So going back to colonoscopies which is the gold standard. Start at 45. A lot of people get nervous about all this. Can you walk us through, and again no, no major details, just the steps in getting a colonoscopy from prep to the end. Give us a picture of what that looks like for people.

Dr. Whiyie Sang: Yeah. So when someone comes to my office to get a screening colonoscopy done, this is the exact conversation that we have. So I give you a handout. And it gives you basically the instructions of things to do leading up to the procedure. So, for example, the week before, you shouldn't take, for example, the weight loss drugs, Ozempic, and things like that, because that can mess with your digestion.

We tell you don't take certain blood thinners if you do take that before a certain period amount of time. The prep is where people get a little bit uncomfortable. Well, that's the toughest part. But, it's absolutely important because we want to make sure your system is cleared so that we can see everything.

There's different ways of clearing your colon. The most common one that we use is called Miralax. It's the same one that you get over the counter, but you just take a bigger dose. There's other types of preps that you can also do. There's some pills, there's some that are just powders. But essentially you're taking that the day before your colonoscopy.

And on the day before your colonoscopy, you're also just drinking clear liquids. So that way you're not starving, you're drinking, you're staying hydrated. It's very important to stay hydrated because you can, you know, with the prep, you could potentially get dehydrated, pretty much. You can drink liquids up to two hours before you come for your procedure.

They put an IV, they put you to sleep, and then we go ahead and do the colonoscopy.

Host: Now during that phase where they're just drinking liquids, they still take their medications, right? That doesn't stop.

Dr. Whiyie Sang: Yup. Depends on the medication, but overall, yes.

Host: Yeah, you're right. You mentioned like there may be a few that you would recommend, but in most cases you still take your blood pressure stuff. You still take, all of that. Dr. Sang, I think you hit on something there. The prep, I think, is what most people are scared of.

Dr. Whiyie Sang: Yeah.

Host: Cause we've, you know, people hear kind of horror stories sometimes online and what have you. Overall though, hasn't, hasn't the prep for a colonoscopy gotten better? It's not quite as rough. It's not quite as bad. What do you think about that?

Dr. Whiyie Sang: I think it's gotten better and, there are these new drug companies that come up with easier, better ways to people to tolerate it. Before we used to there used to be this thing called Go LYTELY. We still use it sometimes. And it's this big four gallon bucket of water, essentially, that we have you drink and clear everything. At least with the Miralax, it's just 230 grams. So like the medium to large pot of Miralax, you mix it with, with a big Gatorade bottle and you drink it throughout the day. There's other brands that you just take a couple of pills.

It's all to keep in mind the person taking it and so that they can tolerate it and be as smooth as possible, potentially.

Host: So this is great. Great conversation on risk. Interesting about younger people. You know, we talked about screening. When it comes to symptoms what are some of the symptoms you would like people to be aware of that they may want to go talk to their doctor about?

Dr. Whiyie Sang: Yeah. So number one is blood in your stool is never normal, okay? So if you see that you have blood in your stool, then that should raise some red flies and you should see your doctor. Can you have blood in your stool with other things? Absolutely, but that's why you gotta get checked. Hemorrhoids can cause blood in your stool. Other things can cause blood in your stool. Belly pain that doesn't go away, that's not normal. Weight loss that's unintentional. So if you're not on a diet or you're not exercising normally or maybe more than usual, and you're losing all this weight, that's also a red flag.

Host: Fantastic information. Dr. Sang, just to kind of summarize for the audience, is there any key takeaway that you would like us to know about colon cancer, screening, treatment, whatever you want to leave us with?

Dr. Whiyie Sang: I think the number one thing people should take away is one is get screened, But two, listen to your own body. Everyone tells me, I know my body. Of course you do. So you can tell when something's not right. So when it's not, then go and get checked out by your doctor. Because that's how we catch the folks in their 20s and 30s when something's not right.

Host: Yeah. I love that Dr. Sang. Cause people do know, right? We kind of know like something feels wrong, right? They're like, we kind of know that in our own self. So that's great. I think that's wonderful advice. Hey, Dr. Sang, great job. Thank you for coming on the show today and having our conversation. It was great.

Dr. Whiyie Sang: Absolutely.

Michael Smith, MD (Host): To find a physician, visit NovantHealth.org or for more health and wellness information from our experts, you can visit healthyheadlines.org. I'm Dr. Mike. Thanks for listening.