Jaime Lewis (Host): Discovering you have colorectal cancer is understandably overwhelming, but learning the facts about a diagnosis can help empower patients to invest in their own care. Today on the Flourish podcast, we're talking with Dr. Ahmad Aulakh, a colorectal surgeon with Prisma Health who will provide expertise and insight into topics like screening, treating, and recovering from colorectal cancer to help you navigate the complexities of the journey.

 This is Flourish, a podcast from Prisma Health. I'm Jamie Lewis. Dr. Aulakh, welcome to the podcast.

Dr Ahmad Aulakh: Hi there. Thank you for having me.

Host: Of course. I want to start at the beginning with screening. What does it mean to find a polyp during a colonoscopy? Is that the same thing as a tumor?

Dr Ahmad Aulakh: Screening colonoscopies are important. I first want to emphasize that everyone above the age of 45 should undergo screening colonoscopies. And that age has recently been changed to 45 from 50 previously, and it's because we keep finding cancer in younger and younger patients, and hence why the age has to be changed, and now we're at 45. And the reason we do these colonoscopies is because colonoscopies are both diagnostic and therapeutic for patients who have polyps. So when you find a polyp and there's multiple different variations of polyps that you may have, and if you remove them, you can prevent colon cancer, hence why they're both diagnostic and therapeutic.

So, a polyp typically starts as a small polyp and it grows. And over the years, it can become invasive into a cancer. So when someone undergoes a colonoscopy, a polyp is found, you have to figure out what type of a polyp it was. It could be just a benign polyp or it could be a pre-malignant or pre-cancer polyp, like an adenoma or tubulovillous adenomas. Those are just different types of polyps. And based on what they are, they can lead to cancer. A polyp is completely different than a tumor. A cancer is something that invades. So, a polyp is not always a cancer. A polyp, if you leave it in there for a while, certain types of polyps will become cancer. So, it is not the same thing. If you have cancer, that's surgery that you need. But if you just have a polyp, you can remove it with just a colonoscopy.

Host: How often is colon cancer found during a regular screening?

Dr Ahmad Aulakh: The answer to that question is a little more involved. There's two societies. There's a colorectal society, and there's also a gastroenterology society. And some of those data are coming from both of those societies. So typically, when a person undergoes a colonoscopy on average, you can find a polyp on a colonoscopy roughly about 30-34% of the time.

The diagnosis of a cancer in that polyp or invasive cancer is somewhere between-- and the range is quite wide-- somewhere between 5-12%. And I think a lot of that is because we are now doing more colonoscopies in a lot more patients and rightfully so, as we are educating the public on how important it is to prevent colon cancer.

Host: Right. The more you screen, the more you see.

Dr Ahmad Aulakh: That's right.

Host: Well, what happens if you find colon cancer?

Dr Ahmad Aulakh: First, I want to differentiate between colon cancer and rectal cancer. Colon cancer and rectal cancer are two completely different entities. So, it's not the same as if someone has a colon cancer that is equivocal to having a rectal cancer. Absolutely not. And that's because the treatment is completely different for both. And that's why first the provider, the doctor has to differentiate between the two and then figure out what the treatment is based on if it's colon cancer versus rectal cancer. So whether it be colon cancer or rectal cancer, if on colonoscopy or on a CT scan or whatever modality we use, we find a cancer in the colon or the rectum, the first thing you want to do is make sure this is cancer by taking a biopsy of it, which you probably had one done with the colonoscopy. And when the biopsy comes back as cancer, whether it be colon or rectal cancer, the first thing we do is we get imaging. We have to figure out if this colon or rectal cancer has spread to other organs of your body. That imaging helps us stage the cancer, whether it be stage I, stage II, stage III, stage IV. So, there's four different stages of colon and rectal cancer. Following the imaging, and if it's stage IV, then you talk about a different treatment, versus if it's stage I, II, III, then you talk about surgery versus chemoradiation, then surgery. Again, it depends on where the cancer is located, whether it be colon or rectal cancer.

Host: How is colorectal cancer typically treated?

Dr Ahmad Aulakh: So typically, a stage I, stage II, and stage III colon cancer is treated with surgery first. So colon cancer, if you have colon cancer, you get surgery first. And when you get the surgery, we take all the tissue, and we figure out how invasive this was. And after surgery, we figure out if you need chemotherapy for colon cancer.

But rectal cancer is completely very different than colon cancer, hence why we have to distinguish between these two entities. For rectal cancer, surgery is not always the first thing. Typically, for rectal cancer, it may be that you need surgery first, but a lot of times people require chemo and radiation first, followed by surgery.

Host: Can colon cancer or rectal cancer be completely cured?

Dr Ahmad Aulakh: Absolutely. If you get surgery and the surgeon does a good job, takes all the tissue out, resects all the cancer, and there's no spread of the colon cancer or the rectal cancer. Or if there is and you just need chemotherapy, there's a good chance you may be cured of both colon and rectal cancer.

Host: That's good news. As far as recovery goes, do you need a colostomy bag after colorectal cancer?

Dr Ahmad Aulakh: That's an involved question and that's based on where the cancer is again. Typically for a colon cancer, many times, you don't need a colostomy, a bag. A lot of times, you can resect the bowel, and make the anastomosis or a connection and hook things back together with the remaining colon so you don't need a colostomy. Again, there is some little nuances to that, but typically you don't for the colon cancer. The rectal cancer, however, again, because of the variation in treatment, if you need chemo or radiation for a stent surgery, then many times, yes, you need a colostomy or an ileostomy, which is a different type of a bag, that you may need for rectal cancer. So, a lot of times with the rectal cancer, you may need a colostomy. Whether it be permanent or not, it depends on how low or how aggressive this cancer is.

Host: What are the signs that colorectal cancer has spread and how fast does it spread?

Dr Ahmad Aulakh: Some of the signs the colon and rectal cancer have been spread are typically weight loss, significant weight loss, not 4 or 5 pounds or 7 pounds, but significant weight loss. Sometimes on the labs, you can look at the liver functions, meaning sometimes the cancer has spread to the liver, sometimes it's spread to the lung, people have difficulty breathing, sometimes the liver gets enlarged and you can feel the liver when you're examining someone's abdomen. So, those are some of the late signs of spread of the colon or rectal cancer. And how fast does it spread? Honestly, there's no good data that shows that one type is worse than the other. Yes, one type is more aggressive than the other, but we don't have a timeline that, "Hey, if surgery is not done in two weeks, your body's going to be full of cancer." I think that's a scary part for the patient. "Hey, I got diagnosed with colon cancer. I needed the surgery yesterday." I think that's a little aggressive. I think we want to gather all the data, get all the information. That may take a little bit of a time. Come up with the best treatment plan for that one individual patient, because every patient is different, so the treatment has to be tailored towards that patient and the type of a cancer that they have. And then, we decide whether we do surgery or not. So, I think the timeline, we don't have a good data. Now, we know that certain types of cancer are aggressive and they spread rapidly, but we still don't know the timeline. Is it days? Is it weeks? Is it months? Is it years?

Host: What advancements do you see on the horizon when it comes to colorectal cancer screening or treatment?

Dr Ahmad Aulakh: Some of the advancement we have had in the last decade or so is I'm sure people have heard, "Hey, I don't want to do a colonoscopy. I don't want to drink the prep, and I don't have to go through all that hassle." And it sounds, you know, a lot of work. But in my opinion, it's the right thing to do. And, again, I'm a colorectal surgeon. Some of the advancements that we have had in screening for colon and rectal cancer is that we have had some advancement in DNA stool analysis, where you get this kit from one of the pharmacy companies, and they have you ship your stool to them and they analyze it. And again, that's not as accurate as a colonoscopy. And if that study comes back as normal, you still need a colonoscopy. So, we have had some good advancement in other technology aside from colonoscopy to screen patients for colon and rectal cancers.

And some of this treatment advancement that we have had for colon and rectal cancers who needs chemotherapies that we have much better chemo drugs than we did five years ago, ten years ago, even when I was going through my training. Medication for chemo drugs could constantly change for the better, thankfully. So, we have multiple advancement in different type of chemo that are less toxic than they used to be. We also have special blood tests now that we can figure out if there's any DNA of the cancer cell floating in your bloodstream. So, those are all the recent advancements that we have had and we're implementing them as we get new data.

Host: Well, doctor, before I let you go, is there anything you'd like to add?

Dr Ahmad Aulakh: I would like to add, please take care of your health. Sometimes making the hard decision to get the colonoscopy done can save your life, can save you from getting a major surgery to remove your colon. If you get your colonoscopy on time, and follow the appropriate recommendation, it could be that once we remove the polyp, you are essentially taken care of. So, I would strongly recommend that please don't avoid getting a colonoscopy done. I think it's very important. It saves lives. And you would hate to be the one not doing it and then unfortunately turn out that you have an aggressive polyp or a cancer.

Host: Thank you, Dr. Aulakh, for your time.

Dr Ahmad Aulakh: You're welcome.

Host: That was Dr. Ahmad Aulakh, a colorectal surgeon with Prisma Health, and this is Flourish, a podcast from Prisma Health. I'm Jamie Lewis. To discover more episodes on a wide variety of health topics of interest to you, visit prismahealth.org/flourish. And thank you for listening.