Scott Webb (Host): Today, I'm joined by Dr. Irena Rupp, colorectal surgeon with Prisma Health, and she's here to discuss colorectal cancer, detection, treatment, and hope. This is Flourish, the podcast brought to you by Prisma Health. I'm Scott Webb.

Doctor, it's nice to have your time today. We're going to talk colorectal cancer, detection, treatment, and hope, most importantly. Before we get there though, what does it mean if we find a polyp during a colonoscopy? And is that the same thing as a tumor?

Dr. Irena Rupp: A polyp is an abnormal growth in the colon, but when we look at it and we remove it during colonoscopy, a vast majority of these are going to not be a cancer. A good portion of them will be a type of tissue that can eventually evolve into a cancer, given enough time and the right environment.

The vast majority of them are not a cancer. In fact, of all the screening colonoscopies we do, we find a cancer 1% of the time. So, polyps are actually quite common. We find polyps on about 50% of all colonoscopies that we do. And of those, a good portion will be pre-cancerous and have a potential to develop into a cancer, but we either remove them or they potentially necessarily progress to that stage.

Host: For sure.

Dr. Irena Rupp: Tumor, on the other hand, generally implies that there is a large mass. So, can it be a polyp? It can be a polyp, but kind of a very, very large one where just taking it out with a colonoscope is not necessarily always of an option due to sheer size. The tumor can be synonymous with a very large polyp. It can also be synonymous with cancer.

Host: Okay. Yeah, and I think you kind of covered this, but I wanted to make sure we underscore this. How often is colon cancer found during a regular screening?

Dr. Irena Rupp: Less than 1% of the time, provided that the screening is true screening exam, And the patient is asymptomatic. So, we're not having abdominal pain, we're not having bleeding, we don't have any major family history that put its elevated risk, no bowel habit changes, and no positive FIT or Cologuard test that led to the colonoscopy.

If any of those preexisting conditions are there, the chance of there being something found, either a polyp or an actual cancer is going to be higher, but again still very, very low.

Host: Very low. Yeah. So then, what happens, Doctor, if colon cancer is found?

Dr. Irena Rupp: So then, the first thing that happens is identification and biopsy. Colon cancer is the most common cancer to happen in colon, but it's not the only one. So, it's very, very important when we diagnose, you know, a mass that looks like a cancer in the colon that we biopsied and confirm that it's actually colon cancer. There are several other types such as neuroendocrine tumors, GISTs and leiomyosarcomas and lymphomas that can also happen in the colon. And the treatment for them is going to be different.

The second thing that happens. Once we confirm that this is true colon cancer, is staging. And staging, to be simply put, how far along is this? And it uses several radiology modalities, most commonly a CT scan of the chest, abdomen, pelvis to determine has the tumor really just stayed in the colon or has it gone to any other organs, which again, guide our treatment and management.

So once we get the staging accomplished, then we can talk about the plan of treatment. If the tumor's confined to the colon and has not spread anywhere else, then the main upfront treatment for that is surgery.

Host: Wondering, Doctor, about the stages of cancer. I hear about stages when it comes to any kind of cancer. Are there different stages for colon cancer? And if so, how is the staging done?

Dr. Irena Rupp: So, staging for colon cancer upfront at diagnosis is done with the CT scan to make sure that it is not an advanced disease. So, we are ruling out stage IV disease, which would mean the tumor might have gone to other organs and, therefore, the treatment upfront may not be surgery. If that is not the case, then we are up against either stage I, II, or III.

The difference between stage I and II is the depth of invasion of the tumor into the colon wall. And stage III generally means the tumor has gone to lymph nodes—so, tissue that carries lymph away from the colon and into the central circulation. All of those tumors, stage I, II, and III get staged actually after surgery, after we excise it, and the pathologist is able to evaluate the tumor depth of invasion as well as lymph nodes.

Host: Sure, yeah. And I'm sure there's a range here. As you say, there's different stages, obviously. But generally speaking, and maybe broadly speaking, Doctor, how is colon cancer typically treated?

Dr. Irena Rupp: If we are catching it in a process where it has not spread to other organs, the upfront treatment of colon cancer is typically surgery. Surgical resection of the tumor. That will allow us to then specifically determine the stage and design any further treatments that may or may not be necessary.

We also evaluate molecular markers of the tumor, so the kind of chemicals the tumor produces that make it more susceptible to certain medications versus others. Colon cancer, believe it or not, is about 20 different diseases, if not more. So, it's actually very important for us to know some of those molecular profile of the tumor to guide further treatment.

Host: Yeah. Wondering, I know that, often with cancer, the C, the big C is often referenced. But when I think of this, I think about the word cured. And I'm wondering, Doctor, is that a thing? Can colon cancer be completely cured? Is that possible?

Dr. Irena Rupp: Yes. So if we look at SEER database, which is run by the government, and that looks at survival rates for the last five years, and it's on a rolling five-year basis, 65% of all diagnosis of colon cancer will survive five years and achieve a cure. So, 65% of all of those who get diagnosed with colon cancer will survive five years plus.

And that's actually a wonderful result. And we are improving on that result every time we reassess. So, that number, if anything, has gone up and up and up over the years. So, cure is absolutely possible. Particularly, cure is extremely possible when we're talking about lower stage colon cancer. So, stage I, II, or III where the tumor has not gone to any other organs and has stayed either in the colon wall or colon wall and lymph nodes.

Once the tumor has gone to other organs, the cure is much more difficult to achieve, because you then are talking about medical and surgical intervention on multiple organs. In a lot of cases, that is still possible. And there is possibility of cures in some situations, but it is not widespread. And survival goes down substantially in the stage IV disease where the tumor has spread to other organs.

Host: Right. Will some folks need a colostomy bag after colon cancer, Doctor?

Dr. Irena Rupp: In certain situations, that is a possibility. Usually, when we are talking about kind of acute situation where somebody's very, very sick, the tumor has caused a bowel perforation. So, there's a hole and there's stool leaking into the abdomen, and the patient is really too sick to be tolerating reconstruction at that point.

In other situations, the tumor can cause obstruction, so a blockage to the point that, again, you're getting very, very sick, and we have to remove it and do things quite expediently to save a life. A lot of those ostomies, whether they're colostomies or temporary ileostomies, can be reversed. And a lot of the times they do get reversed. A lot of that reversal is really up to how well are we doing with the rest of disease control, what are our other underlying morbidities—heart, lung, liver, kidneys—and are we able to tolerate a second operation.

Host: Of course. Doctor, are there any signs or symptoms that colon cancer has spread for folks? And I guess it makes me wonder, you know, for somebody who maybe was in stage I and is advancing through the stages, like how fast does colon cancer spread or can it spread

Dr. Irena Rupp: That's a very good question. Colon cancer actually is an interesting process because it has a varying behavior. So depending on the type of mutations that led to the tumor being there, it can actually be indolent and there for years, or it can spread very, very fast. So, not all colon cancers are created equal. There are some very small tumors that can spread fast, and there are some very large ones that never do.

So, the behavior of it is very different. What can be some of the signs that it's progressing? It can be very subtle. And I'll be honest, a lot of the times when we see patients who have progressive disease, they don't necessarily have a whole lot of symptoms that are acute or severe that would tip us off that this is happening. Some of these things get found out on incidental scans for other conditions or other concerns.

Some of the common signs that we notice are just generalized feeling unwell, particularly feeling very tired, weak, dizzy, irregular bowel movements where previously that was not the case, more abdominal pain, weight loss that's not explained and not due to diet or medication changes, abdominal or rectal pain, particularly ones that's persistent and not just a episodic and goes away.

Host: Right. Not just, you know, "Well, my stomach kind of hurts today." But some of these, you say, that it's persistent. I'll give you a chance, Doctor, I really appreciate your expertise today. Talk about any advancements on the horizon that you're aware of when it comes to colon cancer screening or treatment. You mentioned about the survival rate, how it just keeps going up, which is just, you know, great news and brought a smile to my face, but anything else?

Dr. Irena Rupp: Yeah. So, a couple of things worth mentioning about colon cancer is that it is shifting to be the disease of younger adults. Currently, it is the number one cause of cancer death for both men and women under the age of 50. So if you think about that, that's the population that generally has a pretty low mortality overall, but that's the number one cause of death for adults, less than 50. So, it is shifting to be a disease of younger adults.

And the fact that mortality and prognosis is getting better, that's based on the fact that we are screening and doing a pretty good job with older adults. But we are not doing well enough with younger adults because a lot of them are potentially under the screening age, which is currently 45. And younger adults are increasing at about 3% per year in incidence of colorectal cancer in this country. So, this is kind of the big gap where we are not screening these patients, because they're not yet coming due for a standard screening. We're doing very well with the adults for screening.

What are the screening modalities? So, there are a number. There are several stool-based tests, and some of those can be done at home. One of them is Cologuard. It has an excellent sensitivity, so ability to detect colon cancer. I will say that it also has an 8% false negative rate which one must always remember that that's not zero. It also has a false positive rate of 13%, meaning comes back abnormal, but there's actually nothing found. There's also a FIT test, that's fecal Immunochemical test. And that has also a very good sensitivity, a bit less than Cologuard, along the lines of, you know, 73-93%. But both of those tests are not as good for detection of adenoma, a type of polyp that, you know, ultimately develops into colon cancer. Both of those tests are along the lines of 40%, maybe up to 50% for adenoma detection. So, they're very good for cancer. They're a little bit under par for adenoma. And for that, colonoscopy still remains the gold standard of care for both removal and detection of adenomas and colon cancers.

There are additional things on the horizon. As far as screening for colorectal cancers, there are a number of companies in the world that are working on blood tests for not just colon cancer, but a multitude of cancers. Some of those are FDA approved. The unfortunate thing about those tests is that although they are easy to do. Their ability to pick up colon cancer, especially at early stages, is still quite poor. So, substantially less, you know, viable alternative to a stool test or the gold standard, which is colonoscopy.

I will also say that those that have symptoms, have inflammatory bowel disease, have family history of colon cancer, should really have a colonoscopy as the screening exam because of its ability to detect adenomas, which ultimately can lead to cancer faster in those circumstances. Where a stool-based study or a blood-based study will often not detect pre-cancerous lesions and may give a false sense of security that things are well. But family history is particularly one where colonoscopy should be favored over a stool-based study.

Host: Right. Yeah. And as you say, it remains the gold standard for now for a reason, and you've given us some of the reasons today. So, appreciate your time and your expertise. Thanks so much.

Dr. Irena Rupp: Thank you.

Host: For more information and other podcasts just like this one, head on over to prismahealth.org/flourish. This has been Flourish, a podcast brought to you by Prisma Health. I'm Scott Webb. Stay well.