This is “Healthy Conversations,” a podcast presented by Adventist Health.

Prakash Chandran (Host): March is National Colorectal Cancer Awareness month. And colonoscopies are a very effective procedure to test, screen for, and even remove polyps before colorectal cancer fully develops. Sometimes if you're a woman who wants to receive the service, finding a female provider can be difficult, but today's guest is bringing that access and sharing her knowledge today. 

Let's welcome Dr. Rabab Hajar, Gastroenterologist and the only female gastroenterologist in San Louis Obispo County. My name is Prakash Chandran. So, Dr. Hajar, thank you so much for being here today. I'd love to maybe get started with just some basic questions if you don't mind, what age should you get your first colonoscopy?

Rabab Hajar, MD (Guest): Sure, thank you for having me Prakash. You should start having your colonoscopies around age 45. It used to be age 50, but the guidelines have recently changed and we are starting to screen people at age 45 now.

Host: Okay. And regardless if you're a man or woman it's age 45.

Dr. Hajar: Exactly, age 45 regardless of your gender, if you are an average risk person and we can define what that term means. If you're an average risk for colorectal cancer, your screening should start at age 45.

Host: Okay. And I do want to get into average risk and then more elevated risk. But you know, one thing that's been on my mind recently is that Black Panther actor, I think Chadwick Boseman recently passed away from colorectal cancer at 43 and me just having turned 40. I sometimes wonder if I should be more proactive and get screened sooner. Do you have any thoughts about that?

Dr. Hajar: Absolutely. So generally, if you're an average risk, you should start at 45 and not prior, unless you have some symptoms that are bothering you. But you know, we have been unfortunately noticing an increase in deaths from cancer in age 55 and younger since 2008, basically this rate has been increasing by an average of one to 2%, despite, you know, the decrease in overall colorectal cancer rates due to the widespread screening efforts. And the recommendations to start at age 45, come directly from the study observations. So, if you are an average risk, with no symptoms, 45 is your age. If you are at a higher risk or experiencing any symptoms, then it should and could very well start before age 45.

Host: Okay, understood. Now you mentioned average risk a couple of times. Could you talk to us a little bit about what it means to be at average risk and then what it means to be more elevated in that risk?

Dr. Hajar: Absolutely. So, average risk is usually the absence of any of these elements that we'll mention. And these include a family history of colorectal cancer or advanced polyps, you know, especially in first degree relatives, any personal history of inflammatory bowel disease, such as ulcerative colitis or Crohn's disease. Any suspected or confirmed hereditary colorectal cancer syndromes things such as familial adenomatous polyposis known as FAP or Lynch Syndrome. Also any personal history of radiation to your belly or your pelvic area, or as well, any history of prior cancers during your lifetime, so far. All these, if they're not present puts you as an average risk. The presence of any of these puts you at an elevated risk for colorectal cancer.

Host: Okay. That's really helpful. And one of the things that you mentioned was if you are at average risk, as long as you're not having symptoms, you can wait till 45. When we talk about symptoms, what exactly does that mean?

Dr. Hajar: Symptoms to look for, are usually any change in your bowel habits, change in the caliber of your stools. If you were going normally now you're suddenly constipated or you're suddenly having diarrhea, that's cause for alarm. Seeing any kind of blood in your stool. Having any kind of unintentional weight loss, having any kind of abdominal pain, that's not remitting. All these symptoms should raise your red flag and make you contact your doctor. At this stage, it will be a diagnostic and the screening at the same time, you know, type of colonoscopy.

Host: Okay, so let's move into the dynamics of the colonoscopy itself. Can you briefly describe what a colonoscopy actually is? And the preparation before the screening procedure?

Dr. Hajar: Yeah. So, a colonoscopy is a visual exam. It's done with the long flexible tube call a colonoscope which has a small fiber optic camera at the tip which allows the examiner basically to look for any growths, any irregularities or abnormalities of the inner lining of the colon. We have channels running through the instrument, which allow us to do basically therapeutic measures, such as removing polyps, you know, stopping bleeding sources, dilating strictures or even some more advanced therapeutic measures if we need to be.

Host: Okay, so just so I can understand, you're saying that when you're doing a colonoscopy, you can actually administer treatment at the same time as you're doing the screening, is that more or less correct?

Dr. Hajar: Absolutely. And that's what makes a colonoscopy, the gold standard test for screening and treating precancerous polyps. And at times even early stage cancer whereas, you know, you have other screening tests that could tell you that you may be at risk, or there may be a sign that you may be having something going on in your colon, but that would still lead you to a colonoscopy. Whereas a colonoscopy is a procedure that screens and treats at the same time.

Host: Now, one of the things that I wanted you to maybe expand on is I've always heard of preparation for a colonoscopy or the different types of prep. Can you talk about each different type of prep and the pros and cons of each.

Dr. Hajar: Absolutely. So we have several types of preps. Some are considered large volume, some are low volume, some are over the counter, and some are in pill form. The large volume preps were the initial preps. Things like Golytely, Nulytely. And the joke usually goes that there's nothing light about Golytely, you know. So, these large volume preps usually cause they're low cost and they're widely covered by insurances, but they were poorly tolerated by patients because they had to be administered in a short period of time, large volume causes nausea and stomach upset, and they contain several types of laxative salts, which give an or rather unpleasant salty taste.

Pretty much, almost outdated and replaced by low volume preps. And these are, preps that have shown very good cleansing power, as well as tolerability for patients. I mean, the volume could be as low as eight ounces and we also administer them in a split fashion, meaning you drink the first eight ounces the evening of your procedure, the second eight ounces, the morning of your procedure, which makes it a better tolerated process and a better cleansing process as well.

The cons usually they still have some amount of saltiness in them because they still use laxative salts and then cost could be prohibitive. Sometimes insurances do not want to cover these low dose preps. Over the counter ones, things like MiraLax, usually mixed with a sports drink, like gate such as Gatorade.

These are on average, very well tolerated, and they're usually good at cleansing as well. We use them sometimes as a second option if the patient is not able to have the other ones for any reason. And more recently the FDA has approved the first pill form prep called SUTAB. And this one, the data shows that it's pretty good at cleansing. However, I think the cost is so prohibitive, most insurance don't cover it as the first option yet.

Host: Okay. So, you know, all of this, as you mentioned is meant to cleanse the colon before having the colonoscopy and when a person hears that, sounds let's just call a spade it relatively uncomfortable. And for some people, the prep might be the most difficult part of the screening. Right. So are there any helpful tips to make the prep process an easier experience?

Dr. Hajar: Definitely let's face it. I mean, a colonoscopy prep is no one's the idea of a fun time, you know, and we reliably see that patients avoid having colonoscopies and dread them because of the prep process and not because of the procedure itself, but, you know, rest assured we have tips and tricks and we're here to support you through the process.

As I mentioned before, we now administer most of the preparations in a split fashion. So half a dose in the evening before and half a dose morning of. This shortens the time you have to, you know, drink the laxative, it also gives better tolerability and better cleansing. We also recommend that patients pace themselves, you know, a lot of patients because they're very averse to the process, they try to just chug the whole thing down very quickly. And that might cause, you know, distension and nausea and it just ends up coming up, you know, the other way. So, we recommend that patients pace themselves when they're drinking and pay attention to what their body is signaling. If they feel like they're getting a little nauseous, that they feel like they're descended to give it a break, it's okay to stop and come back when you feel a little better, you know, around 15 or 20 minutes and then drink at a slower pace. We also recommend chilling the preparation.

It does help a little bit with the taste aversion as well as using a straw to bypass most of your taste buds. And at times we recommend to hack your drink. You know, you can, once you mix up your prep, we ask you to add any drink of choice amongst the list of the clear liquids, that we give you. It could be any carbonated drink, any sports drink, you know, just to allow for better palatability in general.

I think these are most of the tricks basically to just get it down. And because we do prefer that you, most of your prep goes down to ensure the best cleanse possible.

Host: Yeah, and that makes a lot of sense. Another question that I had is just altering diet or eating habits. I imagine that is ideal that someone do that prior to the colonoscopy to make things easier, including the cleanse. Can you talk a little bit about that. And also the timeframe that one has to modify things if they need to before the screening itself?

Dr. Hajar: So generally diet wise, we recommend that you lower your fiber intake within the two to four days leading to your colonoscopy. So, generally things like whole grains, high fiber fruits, and vegetables, sometimes nuts and seeds, as well as any fiber supplements are stopped around two days prior to colonoscopy.

On the day prior to the procedure, you are advised not to have consume any solids and to be on a clear liquid diet. Just to simplify it, a clear liquid diet could be anything that if you put it through the glass and you can see through, you can consume it. And this will include things like tea and coffee and carbonated drinks, sports drinks, even jello, broths. These are all things that you can consume during that day. And then generally two hours prior to a colonoscopy, you are not allowed to drink or eat anything in preparation for the procedure.

Host: So because you're on a clear liquid diet the day before, you're effectively on a fast. So I imagine this is new for a lot of people. there tricks that you can share that can help them curb the hunger during this time?

Dr. Hajar: Sure it can be a little rough going from a, you know, shifting from a full, solid diet to a liquid diet. However we've noticed, and this could be extrapolated from fasting studies that increasing your healthy fats and protein content in the two days leading to that clear liquid day could actually help curb your hunger signals longer. We also recommend frequent use of warm liquids just because they have shown to increase satiety better than cold liquids. So, I personally recommend to use frequent salted broths, warm broths with some lemon, regularly, throughout the day. Broth does have some protein content.

And that also helps curb appetite. Also maintaining a regular intake. You know, many people make the mistake of not ingesting anything and just drinking water and the laxative later in the day. And that can make for hypoglycemia, headaches, and fatigue by the end of the day. So, you know, you are given a list of liquids. And you can actually use all of those throughout the day in a regular fashion every hour or two. And that usually helps keep you hydrated, curb the headaches, curb your hunger as well as, you know, make the quality of your prep even better.

Host: So, we've talked a lot about preparation before the procedure. I'd love for you to talk a little bit about what things look like after the procedure.

Dr. Hajar: So, during the procedure, you will be in a comfortable state of what we call moderate sedation. The exam usually takes about 30 minutes. Most people wake up within five to 15 minutes of the end of their colonoscopies. You will be lucid and able to hold a conversation, but you may be a little forgetful.

So, expect usually for the effect of fully and about two or three hours. But we still recommend that you just take it easy that day and not, you know, do any rigorous exercising, any intellectually demanding decisions that day. You may also notice some mild side effects, you know, related to the technicality of the procedure.

You know, some mild bloating and cramping. This is generally secondary to us using a little bit of air to inflate the colon and to have good visibility, 360 degree visibility. This is mild and expected, and you usually resolve quickly after two procedure once the patient is able to consume some liquid and, you know, have a little walk.

And if that doesn't help, we ask them to just lie flat on their stomach for a little bit, and then they should be able to expel the air, and improve their symptoms. Sometimes if we have done biopsies or removed polyps, you may see small amounts of blood in your stool. That's not a reason to be alarmed unless the blood is large volume and persistent. And then it may take anywhere from one to several days for you to have a bowel movement, again, depending on your food intake and your transit and other factors. So don't be alarmed about that as well.

Host: Now afterwards, are you able to just go back to eating normally, you know, you haven't eaten in a while. You're probably starving. You're craving like a cheeseburger or a pizza or something like that. Are you able to just go right back to normal?

Dr. Hajar: Absolutely. You know, most patients are back to their regular diet the day of. They generally report everything tasting better after their fast. But there are no contraindications. We usually test your tolerability while you're still with us. We give you a little snack and a little fluid to see, make ensure that you're not nauseous. You're able to tolerate a diet. And then when we recommend that you slowly ramp back up to your regular diet when you go home.

Host: So, just before we close, I just wanted to address the fact that you're the only female gastroenterologist in San Luis Obispo County. And I imagine that's important because women that are getting their colonoscopy screening, they want to be cared for by a female provider. Is that something that you can speak to?

Dr. Hajar: Absolutely. Absolutely my experience across the board has been that, you know, it's intimidating enough to have a colonoscopy. It's a little more intimidating when you know, a female has to undergo the procedure with a male provider, you know. So it's been really a wonderful opportunity to be able to serve the female community in our county and hopefully ramp up our screening procedures, you know, and take care of any complaints they may have.

Host: Just a final question, Dr. Hajar. Is there anything else that you'd like to share with our audience before we end here today?

Dr. Hajar: Yeah, thanks Prakash. I would definitely like to conclude with some statistics, I think numbers speak strongly and they speak for themselves. You know, colorectal cancer is the second most common death from cancer in the United States. We are expecting around 150,000 new cases this year of which about over 52,000 will unfortunately end in death.

So, it is one of the most preventable cancers. The ability for us to detect and remove polyps in their early stages is crucial in this process because 95% of cancers start as polyps. It is also known that only maybe one in three people who develop colon cancer, colorectal cancer in the US have actually undergone a screening colonoscopy.

And there are studies that show that, you know, colonoscopies by removing those precancerous polyps can decrease your chance of death from colorectal cancer by 53%. We know that the process may not be fun. We know that it may be challenging, but we're here to support you. We're here to basically answer your questions, address your fears and concerns and make the process work for you. You know, it may save your life or that of a loved one. So, please talk to your doctor about a colonoscopy.

Host: Well, Dr. Hajar, I think that is the perfect message to end with. Thank you so much for your time.

Dr. Hajar: Thanks a lot for Prakash. Thank you for having me.

Host: That was Dr. Rabab Hajar, Gastroenterologist

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