Transcription:
Colorectal Screening Could Save Your Life

Bill Klaproth (Host): Colorectal screening tests can find cancer early when treatment works best. Here to talk with us about colorectal screening options is Dr. John V. Flannery Jr. from Southern New Hampshire Health. Dr. Flannery, thank you for your time. So why are colorectal screening tests so important?

Dr. John V. Flannery Jr., MD (Guest): Well you know, colon cancer is the second leading cancer killer in the United States, and if detected early, most of those cancers can be cured. So we highly recommend regular screenings. There's a variety of options but early detection usually leads to a cure.

Bill: Early detection is so important, and as we like to say, you're not allowed to get this cancer because the detection works so well. Isn't that right?

Dr. Flannery: Correct. Absolutely correct.

Bill: So Dr. Flannery, what are the current screening guidelines we should be following right now?

Dr. Flannery: So the recommended age to begin screening for colon cancer is age fifty in the average risk individual, meaning there's no family history of colon cancer, no immediate relative like a sibling or a parent. That being said, as you may be aware, the American Cancer Society just came out with a recommendation to start screening at age forty-five, and the rationale behind that is because we are detecting and seeing colon cancer in patients younger than fifty.

So that kind of muddies the water a little bit. Well is the recommended age forty-five versus fifty? And my answer to that would be the gold standard is still age fifty. The American Cancer Society is just one society who makes recommendations for screening, and thus far the American Society of Colon and Rectal Surgeons, the American College of Surgeons, the American College of Gastroenterology have not yet changed their recommendation to forty-five.

And when you look at these recommendations given by any society, they have different grades or ranks, if you will. So anywhere from suggested, recommended, strongly recommended, highly recommended, et cetera. And if you look at those American Cancer Society Guidelines, they call that a qualified recommendation. So they're recommending it, but it still doesn't bear their highest ranking recommendation which is a strong recommendation. Their strong recommendation is still age fifty.

So at this point in time, my answer would be the gold standard is still to start screening at age fifty with the caveat being that other societies down the road may be changing that recommendation, and there may be a universal recommendation to start at age forty-five at some point in the near future.

Bill: Are there people with certain risk factors that should be screened earlier?

Dr. Flannery: Sure. Patients with a family history of colon cancer, especially first degree relatives, which means like a parent or a sibling who have colon cancer, then the recommended guideline for that is basically you have a colonoscopy five years prior to when they were diagnosed. So for example, if you have a sibling who had colon cancer at age thirty-five, your screening should start at age thirty.

Bill: So earlier you mentioned finding polyps. If a polyp is found, it doesn't necessarily mean you have cancer. Is that right?

Dr. Flannery: Correct. There are different types of polyps. Some of them would never become a cancer, for example hyperplastic polyps are benign polyps that never evolve into a cancer. Adenomyosis polyps are pre-cancerous polyps that if in the colon left and were not removed ultimately would go on to become a cancer. And there's sub-types of those polyps as well, some of which are more aggressive than others. But yes, there's a variety of different polyps, and some of which can certainly go on to become cancers.

Bill: Is it a fairly easy process to remove the polyps if found?

Dr. Flannery: So there are a couple of techniques we have, but in general, yes. Unless the polyps are really large or evolving a significant amount circumferentially of the colon, then sometimes those actually require an operation to remove them, but for the most part small polyps can either be kind of cherrypicked with a snare forceps or we can lasso them with a snare and remove them. We could also raise them with saline and then remove them with a snare, so we have a variety of options. But in general, for most polyps they can remove them under colonoscope and they do not require surgery.

Bill: And Dr. Flannery, are there any symptoms that we should be aware of?

Dr. Flannery: So in general, most polyps are asymptomatic. Unless they've become really large, then they can bleed, and the patient will notice some bleeding. But typically polyps do not cause pain, which is another reason that we recommend early detection, because most polyps don't have any symptoms at all, so that's another reason for having a colonoscopy at the appropriate age at the recommended screening level because they typically don't become symptomatic until they're large or go on to form a cancer.

Bill: Dr. Flannery, the colonoscopy is the gold standard of screening, but there are different options today. Can you cover the options that are available right now?

Dr. Flannery: Sure there's occult testing for blood in the stool. There's a couple of techniques for that. One is a guaiac test which basically looks for occult blood in the stool, and that involves three stool samples looking for occult blood, which means hidden blood. There's also a more sophisticated form of that which is immunological fecal occult blood testing, which is iFBOT, which just involves one sample. There's something that you may have seen in the media called Cologuard, where a stool sample is sent off and analyzed in the lab and they actually look for polyp DNA, and if that comes back positive- if any of these tests come back positive, then a colonoscopy is indicated.

But those are the two most common- or three most common. There's also a CT colonography, which is a CAT scan, which can detect polyps in the colon. But that is- it varies on the radiologist's reading. Some radiologists are very good at that, but it depends on the institution and how good the radiologists are with reading those. So the results of that are somewhat variable, and again, if that comes back positive for a polyp then the patient would require a colonoscopy.

Bill: So if someone doesn't want to go through a colonoscopy, they can choose the Cologuard process, which as you mentioned, you can see on TV. If somebody listening to this says, "You know, I don't want to go in and have this done, I just want to do the Cologuard thing." Someone can do that on their own?

Dr. Flannery: Well you need a doctor's order for it, but yes, it could be done and then typically the DNA test is recommended. There's no hard guidelines, but most physicians would agree every three years if that's the route you're going to go. But you would require an order from a physician to get the test. It's not something you could just go online and buy on your own.

Bill: And is there a difference in the efficacy of these options?

Dr. Flannery: I mean they're all pretty sensitive, but again, there's always a false negative rate. And again, even with the colonoscopy, though that's the gold standard, a polyp can always be missed if it's small, flat, less than one centimeter in size. There's about a 5% chance of being missed, so no test is perfect, but in general all these are sensitive for detecting polyps and / or cancers, and are sensitive enough to be recommended for screening techniques.

Bill: So with these new options for people that don't want to get the screening, because they hear the prep alone is daunting, I mean there really is no reason now to not get screened. Is that right? Because it is so important.

Dr. Flannery: Correct. I think certainly there's potential complications with colonoscopy and if patients are leery of undergoing the procedure because they don't want to do the prep, or for whatever personal reason they don't want to do it, there are certainly other backup options, and there's absolutely no reason that everyone shouldn't get screened at the appropriate age and avoid developing a cancer.

Bill: Dr. Flannery, we talked about how the colonoscopy is the gold standard. Can you describe that process? Because I still hear a lot of people talking about the prep, and "I don't want to go through with it." Can you talk about it? It really isn't that bad, right?

Dr. Flannery: Sure, I mean the prep- there are a variety of preps and most people that are leery of undergoing it have had the high volume prep, which is a fair bit of fluid to drink. But there are some newer preps out that are much smaller in volume, and the key to them is you just have to drink a lot of fluids to flush everything out.

But most patients tolerate the prep fairly well. I give an anti-nausea medicine with the prep just in case some patients have some nausea associated with that. But there's a variety of preps that can be done. You know, I'll be honest, it doesn't taste very great, but most patients are able to tolerate it, especially if they have some nausea and you give them a nausea medicine. They can do the prep, which is done the day before typically, and then you come in for the procedure. Most patients are sedated in one form or another for the procedure, and take it easy the rest of the day, and the next day after the procedure you're back to your normal routine.

Bill: It's actually pretty easy, and the prep is a lot better than going through chemo.

Dr. Flannery: Absolutely, that's a great point.

Bill: And lastly, Dr. Flannery, is there anything else we should know about colorectal screenings?

Dr. Flannery: You know, I think we've hit on all the high points, it's just important to get it done because you can avoid yourself developing a cancer, having to undergo surgery, and potentially having to undergo chemotherapy. So this is one of the slam-dunks in terms of screening for diseases that every patient should undergo.

Bill: That's a great way to put it. Well Dr. Flannery, thank you so much for your time today. For more information on colorectal screenings, please visit www.SNHHealth.org. That's www.SNHHealth.org. This is Simply Healthy, a podcast by Southern New Hampshire Health. I'm Bill Klaproth, thanks for listening.