Joey Wahler (Host): It's the second leading cause of cancer deaths in the United States behind only lung cancer. So, we're discussing colon cancer and the importance of screening. Our guest is Dr. Andrew Kostiuk, a colorectal surgeon.

This is Curating Care, a podcast from St. Clair Health, expert care from people who care. Thanks for joining us. I am Joey Wahler. Hi, Doctor. Welcome.

Andrew Kostiuk, MD: Hey, how you doing, Joey? So great to be here.

Host: Great to have you aboard. We appreciate the time. So, colon cancer cases are actually rising among younger adults in the US in recent years, and yet there's really no known reason for that. Am I right?

Andrew Kostiuk, MD: That's correct, Joey. I think a lot of what people would speculate is that our screening protocol is becoming much more efficient, and our detectability for cancers has become a lot stronger. And I think that that probably points us in the direction as to why we're seeing some of these cancer diagnoses in younger patients, just because people are going through the process a lot more efficiently and we're able to find these things a lot more clearly. But certainly, you know, we as scientists have to at least entertain the possibility that there's other things going on, and that's why we keep doing the work that we do.

Host: Certainly makes sense. So, how young are people that are now sometimes getting colon cancer, and how alarming is that increase to someone like you?

Andrew Kostiuk, MD: Well, I mean, just anecdotally, I can tell you that, even as recently as this past few months, I've treated somebody who was in their early 30s with colon cancer, which is extremely alarming to me as somebody in their early 30s. But, you know, ultimately, like I've mentioned, that's why we do this, and that's why the screening protocols exist and that's why people like myself and my partners and colleagues, why we do what we do every day, is because we want to be able to help try to get people back to their lives for something that, as you mentioned, is a huge cause of mortality in the United States.

Host: So, just how much of a difference does colorectal screening make regarding early detection of colon cancer if present?

Andrew Kostiuk, MD: I think that there is very little argument to be made that it doesn't make any difference at all. It's a gigantic difference. And the thing that we see is that the guidelines that are in place have been recently updated as far as the last even few years ago, whereas the previous screening guidelines were for average risk Americans to be screened at age 50. And then, we've now seen that decrease to 45.

We'll continue to reevaluate these, especially in light of younger and younger cases like I've described. There's a potential that, in the future, that screening guidelines may decreased further. We can't be certain. But it's something that we stay focused on and stay on top of.

Host: And so, when we talk about the crucial aspect of that screening, talk to us please about just how much that can make a difference literally between life and death sometimes, right?

Andrew Kostiuk, MD: That's a wonderful point, Joey. And that's the wonderful thing about colonoscopies in general is that they're not only diagnostic, they can be therapeutic in many senses as well. Colon cancers don't just pop up out of nowhere. There's a natural progression into their development. And what we see is that these develop from polyps by and large. And some people are more apt to polyp development than other's are. But the guidelines in the way that they exist help us to detect those polyps earlier so that we can potentially remove those growths before they develop into cancers or develop into invasive cancer.

And I want to even add certain cancers, if they remain relatively contained within that polyp, can even be treated with a polypectomy alone before they would need radical surgery. So, it's another thing to keep in mind and another reason why I encourage everybody to, you know, continue to get their colonoscopies.

Host: So, Doctor, you touched on it a moment ago, but just to be clear, for the average person, it's recommended that colonoscopy start at 45. And then, how regularly would most need to go repeatedly again the next time? And what about those that are considered higher risk, and who would they be?

Andrew Kostiuk, MD: That's a great question, Joey. Like you mentioned, the standard in the United States of America as it stands, 45 for an average risk person would be when we would start screening. How often we would survey them afterwards would really be predicated upon what we find during that initial colonoscopy.

For example, if it's completely clean, we would do another 10 years. If we find some very small polyps that are, you know, small in number even as well, you know, less than three that are less than half of a centimeter or so, you could even screen them again in seven to 10 years. People who have larger polyps, polyps with advanced features, and higher numbers of polyps need more aggressive surveillance. And so, their window or their interval for repeat colonoscopy is lower.

Typically, we do intervals depending on what we find around three, five, and 10 years. That's kind of the standard regimen. People who would need just as a basis earlier colonoscopies and potentially more aggressive surveillance based on history alone would be people who have family history of major polyps, family history of colon cancers, or personal history of related cancers. Patients with inflammatory bowel disease certainly can't go unmentioned. Those patients should even get diagnosed within eight years after their initial diagnosis of inflammatory bowel disease. So, you know, even a 20-year-old who gets diagnosed gets a colonoscopy before age 30. And those intervals are much less again, because those patients are at higher risk for development of cancers.

Host: Gotcha. So for those unfamiliar who've not yet had one, or maybe it's been a bunch of time in between times that they have, the screening gold standard is a colonoscopy. What does that involve in a nutshell?

Andrew Kostiuk, MD: So for a colonoscopy, it's really a two-day process for most people. We have you do a standard bowel prep. My partners and I use a MiraLax-based prep with some Gatorade, and they do that the night before the procedure or the day and night before the procedure. There's nothing to eat or drink after midnight, nothing to eat or drink the day of the procedure. There's a couple other little nuances in there, like you can't drink anything red or things like that just because it throws off our field of view. And we want to make sure we see anything that might be bleeding or things like that.

And then, you would come into our endoscopy suite, we have a whole wing kind of carved out in outpatient center that does colonoscopies. And then, you know, they go through the general process. Nurses will check you in, the anesthesiologist will see you. And then, you know, myself or one of my partners would see you. You'd come back to the procedure room. We'd put you under a procedural sedation, so you wouldn't be under general anesthesia. It'd be in kind of like that twilight state that's often described. So, you wouldn't remember any of the procedure, but you'd be comfortable and you wouldn't feel any discomfort.

And then, we would complete the procedure. And if there's anything to remove, we would remove it at that time. And then, I talk about the findings with all my patients afterwards and let them know, "Hey, This is what I found. This is what I think you need to be worried about if anything. This is maybe some things you can do to change, if you want to have more healthy bowel habits. And this is when you need to see me again." And that's typically how we do it. And then, we make calls out to the PCPs offices that keep everybody in sync and the machine keeps rolling.

Host: And so, as someone yours truly that's had this done multiple times, I can attest, Doctor, to the fact that it's really much ado about nothing because. There's no pain. There's no recovery time, really. I mean, once you're out of being sedated, you're ready to go home. There's no real after effects other than you get to finally eat, which is great. So, it's really the prep, right? The prep process of drinking that solution that doesn't always taste so great, and going through the process of many hours the night before, the morning of, having your system cleaned out, if you will, that's the most unpleasant part, right?

Andrew Kostiuk, MD: I would say that's certainly the most unpleasant part. To your point, about the big bottle of, you know, solution that you have to drink prior to, I think, a lot of practitioners have moved away from things like that. And what we do is generally more tolerated now than I think any other prep that we've used in the past. And patients who've had colonoscopies 10, 20, even 30 years ago, in some cases, depending on, again, the population have told me that what we do now is much better than the things that we've done in the past, which they're very thankful for as you can imagine.

Host: You took the words right out of my mouth. I was just going to say, I'm sure those joining us that have had to taste the ones that weren't so great, that sort of thing. They'll definitely be very relieved. Couple of other things. There are screening options, am I right, besides a colonoscopy. But they're not considered as accurate, correct?

Andrew Kostiuk, MD: Yeah, I certainly think that my colleagues and partners, both in gastroenterology and colorectal surgery would argue that the colonoscopy is the gold standard for the reason. There's a lot of discussion about the Cologuard tests now, and the use of that because it's non-invasive and generally very well-tolerated by people. And I think, in some cases, it's even covered by insurance.

The thing that I always mention to patients with that is that test has a higher false positive for a reason. It doesn't want to miss things, and it can be positive for a number of different reasons that wouldn't be necessarily really related to having polyps or cancer, even bleeding sometimes can cause those things to be positive in my experience. And then, you end up needing a colonoscopy anyways, whereas it seems just as easy to go back through the colonoscopy process. Because, like we discussed, it's a very well-tolerated procedure with pretty limited risk, especially as we've gotten better and better at this.

And really, the future is so bright. And the sky's kind of the limit for what we're going to be able to do going forward with that and even as far as intervening on more advanced lesions with that. So, you know, I always encourage people stick with the gold standard. It's the gold standard for a reason.

Host: Absolutely. Certainly makes perfect sense. And in summary here, Doctor, for those joining us that may be procrastinating about having a colonoscopy, be it their first one, or maybe it's been again a while between visits, what's your advice to them? How do you get across just how crucial it is to not put this off?

Andrew Kostiuk, MD: Well, what I always tell patients is that it's very easy to ignore symptoms until they're impossible to ignore. Patients who maybe have a little bit of bleeding here and there and they let it go, and then they come in one day with an obstructing cancer and it's led to the necessity for an emergency surgery. Whereas something like that maybe could have been dealt with in the past with a simple polypectomy. It's about nipping things in the bud, so to speak.

And I think that the procedure itself, as I've mentioned a couple times and we've talked about, is so well-tolerated. It's a well-oiled machine with how we run these things now. And we're really able to do a great deal of difference and, oftentimes, cure cancer before it happens. For me, again, it just kind of seems like the best option. And, you know, I always tell my patients, if you're worried about pain or feeling uncomfortable with everything like that, I can assure you the prep is much better than it's ever been, and the anesthesia's better than it's ever been. So, I wouldn't worry about any of those things.

Host: Absolutely. Curing cancer before it happens. Very well put.

Andrew Kostiuk, MD: Well, thank you very much, Joey.

Host: Absolutely. Well, folks, we trust you are now more familiar with colorectal cancer and screening. Doctor, keep up all your great work. Valuable information and advice indeed. Thanks so much again.

Andrew Kostiuk, MD: Oh, it's my pleasure. Thanks so much for having me.

Host: And for more information or to contact Dr. Kostiuk, please call 412-572-6192. Now, if you enjoyed this podcast, please do share it on your social channels. Check out our entire podcast library for topics of interest to you. I'm Joey Wahler. And thanks so much again for being part of Curating Care, a podcast from St. Clair Health.