Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're offering new perspectives on current screening guidelines and the future of colorectal cancer. We have a panel for you with Dr. Drew Gunnells, Jr., he's an assistant professor in the Division of Gastrointestinal Surgery; and Dr. Shajan Peter, he's a gastroenterologist and associate professor, and they're both with UAB Medicine.

Doctors, thank you so much for joining us today. Dr. Gunnells, welcome back. And I'd like to start with you. Talk a little bit about screening and the current screening guidelines. What are the latest guidelines for colon cancer screening and what's changed? What do other providers and patients need to know?

Dr Drew Gunnells: Thanks, Melanie. And it's great to be back and really a great platform, and really appreciate you having us on. Yeah. So in the last few years, most people at this point have seen that the task force, the National Task Force, changed the screening guideline for colorectal cancer from 50 to 45. And so naturally, most people ask the question, "Well, why do I need a colonoscopy, you know, at 45 instead of 50?" Well, that incidence we saw from a national perspective of colon cancer, how frequently we were seeing that was actually going up in the younger population. We were doing a better job of those over 50. So, the colon cancer incidence was going down, presumably from better screening for those over 50. But those under 50, the incidence was rising. So, fairly alarming to see that, especially for younger patients getting cancer at a younger age. So, the task force recommended that we should start screening people at 45 instead of 50.

The same principles of people that need to get screened earlier still apply. You know, some need to be screened even younger than 45. And so, that could be someone that had a family history of colon cancer, mother, father, sisters, brothers or somebody that's high risk, like if you have inflammatory bowel disease, ulcerative colitis, Crohn's disease, something like that, we usually start screening those patients younger.

And there are other genetic syndromes that can apply to those patients as well. And so, it's certainly something that you want to talk to your primary care doctor about. Go thoroughly through your history and make sure that you are getting screened at the appropriate age. Because unfortunately, we are seeing younger patients get colorectal cancer. And right now, we don't know exactly why. There's a lot of research going into it, and it's got to be a multifactorial thing, right? Both an environmental, a genetic, a dietary. And in our obesity pandemic, we know that obesity has higher risk of colorectal cancer. So certainly, we're putting a lot of effort into trying to figure out why. But while we figure that why question, we know we need to screen people earlier so that we catch people early so that we can get the appropriate treatment for them.

Melanie Cole, MS: Well, thank you for that. And Dr. Peter, as adherence to colonoscopy, despite what Dr. Gunnells was just discussing and despite its effectiveness may be limited, do you feel that offering non-invasive tests as a screening option may effectively improve adherence to screening? I'd like you to speak about the role of stool tests and other tests play in screening patients for colon cancers, some advantages, disadvantages, and what you see for other providers as they're counseling their patients. Because some patients, many patients, really have an adherence problem to colonoscopies. I'd like you to discuss that whole picture.

Dr Shajan Peter: Thank you, Melanie. And it's a pleasure to be with you and Dr. Gunnells today on this panel discussion. And I think Drew has clearly underlined the importance of screening. And as we know, nearly one in 20 people will be diagnosed with colorectal cancer in their lifetime. And therefore, the importance, as you brought up the question of adherence to screening, early screening is a definitely a good preventive measure. And from our data, only 60% of age-eligible adults are up-to-date on their colorectal cancer screening. And that points out to the importance of reachability of this test to the population and adherence also.

With that in mind, the Preventive Task Force has brought out, in addition to colonoscopy, other tests that would play an important role, especially to cover a large amount of people. And so, these non-invasive tests are the stool-based tests, which are available. And the two ones that are primarily recommended are the FIT-based test, or what is called the fecal immunochemical test. This is a stool-based test and it's just to be collected by the patient himself. No prep is needed, there are no physical risks. It can be done at home. But the important thing is that it is a two-step test. And what I mean is that if your test is positive, you definitely need to followup and get a colonoscopy to make sure that any test of the polyps are looked after or taken care of.

Another test is the multi-targeted stool DNA-based test or otherwise you might have heard of the test called a ColoGuard. And this is another test which, in addition to the FIT that I mentioned, looks for fecal DNA and specific mutations which are relevant to advanced colorectal cancer detection. And similarly, this test can be done at home. There are no dietary or medical restrictions.

Also, to underline that these tests require a closer interval of screening. So if you do a FIT test, you might have to do one every year annually. Or if you do a fecal DNA-based test, that may have to be done every three years. And also, to underline that these stool tests are potentially a dual test. That means they're two-step tests.

We did mention that there were other tests also that can be done, which are non-invasive. And I bring to your attention two tests. These are imaging-based tests. One is a CT colonography, which is just like a regular CT scan of the colon. Another is a pill cam test or what's called a colon capsule screening test, which you swallow a little camera the size of a pill. Now, these tests use imaging to look at the colon. They require a good bowel prep if needed. In fact, you might need a very good bowel prep. They can be completed, done at, you know, discretion. And the disadvantage is that it may miss smaller polyps or flat lesions like what we call sessile polyps. In addition, it's also a two-step test that you will require a colonoscopy to be followed up if you have a positive result in either of these tests. So, these tests together also complete what is called the whole armamentarium that we have for early detection of colon cancer in addition to colonoscopy.

Dr Drew Gunnells: Dr. Peter, I'm always interested. I was just on a panel in the Black Belt of Alabama where testing is quite difficult for a lot of patients. What do you recommend for those that may have trouble getting a colonoscopy? And do you like the FIT test or ColoGuard? Which do you think is better and easier for a patient that may have trouble getting a colonoscopy?

Dr Shajan Peter: Now, I think that's a very important point, especially when we look at our state with the increased disparities that we have health based, and colon cancer screening is also one of those. And therefore, I think something that can have a good outreach in the population is important. And therefore, I think either of the FIT or the fecal DNA, wherever they can be reached, can be used and is potentially available tests.

Now, keep in mind that the FIT test will have to be done annually, whereas the fecal DNA can be done every three years, so that's a slight advantage on that. However, the FIT test is a much more cheaper test as compared to the fecal DNA test. So, these two things will kind of have to balance your decision on how and where you want to do these tests and in different settings.

Dr Drew Gunnells: I had a similar thought and similar strategy counseling patients there, you know, especially the ones that just have a little bit more difficulty traveling. And it makes me nervous as a provider, I don't know what your thoughts are. Because Cologuard is such a great test and the FIT test obviously is good as well, but I hesitate not recommending an initial colonoscopy and then doing followup stool tests. What's your thoughts on that? And do you recommend people get at least one colonoscopy, then followup with a stool test, or do you think the stool test is an okay initial screening?

Dr Shajan Peter: I think not just because I'm a gastroenterologist, but because I deal with these kind of polyps on a daily basis. And that advantage of doing a colonoscopy is that you can see a polyp and remove polyp at the same time. And in a population, you may have almost a 25% risk of having a polyp on the first index colonoscopy. See, all the more reason to do a colonoscopy as a first line test. But we have to accept the reality that this test is not freely available to everybody. And therefore, the other tests are definitely an advantage that could, at least on a population base, get a lot more people under the screening umbrella. But there would be certain situations, for example, in the age groups that are above 75 years old or they are not medically fit to undergo a colonoscopy. They have other disadvantages in that sense on a medical basis. In that case, these tests definitely prove an important role for the target to prevent colon cancer.

Melanie Cole, MS: Dr. Gunnells, I'd like you to touch on, as we're talking about colonoscopy and these other options and certainly adherence, and that was a great question that you asked, was did you think that this should be a first line because those other ones that are two-step and they have to go back in anyway, and certainly if a polyp is detected, they still have to go back in. Tell us some of the exciting advances in colonoscopy. And Dr. Peter, then jump in and discuss some of that AI assistance, because this is where I think is really an exciting part of your field.

Dr Drew Gunnells: I think the advances in colonoscopy are exciting. And just colonoscopy in general, obviously, can be very daunting to patients, but it's one of the few instruments we have in medicine that can both screen and prevent people from having cancer in the future. Because Dr. Peter alluded to, we can take out polyps before they become cancer. And so, it just underlines the importance of colonoscopy and the advantages. And so moving forward, we've tried to make colonoscopy as easy for patients as they can. Most patients will get good anesthetics, so that they're completely asleep and completely comfortable, and can wake up quickly and then go about their day. We are trying our best to make that prep, as bad as it is, to be better. And then, making the scopes themselves, there's so many advances in 3D technology and wide-viewing scopes. And then, Dr. Peter will talk about, because he's personally doing research, but in artificial intelligence, helping us identify these small polyps, that sometimes we can't see as providers. So, I know Dr. Peter can talk about that even more.

Dr Shajan Peter: Yeah. Thank you, Drew. I think you clearly underscored the importance of a high quality colonoscopy. And we have to keep in mind that polyp miss rates could be as high as 20%, and they have a detrimental downstream effect. So, these important quality metrics that we continuously try to measure is something called an adenoma detection rate. An adequate bowel prep, good withdrawal time of at least six to nine minutes, and these stand as good benchmarks for a standard endoscopist to achieve. So for example, an aspirational target or important target for an abnormal detection rate, at least 30% to almost 35% is a good target. And to that extent, what we do is we generate physician report cards every month. So, the physician is actually aware of his own performance skills and performance levels, how to improve these quality metrics.

The other important point also that you mentioned that we need to underscore is that, for every one increase in the detection rate of a polyp, there's a 3% decrease in the risk of cancer. So therefore, the importance of detection becomes very important. Now, colonoscopy has improved from the days it started. And as we know, you know, the first endoscopy was invented here right at the UAB by the famous gastroenterologist called Basil Hirschowitz, and we've come a long way since then. A lot of new techniques have improved over the last few years. And now, we're using techniques such as water-assisted colonoscopy, right-sided retroflexion, double right-sided examination. These have improved our adenoma detection rates. We have devices like caps and cuffs that can be attached to endoscope and look behind folds and try to avoid missing polyps.

Now, the new kid in the block is what is called the artificial intelligence or otherwise called computer-aided polyp detection system. And it's found to be a very promising tool. Good studies that are performed from multi-center studies all over the world have shown that the use of these computer-aided detection tools have increased that adenoma detection rate to almost a 30% increase and also a 50% reduction in the miss rate of colon polyps.

We have been fortunate to have this AI detection incorporated in our colonoscopy suites here at UAB. They just turn on and they are able to have a light-aided detection that tells you whether it is a polyp here or there. It could be either a visual kind of cue or it could be a sound-based cue, and your mind immediately goes and puts attention to that area and takes up these polyps.

We are also looking specifically to look at these polyps and whether it can also bridge the gap and disparities with detection of polyps. So, I think it's a useful tool and more data is coming out and other developments are coming in this area, which we'll have to see how it goes down the road.

Melanie Cole, MS: Dr. Peter, speak just a little bit more about advanced polyp and treatment options for removal prior to surgery and when you feel it's important that patients be referred for surgery, the options that they have. Give us a little brief overview of that.

Dr Shajan Peter: I think that's a very important point to bring up. Polyps can be of varying sizes, or they could be simple polyps, like little polyps, or what we call little moles. Or they could be advanced, and these advanced features are polyps like more than 10 millimeters or have advanced histological features of something called dysplasia, villous or tubulovillous pattern. And this is on a histological basis. And these are advanced polyps, and we call them advanced because they have an increased potential to progress onto cancer.

So therefore, the important thing is, one, is to detect these polyps and, two, is to safely remove them, and take care of them. Now, 15% of these polyps can be what's called difficult polyps, and they can be challenging for an endoscopist to remove, owing to its shape, location or size. And, so we need advanced techniques or skills to remove these kind of polyps. Some of these techniques have evolved over the last few years and nowadays endoscopists are much more comfortable of removing these polyps, and therefore, preventing surgery removal.

Some of these techniques can be something like an endoscopic mucosal resection, underwater resection, endoscopic submucosal dissection, or even endoscopic full thickness resection. Now, the selection of the appropriate modality depends on the morphology or endoscopic diagnosis and recent advances, like I mentioned, advanced imaging, these equipment that assist in removing these polyps, the closure devices and techniques for managing any complications such as bleeding or perforation can be immediately addressed. And with these in mind, many of the times we're able to achieve the goal of removing these advanced polyps. And therefore, avoiding surgery in these circumstances.

Melanie Cole, MS: I'd love to give you each a chance for a final thought. This is such an interesting conversation that we're having and such an exciting time in your fields. Dr. Gunnells, I'd like to start with you. Please speak about the initiative for free colonoscopies for Jefferson County residents through Cooper Green.

Dr Drew Gunnells: Yeah, it's a really exciting opportunity through our Cooper Green partnership is that if you're a Jefferson County resident, there's eligibility where you can get a free colonoscopy despite insurance status or any other barriers there, so that we can try to alleviate some of the disparities that we see within not only in our own state, but in our own county. And so, that information can be found on our website as well as the Cooper Green website about how to register and sign up for those colonoscopies.

Melanie Cole, MS: What an important initiative. And Dr. Gunnells, last word to you. I'd like you to tell us how GI medicine and surgical teams are coming together for these patients. I'd like you to speak about why a multidisciplinary team is so important right now when it comes to colon cancer and screening, most importantly, to prevent it in the first place.

Dr Drew Gunnells: Absolutely. You know, it's a conversation we have every day, between Dr. Peter and our colleagues. And specifically, it ends up being about these advanced polyps. And these are polyps where I tell patients, "Listen, I'm a surgeon, I love fixing things. And if I can operate on you and fix you, I'd love to do that. But your goal is to avoid surgery if you can." And that's where Dr. Peter and his colleagues just do a fantastic job here of tackling some of these hard polyps that normally would have gotten a big surgery in the past, but they're able to take these out endoscopically with the scope, so that they can avoid surgery in the future. Now, if that's not the case and you need to have surgery, that's where that collaborative approach happens, where Dr. Peter talks to us and we have tumor boards and multidisciplinary conferences where we discuss what is the right modality and the right treatment for the right patient at the right time.

And so, if you need surgery, the nice thing is that we do the majority of our surgeries now are minimally invasive, so either robotic or laparoscopic surgery so that the patient can heal faster, get out of the hospital sooner, and get back to living their normal life. But collaboration and the multidisciplinary clinics and tumor boards that we have are certainly paramount to, again, making sure that right modality of treatment is given to the right patient at the right time.

Melanie Cole, MS: And Dr. Peter, last word to you here. What would you like other providers to take away from this episode, this podcast, and all the exciting things that you're doing at UAB Medicine?

Dr Shajan Peter: I really want to underline what Dr. Gunnells said that at UAB, we're really blessed to have a great team, a multidisciplinary team with an amazing communication that involves the gastroenterologists, the pathologist, an oncologist, a surgeon and primarily putting the patient in the center of all this discussion. And that's what's called a shared decision-making where we come to achieve a common goal for the best of especially the topic that we just talked about, preventing colorectal cancer.

A lot of new things that are evolving and UAB is a center of that in terms of providing that advanced care, multidisciplinary, and along with that, research to pioneer newer techniques and methods. A new thing that could evolve over these ages could be blood-based tests or what is called liquid biopsy to diagnose colon cancer, early detection. And this is something that we're also working with and with research teams. And things will evolve down the road.

Melanie Cole, MS: Thank you both so much. What an interesting and informative episode this was. Thank you both for joining us. And I hope that you'll join us again and update us as more things are really exciting in these advancements in colorectal cancer. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB Medcast. I'm Melanie Cole. Thanks so much for joining us today.