Scott Webb (Host): March is Colorectal Cancer Awareness Month. And my guest today is here to tell us about colorectal cancer, how it's diagnosed and treated, but most importantly, how it can be prevented through colonoscopies. I'm joined today by Dr. Roger Hsiung. He's the Chief of Colorectal Surgery, Department of Surgery, Summerlin Hospital; Fellow with the American College of Surgeons, Fellow with the American Society of Colon and Rectal Surgeons and Clinical Professor of the School of Medicine in the Department of Surgery at UNLV.

Scott Webb (Host): Welcome to Health Talk with the Valley Health System, presented by the Valley. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to talk about colon cancer. And March, of course, is Colorectal Cancer Awareness Month. So, there's maybe a never a bad time to talk about this and colonoscopies and all of that. But particularly, we're doing it now because of March. And I just want to have you start with the basics. Talk a little bit about colorectal cancer, just so listeners will understand kind of a baseline here, and maybe you can explain just the anatomy of the colon and the rectum, sort of paint a picture for us as best you can.

Dr. Roger Hsiung: The colon is a conduit that measures—including the rectum—about five foot long. It is considered the middle to the lower GI tract, and that basically starts from the end of the small intestine. By the way, colon is also called the large intestine. So at the end of the small intestine, it transitions to the colon. A good landmark is the appendix marks the beginning of the colon. It's attached to the beginning of the colon called a cecum, and they measure about five-foot long, and it goes all the way ending into the rectum where the stool exits.

Host: Yeah. And just in terms of colorectal cancer, like, why is there a month dedicated to this? Why is it so important that we're having this conversation?

Dr. Roger Hsiung: Well, colon is an organ that everybody has. Colon cancer is a worldwide problem. It is the number two cancer killer on the planet, trailing behind just lung cancer. And that's because lung cancer is heavily instigated or induced by cigarette smoking, which is an epidemic as you know. If you are one of those that doesn't smoke habitually, then statistically speaking, colon cancer becomes number one in your lifetime. Therefore, if somehow you can prevent a number one cancer killer in your lifetime, chances are you are going to live longer. And that therefore is the rationale on why it is so important, and that recognition and prevention strategy should be widely known, and that a whole month should be dedicated to its prevention and recognition.

Host: Yeah, it almost sounds like it should be every month. Doctor, I know that probably most people know the colonoscopy is the gold standard, if you will, for colon cancer screening. And I know the guidelines have changed, now starting at 45 or maybe younger, if you have a close family history of colon cancer. As a surgeon, you know, as someone who does this for a living as an expert, maybe you can just kind of walk us through, like, what are you looking for exactly? And what happens during a colonoscopy?

Dr. Roger Hsiung: Yes, absolutely. First of all, there's a lot of misconception about colonoscopy. It is a gold standard for screening for colon cancer. But it is actually created or designed to prevent colon cancer. Surely, it can find colon cancer and, therefore, lead to its treatment. But its actual goal is to prevent it. It's not so much to find it. Rationally and logically, why will one want to find colon cancer if one can prevent it? And that's what colonoscopy's mainly created for.

Host: Yeah. Maybe you can just take us through for folks who haven't had a colonoscopy, maybe they've been dragging their feet, maybe they're not of age yet, if you will, what exactly happens during a colonoscopy?

Dr. Roger Hsiung: Colonoscopy takes about 15 minutes. The patient will be sedated. It's IV propofol, so there's no intubation, so it's a very comfortable sleep. And from the patient's perspective, they go to sleep for 15 minutes, and when they wake up, it's done. And patients don't even know that it was done So, it is a very non-invasive and relatively benign procedure that is same day.

During the colonoscopy, a colonoscope, which looks like a hose about five foot long is inserted from the anus and navigated all the way to the beginning of the colon so that the entire colon, every single centimeter is visualized. Once again, there's no pain. Patients are usually very comfortable. And upon exiting, every single centimeter of the colon is examined. All the mucosa, all the colon wall, mainly to look for cancer junior, they're called polyps. On the skin, they have a different name. They're called moles. As, you know, when we get older, we grow moles on our skin. A lot of people see that as a sign of aging. By the same token, when we get older, we grow moles or polyps in the colon. But we don't call them moles. But assigned by the medical professional as nomenclature, we call them polyps because they are exposed to a different environment, mainly stool. If you think about a stool, to us, it's gross, it's waste, you want to get rid of it. But not to the polyps. To the polyps, they're highly nutritionalized, very, very powerful fertilizing agent.

Imagine you form a little polyp or a mole inside your colon just because we're lucky enough to get older. And it's being showered by stool. It's like putting it on steroids, So, it grows very fast. And by the time it grows to a certain size, it transforms into colon cancer. And therefore, colonoscopy is to physically enter the colon, find the polyps. And if it's there, remove it. It takes about 15 minutes. Afterwards, a patient goes home. It's usually a very comfortable sleep.

Host: Yeah, that's perfect. And as you say, you know, a lot of this is about preventing cancer, right? So, preventing those polyps from becoming cancer, right? So, you're removing the polyps. So, maybe just take us through that then. As you go through, you see some polyps, some suspicious polyps, right? And you remove them. Then, what happens next? Are they then sent out, you know, to be examined and then determine if they are cancerous or pre-cancerous? Like, take us through this process, if you will.

Dr. Roger Hsiung: Right. Obviously, not every colonoscopy finds polyps. If there are no polyps, great. in and out about 10, 15 minutes. But if a polyp's encountered, it is first photographed. Then, a snare or a hot forcep is threaded through the colonoscope channel, cautery is applied and the polyp is shaved or snared, kind of like how a mole is shaved in your doctor's office from your skin. Then, a photograph is taken again. So, there is a before and after image. And usually, patients usually get those photos as their souvenir, if you will.

Host: Souvenir. Right.

Dr. Roger Hsiung: Yeah. And the polyp is retrieved by suctioning it up, and every single polyp removed will be sent to the lab for microscopic analysis.

Host: Yeah. And obviously, they'll do the analysis and sometimes it may be cancer. And I wanted to ask you then like about the staging of colorectal cancer. How does that work? How do you stage? How do you know whether the cancer is spread, all of that?

Dr. Roger Hsiung: When a mass is found in the body, especially in the colon, in general, there are four general steps. First is biopsy. Like what we talked about, mass is biopsied. You send it to the lab, and they test it. Now, should it become cancer, after biopsy, the second step is staging, like you said. Staging these days is mainly done by x-rays. The standard for colorectal staging right now is still as dictated by the American Cancer Society, the standard is CT of the chest, abdomen, and pelvis. Although the PET scan, which is a whole body scan, is being involved into the standard of care where you take photographs or images of the body and see where the cancers are. And that basically constitutes staging.

There are four stages for every cancer, colon cancer is no exception. Stage I and II are confined inside the colon with no regional or extracolonic involvement. Now, stage I and II, the difference between the two are basically the size and its thickness within the colon wall. That's stage I and II, and it is considered low stage. Mid stage is considered regional, meaning that it has already shown evidence that it's spread outside the colon but not distantly to any organ, mainly the lymph nodes, that's stage III. So on CTs, you'll see the lymph nodes around the colon are enlarged. That is basically evidence of stage III or a mid-stage. And obviously, high stage or stage IV is distant involvement. The first place the colon cancer spread to is the liver, and the second place is the lung. So, the CT scan will show spots in the liver or the lung. And thus, that's usually how we stage initially. Of course, the more accurate stage is by surgical staging after the colon cancer is surgically removed.

Host: Right. And I wanted to ask you, you know, for colorectal cancer patients, what are their treatment options? And maybe you can share a little bit about the surgical treatment. It probably involves medical oncology, radiation oncology, you know, the whole team, if you will. Maybe you can just sort of explain what the procedure is, or just how all the team members kind of work together to help a patient.

Dr. Roger Hsiung: Right. So as I alluded earlier, step one, once a mass is found in the colon, it's biopsied. Step two is staging. And step three, like you said, is treatment, followed by step four surveillance. In terms of colon cancer treatment, once the staging is done and colon cancer like any other cancer, the treatment is guided by the staging. And it's mainly curative by surgical resection. So, surgery is the mainstay treatment for colon cancer.

Stage I, stage II colon cancer is treated by surgical resection. These days are usually done by the minimally invasive technique, the robotic platform. And usually, stage I and a very small amount of stage II after, surgical resection, it's also treated by adjuvant chemotherapy. Stage I, stage II are usually treated by surgical resection. We remove the colon cancer by surgery and hook it back together, and that's considered curative. Stage III, however, is surgery followed by chemotherapy afterwards. Usually, it happens about four to eight weeks after surgery, then you get chemotherapy. The chemotherapy basically goes everywhere, your circulation, your blood goes to go after those possible cancer cell that had escaped surgery, and that had already spread out.

And finally, stage IV, it's usually treated by chemotherapy only since this has already spread out to the liver or to the lungs. And therefore, just by removing a primary using surgery, there are still cancer cells circulating inside your body and in those distant sites. And the only entity we have that can go after those escaped cancer cells is chemotherapy. surgery is only reserved for complications such as obstruction.

Host: Okay. Yeah. And you mentioned earlier that, you know, the magical part of colonoscopies, if you will, is really that it's for diagnosis, it's for prevention. And yet a lot of folks, Doctor, they drag their feet or they aren't aware of the guidelines. Maybe you can, as we get close to wrapping up here, just kind of talk people into getting those colonoscopies.

They've heard about the prep. And have a variety of reasons. You know, we all find reasons not to do things we should do, right? So, just from your words, from an expert, like how can we convince folks, in honor of, you know, Colorectal Cancer Awareness Month, to get those colonoscopies?

Dr. Roger Hsiung: I am quite glad that you asked that question. I think that's something that needs to be clarified shortly. First of all, the prep is no longer, at least for a lot of people, the rate-determining step of colonoscopy. These days with medical advances, the prep is no longer liquid. It's mostly pills only. Of course, you swallow it with water normally. And it works just as well. Of course, you still have to run to the bathroom to evacuate yourself, but the delivery system instead of gulping down a very nasty tasting liquid. Now, it's all pills. So for most people, that appears to be easier,

And there are a lot of myths out there in which there are entities that could replace colonoscopy. And I think that deserves a two-minute conversation, the myths. One has heard of, say, CT colonography, MRIs, and defecating in a bag called Cologuard. Those entities, they serve as adjunct, but they are never meant to replace colonoscopy. If you understand how colonoscopy works, this is to physically go into your colon, find polyps, and remove the polyps, thus interrupt that sequence to prevent colon cancer. There's really nothing else besides colonoscopy that can prevent colon cancer in that regard.

For example, the CT colonography or the Cologuard, they can maybe find colon cancer to its merit, its sensitivity of finding colon cancer by the stool DNA, it is about sensitivity of 90 something percent. However, again, logically, why would you want to find colon cancer if you can prevent it? And therefore, those adjuncts don't find small polyps and they certainly cannot remove them. So when the time comes, when it's that age, if you are ready for a colonoscopy, you should do one instead of just having those adjuncts as a replacement. Because if they were negative, they couldn't find small polyps or remove them. Therefore, it defeats the purpose of colon cancer prevention.

If they were positive, then you certainly need to do a colonoscopy to find out why they're positive. So either way, one needs a colonoscopy when the time comes, so why not just bypass the middle man?

Host: Doctor, it's been great to have you here. Great to have your expertise. Just want to give you a chance here at the end, final thoughts, takeaways. When we think about colonoscopy, colorectal cancer, what do you most want folks to know?

Dr. Roger Hsiung: Colon cancer is a worldwide problem. And there are estimated about 150,000 colon cancer diagnosed every year, and there are about 50,000 deaths every year. It is very preventable. It is called a silent killer for a reason because you can't see it, you can't feel it until it becomes so large and so extensive that it becomes almost untreatable.

It is very treatable and preventable . And therefore, as long as the colonoscopy is done routinely and at the right time, it is quite preventable. And therefore, we want you to you really focus on getting your colonoscopy done when the time comes.

Host: Yeah, that's perfect. As I was saying earlier, folks find reasons not to do things to help themselves. But when we have an expert on, and he or she says, "Get that colonoscopy, it might save your life," that's good advice to heed. So, I appreciate your time and your expertise today. Thanks so much.

Dr. Roger Hsiung: Thank you.

Host: And for more information, visit valleyhealthsystemlv.com. And if you found this podcast to be helpful, please share it on your social channels. Be sure to check out the entire podcast library for additional topics of interest. Thanks again for listening to this episode of Health Talk. I'm Scott Webb. Stay well and we'll talk again next time.

Disclaimer: Physicians are independent practitioners who are not employees or agents of the Valley Health System. The system shall not be liable for actions or treatments provided by physicians.