Evo Terra (Host): Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm Evo Terra, and today I'm joined by a panel of experts for a conversation about colon cancer screenings. First up, Dr. Dobbin Chow is a Professor at the University of Maryland School of Medicine and an Internal Medicine Provider at the University of Maryland Midtown Health Center.

Welcome, Dr. Chow.

Dobbin Chow, MD: Thank you.

Host: Next we have Dr. Greg Lalonde, Assistant Professor at the University of Maryland School of Medicine, and an Internal Medicine Provider at the University of Maryland Midtown Health Center. Thanks for being here, Dr. Lalonde.

Greg Lalonde, MD: Of course Evo. Well, thank you.

Host: And also Dr. Jeff Gerbino, the Medical Director of the University of Maryland Midtown Health Center, and an Assistant Professor at the University of Maryland School of Medicine.

Nice to have you on the program as well, Dr. Gerbino.

Jeff Gerbino, MD: Thank you.

Host: So Dr. Gerbino, I will start these questions off with you. We're talking about colon cancer screening, so what is colon cancer? And talk to me about the risk factors.

Jeff Gerbino, MD: So colon cancer, also known as colorectal cancer, is a type of cancer that involves the large intestine, which is the end part of the intestines of the digestive tract. And typically it starts off as benign growths, called polyps. Over time these polyps can become cancerous. Typically the early stages of colon cancer or when you have polyps like this, they're completely asymptomatic.

But later stages when it becomes larger or it starts to spread to other places, it can then cause symptoms such as change in bowel habits, blood in your stool, abdominal pain, weight loss. Some of the risk factors for colon cancer are age. Most colon cancers happen in people over the age of 50. If you have a family member, or a personal history of some medical conditions, some things can raise your risk of developing it yourself. Medical conditions like Crohn's disease or ulcerative colitis can increase your risk. Certain dietary and lifestyle factors such as diet high in red meats, processed meats, and low in all the good stuff like fiber, fruit, vegetables, have been linked to colorectal cancer as well as alcohol, smoking, obesity. And some people unfortunately from different racial backgrounds can have higher risk of colon cancer, specifically African Americans.

Host: Dr. Chow, I'll turn to you. I know that screening means looking for cancer in the early stages before it's causing the symptoms. Tell us why that's important.

Dobbin Chow, MD: Yeah, thank you. So in the early stages, often patients don't have symptoms. I guess imagine a large garden hose and there's a like a little pimple in the garden hose. It won't cause much in the way of obstructing the flow of water through the garden hose. But as that gets larger and larger, then you can get some symptoms like blockage.

And as Dr. Gerbino mentioned, the symptoms can be quite serious and compelling. But in the early stage, there's often no symptoms. But that's the time when you want to catch it because that's when the treatment options are less invasive. That's when there's a potential for cure. In the late stages, sometimes the chance for cure is lost and then we have to try to just aim our therapy at ameliorating your symptoms rather than cure.

So finding the cancer in the early stage is, we can address it in an easier way and the potential of prognosis is much better.

Host: Definitely understand that. Now, Dr. Lalonde, from what I understand and just learning about this today, there are multiple ways that people can be screened. I've had two screenings and I was only given one option. So tell me about these other screenings and which one way is preferred over the others.

Greg Lalonde, MD: Yeah, you didn't get the full menu of all the options, but there are lots of options that are there. like Dr. Chow was saying, you know, the goal is to catch it as early as possible. And he's talking about kind of early cancers. We'd love to even catch even before then, like what Dr. Gerbino was saying earlier about things like polyps. So even if we can catch polyps, that could become in years the cancers. That's the goal of us screening. There's various kinds of screening options. I'll kind of break them out down into various types. We have our stool-based testing.

That's where we're testing various parts of your stool or your poop, looking for various components that could make us worried about colon cancer. So two big kinds there. One is called the FIT test. That's the fecal immunochemical test. A lot easier to say FIT testing. But that's looking for blood in the stool, specifically with antibodies.

And then a newer FIT DNA test, which has that prior FIT test, but also looks for abnormal DNA markers. And we'll talk about that a little bit I think later on. But those are the two main stool-based testings. There's endoscopic testing and that's what people kind of think of as that procedure. You go to see your GI specialist and then you have the procedure where there's the camera on the scope looking into the intestines themselves. There's two kinds there. The most common that people know, right, is the colonoscopy. But then there's also one called a flex sigmoidoscopy. And basically all that is, is it's still a endoscopic evaluation.

So still the tube with the camera on it, but it's only looking at that first one third of the colon from the rectum up. So you're not looking at the full colon, you're only looking at that kind of last bit before the rectum. And then probably the least common, but still as an option are imaging ways to screen for colon cancer, called a CT colonography. And effectively you're having a special sort of CT scan of your abdomen that's looking at the colon specifically for changes concerning for colon cancer. So, lots of different ways to test. They all have different recommendations for them, but all have data supporting it.

Host: Excellent. Dr. Gerbino, at what age should people start getting checked for colon cancer? I know when I turned 50 they said, you need to do this. Is that still the number?

Jeff Gerbino, MD: Yeah, so actually they lowered it within the last several years to age 45. And just to make that a distinction, when we're talking about age 45, we're talking about people that are at average risk of colon cancer. So people that have a family member that has had colon cancer, they'll start at a, a little bit of an earlier age. But for most people at average risk, the United States Preventative Services Task Force, which is the major body that comes up with these recommendations, recommend screening from 45 to 75, at one of those modalities that Dr. LaLonde mentioned. After the age of 75, it's really a discussion between the patient and their doctor in terms of, you know, what other health conditions they might be battling to figure out if colon cancer screening still makes sense at that age for them. If somebody is considered high risk for colon cancer because they have a family member, typically we start at age 40 or 10 years before that family member was diagnosed. So if you had a father that was diagnosed at age 45, you would start screening at age 35. And for those high risk patients, really the recommendation is to do a colonoscopy.

And then some of those other tests that Dr. LaLonde mentioned are kind of off the table.

Host: Dr. Chow, I want to turn to you and then ask about the colonoscopy itself. And I have really two questions, about that. Well, one comment and then a question. The comment was, the prep was way overblown. The worry, my friends who were older than me gave me, I think they were just messing with me.

I thought it was a very relatively straightforward procedure, the twice I've had it done. So that's a comment and the question is, telling us more about colonoscopies and why don't we just give them to everyone?

Dobbin Chow, MD: I'm like you. These are young men who are here on this show, but I'm like you. I've had two colonoscopies myself. There's some work involved there. You do have to do a prep, and what I mean by prep is you, you drink some fluid and the fluid results in cleaning out your colon. It basically you self-induce diarrhea. That day that that happens, it's not the most fun day in the world. And then so the next morning you go to the place to get the colonoscopy, and then you meet a gastroenterologist. Who's the doctor who performs this procedure. You get an IV and then they put you in a twilight kind of sleep. I don't know, I was pretty out, I was pretty sleepy. I don't remember anything.

But then afterwards, they wake you up. It probably takes about 45 minutes and then you're done. But when you're done, you have to have someone drive you home. You can't just leave the facility on your own. So getting a colonoscopy involves having a companion, someone to bring you home, involves drinking this prep overnight, which to me was much more challenging than the actual procedure. On the day of the procedure, you just go and they put you to sleep and then you wake up. You really don't know that anything happened, that's the usual experience. Not everyone can do all that. Meaning maybe some people don't have a companion that will take them home. Maybe some people don't want to or, have difficulty tolerating the prep. Our theme here is that whatever tests that people have is that whatever tests that they can do, and that's what we want them to do.

Host: That's, the right advice right there. I'm sure. So, Dr. Lalonde, earlier you mentioned that FIT DNA test. Can you tell me a little bit more about that please?

Greg Lalonde, MD: Yeah, so probably one of the newer kind of testing modalities. Again, kind of going back to to earlier, it combines both the FIT testing, which is looking for blood in the stool itself. And then the DNA component is looking for those abnormal DNA markers. There are multiple companies, for the FIT DNA test.

The most common that people might have heard, or those listening to the podcast might have heard is the Cologuard testing. Strong kind of ad campaigns and things there, again, try to increase awareness for the testing. Generally that does go through a primary care physician, so as all primary care doctors here, putting a strong plug out to make sure that you're established with a primary care physician to talk about all these screening tests. For the testing itself, the order is placed by the primary care physician, and a box goes to your home. It's mailed directly to you. You collect the stool within a kit that's mailed, and then generally whether it's USPS, UPS, what have you.

You call them, they come and they pick up the testing and bring it back. If that testing is negative, meaning if there's no blood in the stool, if they don't see abnormal DNA markers, that testing is good for three years before we need to talk about repeating that Cologuard test, the FIT DNA test.

The important aspect that all of our patients need to know, and something that I tell all my patients prior to ordering a FIT DNA test, is that if it does return positive, that does mean that we need to talk about a colonoscopy. And so going to kind of what Dr. Chow was saying, you know, these FIT DNA tests are good as kind of initial screening tests.

But you know, if you've had abnormal colonoscopies in the past, if you're a high risk individual, if you have a family history of colon cancers, then the FIT DNA test might not be the right test for you. A colonoscopy will. The nice thing about the FIT DNA testing is that it's readily available for our patient population.

It's covered under pretty much all insurances. And it's a very good screening test in terms of ruling out colon cancer. So, I had a, one in the office actually. Again, it comes to the home just in a really simple box, within the box stool collection kits, stool swabbing kits.

And then a really large packet of information for you to be able to read through, and, and easily to follow instructions. So, I find it's, a good option. Again, there are caveats.

Host: Dr. Gerbino, I want to talk about maybe some other options. Like for example, I hear that we now have this camera inside of a pill we can swallow and see on the inside. So what else? And is there one that you think is the best?

Jeff Gerbino, MD: I think Dr. LaLonde had gone over a lot of the options. The capsule endoscopy is a newer option. I haven't seen a lot of people do it. Because typically that still involves doing the whole prep, which is sometimes the reason why people don't do the colonoscopy in the first place. But in certain patients that might be the right option. But like we said before, the best test is the test that can be completed by the patient.

So, usually it's a discussion. We try to figure out what barriers might be in place for the patient to get their screening done. Whether it's a transportation issue, they don't want to do the prep. We kind of give them the menu of options, the stool-based ones, and then the ones that are more procedural based. So really the one that you as a patient and your physician can decide on is the best for you, that's the one you can get done, that's the best test.

Host: Great advice there. Dr. Chow, you've been doing this a while. Any success stories that you want to share regarding colon cancer screening?

Dobbin Chow, MD: Sure I have been doing this well, and after a while, uh, there will be patients that you screen, they screen positive. Yeah. I had one gentleman who he was in his sixties, we had him undergo colonoscopy and he was found to have a small cancer in the early stage he underwent a surgery. Had it removed. Surgery was very successful and I saw him and his wife about two months ago. He's in his eighties now, so it was curative. I had another patient, she was reluctant to undergo screening. And finally, I, I was quite emphatic about it and I said, you really should. And she finally did.

And she had turned out she did have cancer and it was a little bit later stage, so she had a little bit more aggressive surgery. The type of surgery that they do for colon cancer depends on how, at what stage it was detected in. So the earlier the stage, the more tolerable the surgery is and the less symptoms that you have related to the surgery. I'll tell you another story. I had a colonoscopy and the first time it was fine. They didn't see anything. And then I thought to myself, well gosh, should I have a second one? But my doctor said, you gotta have a second one. It's time. So I did.

And the second time I had a polyp. I had an adenomatous polyp. I was surprised. I was, didn't think they would grow that much in 10 years, but is a polyp. I'm so glad that I went. I'm so glad that they removed the polyp during the colonoscopy. If I didn't have that done, uh, a bad outcome would've occurred.

Host: I'm in a similar boat. I'm on the five-year plan now because they found polyps, so they found a few less polyps the last time I did it. So, yeah, I'll just continue doing that and making sure that, that I'm gonna be safe. That's why we do these things because I certainly can't see the issue myself.

Definitely. Well, doctors, this has been an excellent conversation. I want to thank all three of you for joining me today.

Jeff Gerbino, MD: Thank you.

Greg Lalonde, MD: Thanks for having us.

Dobbin Chow, MD: My pleasure.

Host: And if you would like to schedule an appointment with any of these doctors or learn more about the UMMS Midtown Health Center, UMMS primary care services available across Maryland or cancer care at the University of Maryland Medical System; please check out the resources in the episode description. You can find more shows just like this one at umms.org/podcast and on our YouTube channel. Thank you for watching or listening to this episode of Live Greater, a health and wellness podcast, brought to you by the University of Maryland Medical System.

We look forward to joining you again, and please share this on your social media.