Amanda Wilde (Host): Welcome to Neighbors Helping Neighbors, the official podcast of Ward Memorial Hospital. I'm Amanda Wilde, your host. And in this episode, we're focusing on colon cancer awareness with general surgeon, Dr. Subhash Nagalla. We'll talk about prevention, symptoms, risk factors, screening guidelines, and what to expect from a colonoscopy. Dr. Nagalla, thank you so much for being here.

Subhash Nagalla, MD, FACS: Thank you, Amanda. Thanks for having me.

Host: Can you tell us just a little about your background, and what brought you to Ward Memorial Hospital?

Subhash Nagalla, MD, FACS: Yes. I am a general surgeon. And I also did a fellowship in minimally invasive weight loss surgery in Cleveland Clinic, Florida. I did my General Surgery in New York. I was born and brought up in a small village. So, I always knew the troubles people have to access the healthcare to go to your surgeon. And that pretty much takes away the whole day. And especially if they have to provide care for their family members, they have to take time off from their work and they have to stay with the family until the end of the day, even for a simple visit. That's very cumbersome.

I think providing care in rural areas helps a lot. Patients tend to have their issues addressed much more commonly compared to where they have to go to the higher cities and where they have to drive and spend the whole day. That drove me to smaller places to provide healthcare. And people are very, very appreciative, and it's like a big family basically. You treat the patient at the hospital, and you go out and you run into them in the grocery store at public places.

Host: Yeah. So, care continues even when patients aren't your patients anymore because you will run into them in the community. What types of procedures do you commonly perform here locally?

Subhash Nagalla, MD, FACS: I do common general surgical procedures like appendicitis, gallbladder problems with just the pain symptoms associated with the gallstones or acute cholecystitis; chronic cholecystitis, that is chronic inflammation of the gallbladder; and patients who have pancreatitis related to the gallbladder or jaundice related to the gallbladder, hernias, skin lesions, circumcisions, vasectomies for family planning, abscesses, pilonidal disease, and colonoscopies and endoscopies for screening techniques or for any symptoms.

Host: That's a wide variety of surgeries that you do. For understanding colon cancer, what exactly is colon cancer? How does it develop?

Subhash Nagalla, MD, FACS: Yeah. It's one of the common cancers. It's like the fourth common cancer after the breast, lung and the prostate cancers. And basically, the colon cancer starts like a small, tiny, tiny growth in the innermost lining called mucosa. It takes about 10 years for it to get larger and develop into cancer.

So as it is one of the common cancers, until few years ago, the recommendation is to have a screening colonoscopy when you reach 50 years. But we are seeing more and more cancers in younger population. So, they changed the guidelines, and they brought down the age limit to 45 years.

So based on the current recommendations, all of us should have a screening colonoscopy when we reach 45 years, even if we don't have any symptoms. That's why we call it as a screening. Colonoscopy is a gold standard screening technique. And by performing the colonoscopy, we can identify these small growths when they're really small. And we can snip them and prevent them from getting larger and turning into cancer.

Host: So, we often hear about polyps. Is that the beginning or the precancerous version of colon cancer?

Subhash Nagalla, MD, FACS: Yeah, it is the polyps. So, all the colon cancer, they start like a tiny small growth called polyp, but all the polyps necessarily doesn't have to be pre-cancerous. Some of them, they grow into cancer, so they're called pre-cancerous. For example, tubular adenomas, villous adenomas, tubulovillous adenomas. These are the types of polyps that can develop into cancer, whereas some other polyps, like a hyperplastic polyp, they don't develop into cancer. They come and go, okay?

Coming back to the guidelines, if you don't have any symptoms whatsoever, still we should have a colonoscopy when we reach 45 years. But if you have any symptoms like change in the bowel habits, chronic constipation, chronic diarrhea, any blood in the stool or dark color stool or change in the stool caliber; had a bowel moment, but you don't feel empty, you still feel like going again, your appetite goes down, you are not eating well; are you losing weight without wanting to lose? Any of these factors, then you should see the doctor immediately and try to have these scopes as soon as possible.

And the third one is family history. If somebody has a family history of colon cancer, the risk of developing colon cancer is higher than a person who doesn't have a positive family history of colon cancer. So, those patients, either they should have a colonoscopy when they reach 45 years of age or 10 years earlier than the youngest family member diagnosed with colon cancer.

If somebody has a family member diagnosed with colon cancer at the age of 40 years, they should have their first colonoscopy when they reach 30 years, assuming that they don't have any symptoms. Obviously, if you have any symptoms, then none of these things matter. You should go and see your physician and then have the colonoscopy as soon as possible, assuming that there are no symptoms, so 10 years earlier than the youngest family member diagnosed with colon cancer or 45 years, whichever comes first.

Host: So for people who have had their first screening colonoscopy at age 45 and are okay, how often should people like that return for the next colonoscopy? How often should you be getting the screening?

Subhash Nagalla, MD, FACS: Yeah. In normal colonoscopy in a patient who does not have any family history of colon cancer and who does not have any of the symptoms that I just mentioned earlier, the repeat colonoscopy should be in 10 years. And at the same time, if it is a person who has a positive family history of colon cancer and the colonoscopy is completely normal, he or she should have a repeat colonoscopy in five years. So, normal colonoscopy in a person without family history, 10 years repeat colonoscopy. Normal colonoscopy in a patient with a positive family history, five years repeat colonoscopy.

Host: Let's talk about the colonoscopies so that we make sure we have explained that. Many people are nervous about colonoscopies, may have heard from friends that they're not easy. What actually happens during the procedure?

Subhash Nagalla, MD, FACS: Yeah, I know I heard these concerns many times from the patients. I think the worst thing is the bowel prep, not the procedure itself. And all of us have stool in the colon at any given time, significant amount of stool. There is what is called as a colonic transit time. So, the food that we eat, once it reaches the large intestine, it takes some time for it to completely go through the process and come through the other end. So, this time varies from person to person, it's called colonic transit time.

So when there is a stool and the colon is not clean, when you put a camera, you can't see anything there. So, it's essential to clean the colon completely. So, we have different types of medications, liquids that we use. It is called colon preparation or bowel prep. So, different types we have depends on the person we use that preparation. And the patient has to be on liquid diet before the procedure. And they have to take the preparation the day before. And they can have a clear liquid dinner the night before. And after the dinner, nothing to eat or drink. And they come to the hospital in the morning with empty stomach. And they have an IV placed and they will start getting some IV fluids. And then, we'll take them to the procedure room.

And once we confirm what's called as a timeout confirming the actual procedure that we're doing, and then the correct patient and then the date of birth and everything, then the anesthesiologist gives the medication through the IV. The patient goes to sleep. It's called MAC, M-A-C, monitored anesthesia care. So, they're constantly getting tiny amounts of medication to comfortably sleep. But at the same time, all their vital signs, their heart rate, blood pressure, oxygen saturation are monitored constantly. And then, we have this long, flexible tube with the camera and light at the tip, we pass it through the anal opening and slowly advancing into the colon until the starting portion, where the small intestine enters into the colon where the appendix also comes out.

We see that the small intestine entering the colon that we're opening, and we can see the appendiceal orifice inside the colon that's when we make sure that, "Okay, we went all the way in." Then, we slowly start pulling back. When we do this procedure, we have to insufflate the colon with some gas, carbon dioxide gas. So, slowly, we start pulling back and looking circumferentially to see if there are any polyps or any tumors or any ulcers or any arteriovenous abnormalities that can result in bleeding.

So if you see any polyps, we take them out. Sometimes we use just biopsy forceps, sometimes we use what is called the snare, a loop kind of thing. We put the loop around the base of the neck of the polyp if it is slightly larger. And sometimes we use it without any heat. Sometimes you use a tiny bit of heat to make sure that there's no bleeding. And then, we take them out. And we slowly pull the scope back while looking for any polyps or anything.

Okay. Again, anything that we take out or any biopsies that we take out, we send it for testing. Some people, they don't have the previous screening colonoscopies. They delayed their care and they may already have large polyps or large tumors that cannot be removed with a colonoscope. In those patients, we take multiple samples from that mass and send them for testing, and those patients will require surgery at a later date.

So in a person with a normal colonoscopy or a tiny polyp that we take them out, and once the procedure is complete, they're going to be in the recovery room for about half an hour, 40 minutes. Once they're completely awake and alert, they'll get some clear liquid light. And then, they'll get to go home.

They'll have a minimal amount of bloating and they'll pass a lot of flatus. And they feel better after that. So, we advise them to take the rest of the day easy, not to drive, not to make any important decisions, and not to operate any important machinery. But within the house, resting and walking around is good. And the next day morning, they can return to normal activities, their regular activities.

There are two more complications that we look for. One is any bleeding. The larger the polyp, there is a risk of bleeding from the polyp removal side. But anytime there is a doubt, we take some precautions. We may put some clips. We inject some medication called epinephrine to prevent any oozing or bleeding, but this can happen rarely requiring repeat procedure.

 Another complication that everybody is worried about is perforation. Well, perforation is a possibility that's very, very rare. It's like one in thousand scopes. That's very rare, but that's a possibility. But any potential benefits that we get from colonoscopy would outweigh any potential risks associated with it.

Host: If you have a polyp or if there is bleeding or some of the complications you've described, what is the recovery like afterwards and is that painful?

Subhash Nagalla, MD, FACS: Usually not. So, bleeding, anything that happens at the time of the procedure, we take care of it immediately. But sometimes, if you have a really large polyp and patients who are taking blood thinners previously, they were held for the procedure, but they don't follow the instruction, they start them too soon, that increases the risk for bleeding. If there is a bleeding, we have to repeat the scope. And then, we find out where the bleeding is coming from, and we put couple of clips and then that takes care of it.

And the perforation, yes, perforation can be painful, patients can have abdominal distension, worsening abdominal pain, nausea, vomiting, fever, chills, any of these things, they have to call the physician immediately or they have to come to the emergency room. Depending on where the perforation is located, how big the perforation is, if it is very, very minimal amount, very tiny perforation, that can be managed without surgical intervention. But most of the times, patients require surgery to fix that perforated area. It is a possibility, but it's very, very rare.

Host: You've described from preparation, which involves a special diet and medication to sort of evacuate your system and clear things out so that during the procedure, which is completely painless, you are under an anesthesia, a camera. You go in with a camera, it looks at what is going on there. You may take out polyps or any abnormalities that you can. Then, you described the recovery, not being very long at all after the procedure. And then, you go home and sort of take it easy for the rest of the day. And patients can return to normal activities the next day, it sounds like from what you said.

Subhash Nagalla, MD, FACS: Yes. Because of the anesthesia, you cannot drive back from the hospital on your own. You can drive yourself to the hospital. But after the procedure, somebody has to pick you up. You cannot drive on your own because of the anesthesia.

Host: So, this is a great screening tool and a surgical tool too, if necessary. We were talking about earlier what symptoms people might have, a stool change, not feeling full, not eating well. What are symptoms that no one should ever let go or ignore?

Subhash Nagalla, MD, FACS: Any blood in the stool. For example, the most common cause for blood in the stool is hemorrhoids, but you cannot take things for granted. So, you have to see a physician and make sure that nothing else is going on. So while hemorrhoids are the most common cause for blood in the stool, there is no way to make sure that there is no problem higher up in the colon and the rectum. The only way is to take care of the hemorrhoids and see if they're healed, and then do a colonoscopy to make sure that there are no other lesions higher up that are resulting in the bleeding.

And I have seen cancers in very young patients. The youngest adult patient that I have seen with cancer is 21 years old. The youngest adult patient, yes. And I have operated on many patients in their late 20s and many, many patients in their 30s for colon cancers and rectal cancers.

 While it is not common in younger people, it is not completely absent. So if you get symptoms, any blood in the stool, dark color stool, change in the stool caliber or not feeling completely soft, you had a bowel movement, you still feel as if you need to go again, that means there could be some tumor in the rectum giving these kind of fullness symptoms as if you have a stool there and as if you need to evacuate. So, any of these things are not eating well, losing weight without wanting to lose or sudden change in the bowel habits or alternating diarrhea and constipation, all these factors you should not neglect. If you haven't had a colonoscopy, then that's a time to have a colonoscopy.

Host: Dr. Nagalla, what are the biggest factors for colon cancer, including lifestyle and family history? Which you mentioned if you have a family history, you should get tested, screened much earlier at age 30. And you've mentioned you have some younger patients, does that play into what you see as the biggest risk factors?

Subhash Nagalla, MD, FACS: Yes. So definitely, genetics play a role. That's where the family history and the environmental factors and processed foods, red meat, fatty foods, obesity, a lack of physical activity, all these factors can increase the risk for colon cancer.

Host: And why is it important that people get screened locally? What would you say to someone who is putting it off?

Subhash Nagalla, MD, FACS: Yes. So for example, somebody has to travel like 50 miles, a hundred miles to have the procedure and they take a bowel prep at home. They may have to use the restroom again once or twice on their way. And also, they can drive on their own, but they need somebody to come back. So, it's also advisable to have somebody to drive them to the procedure. So, all these factors, create some kind of hesitation. The people, they neglect it. They don't have the means to travel such a long distance, they have to go and see the physician for a visit. Then, they have to have the procedure scheduled and they have to travel while they're taking a bowel prep, all these factors. Whereas locally, it's very easy. It's just five minutes from your home and the facilities are available locally. It's very easy to get into the physician's office, very easy to have the procedure done, very easy to get back home. For example, if you have your father or mother who is like 60, 70 years old and you are working and you have to take that person for the procedure, you can drop them off in the hospital and you can go to work. And then, we do the procedure and we'll call you and we we'll update you after the procedure is done.

So, you can take few minutes off, come back, and then take them home, and then drop them off again. You are not losing your work and the patients are not hesitant in scheduling the procedure. I have noticed that more and more patients are willing and actually having their procedures when it is locally available than having to travel larger distance.

Host: So, that makes a substantial difference and, long-term, that's going to make a difference in people's health. What is the one message you would like our listeners to remember about colon cancer screening?

Subhash Nagalla, MD, FACS: It is completely preventable. And do not neglect the symptoms. If your body is trying to tell you something, please listen and then get medical help. And then, also. Many people, they say that, "Oh, I have never seen a doctor in 50 years, 60 years," and they come and tell you proudly that they're in good shape and they never had to see a physician. Well, I'm happy that you never had to, but I do suggest you to go and see your physician to get age-appropriate screening techniques; not only colonoscopy, prostate examination check for diabetes to look at your hemoglobin A1c, to look at your lipid profile, cholesterol levels and the colonoscopy and, in women, mammograms and pap smears.

And, you know, all these factors by going through these screening techniques, preventive care, you can prevent many diseases, or you can catch them very early in the stage and you can cure them. So, they say prevention is better, right? But the next step is at least curing it. But I always emphasize on the prevention first. And the next stage is curing. And if you neglect it, unfortunately, we may be too late.

I'll tell you one example, I have had at least two patients in the past 10 years, two, three patients patient who had colon cancer. They were operated by another surgeon at some other place. The surgeon did a great job and they took care, they did perfect surgery. The cancer was gone. Patients did really well, but they never had their screening colonoscopies after that. Ten years past now, they developed a second cancer in the colon. It's called metachronous cancer.

So, there are two words called synchronous and metachronous. Synchronous means if you have a colon cancer, one colon cancer, there is at least 4% chance of having another colon cancer at the same time in other parts of the colon. So, that's the reason before you go for the surgery, if at all possible, you have to have a colonoscopy to make sure that rest of the colon is normal. That's one thing. And the metachronous means if you have a colon cancer, your risk of having another colon cancer is slightly higher than a person who never had it. So, you had a colon cancer, you had surgery and you are cured from it, but do not neglect subsequent screening colonoscopy. Just follow the recommendations of your physicians and please continue with the screening colonoscopy as advised.

Host: Because, to emphasize again, colonoscopies really can prevent cancer, and you'll never have to progress to having cancer treatment if you can catch these things early.

Subhash Nagalla, MD, FACS: Yes.

Host: Well, Dr. Nagalla, thank you so much for sharing your insights on colon health and for explaining what to expect before, during and after a colonoscopy, and the importance of rural access to specialty care as well.

Subhash Nagalla, MD, FACS: Thank you very much. Thank you for having me.

Host: That was Dr. Subhash Nagalla, general surgeon at Ward Memorial Hospital. For more information, go wardmemorial.com/podcastast. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. Thanks for listening to Neighbors Helping Neighbors, the official podcast of Ward Memorial Hospital.